NATIONAL COVERAGE DETERMINATION by mikeholy

VIEWS: 50 PAGES: 385

									              NATIONAL COVERAGE DETERMINATION
                                          TABLE OF CONTENTS

80061, 82465, 83718, 84478-Lipid Panels ......................................................... 4
80074-Acute hepatitis panel ............................................................................ 13
80162-Digoxin ................................................................................................... 15
82105-Alpha-fetoprotein; serum ..................................................................... 20
82270-Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces,
consecutive collected specimens with single determination, for colorectal
neoplasm screening (ie, patient was provided three cards or single triple
card for consecutive collection) ..................................................................... 22
82272-Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces,
single specimen (eg, from digital rectal exam).............................................. 23
82378-Carcinoembryonic antigen (CEA) ........................................................ 36
82523-Collagen cross links, any method ....................................................... 39
82728, 83540, 83550, 84466-Serum Iron Studies ........................................... 41
82947-Glucose; quantitative, blood (except reagent strip)........................... 73
82948-Glucose; blood, reagent strip .............................................................. 85
82962-Glucose, blood by glucose monitoring device(s) cleared by the FDA
specifically for home use ................................................................................ 97
82977-Glutamyltransferase, gamma (GGT).................................................. 109
82985-Glycated protein.................................................................................. 135
83036-Hemoglobin; glycosylated (A1C) ....................................................... 137
83700-Lipoprotein, blood; electrophoretic separation and quantitation... 140
83701-Lipoprotein, blood; high resolution fractionation and quantitation of
lipoproteins including lipoprotein subclasses when performed (eg,
electrophoresis, ultracentrifugation)............................................................ 149
83704-Lipoprotein, blood; quantitation of lipoprotein particle numbers and
lipoprotein particle subclasses (eg, by nuclear magnetic resonance
spectroscopy)................................................................................................. 158
83721-Lipoprotein, direct measurement; direct measurement, LDL
cholesterol ...................................................................................................... 167
84153-Prostate specific antigen (PSA); total ............................................... 176
84436, 84439, 84443, 84479-Thyroid Testing ............................................... 178
84702-Gonadotropin, chorionic (hCG); quantitative ................................... 188
85004, 85007, 85008, 85013, 85014, 85018, 85025, 85027, 85032, 85048,
85049 -Complete Blood Count ...................................................................... 190



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               NATIONAL COVERAGE DETERMINATION
                                            TABLE OF CONTENTS
85610-Prothrombin time; ............................................................................... 231
85730-Thromboplastin time, partial (PTT); plasma or whole blood ........... 281
86300-Immunoassay for tumor antigen, quantitative; CA 15-3 (27.29)...... 322
86301-Immunoassay for tumor antigen, quantitative; CA 19-9 .................. 323
86304-Immunoassay for tumor antigen, quantitative; CA 125 ................... 324
86689, 86701, 86702, 86703, 87390, 87391, 87534, 87535, 87537, 87538-HIV
Testing (Diagnosis) ........................................................................................ 325
87086, 87088-Urine Culture, Bacterial .......................................................... 349
87536, 87539-HIV Testing, Prognosis ........................................................... 355
G0103-Prostate cancer screening; PSA test................................................ 356
G0123-Screening pap smear, thin prep........................................................ 357
G0124-Screening pap smear, thin prep, requiring interpretation by
physician......................................................................................................... 358
G0141-Screening pap smear, with manual rescreening, requiring
interpretation by physician ........................................................................... 359
G0143-Screening pap smear, thin prep, with manual screening and
rescreening..................................................................................................... 360
G0144-Screening pap smear, thin prep, with manual screening and
computer assisted rescreening .................................................................... 361
G0145-Screening pap smear, thin prep, with manual screening and
computer assisted rescreening, cell selection ............................................ 362
G0147-Screening pap smear, performed by automated system ................ 363
G0148-Screening pap smear, performed by automated system with manual
rescreening..................................................................................................... 364
G0248-Demonstration, at initial use, of home INR monitoring for patient
with mechanical heart valve(s) who meets Medicare coverage criteria,
under the direction of a physician. ............................................................... 365
G0249-Provision of test materials and equipment for home INR monitoring
to patient with mechanical valve(s) who meets Medicare coverage criteria.
......................................................................................................................... 366
G0250-Physician review, interpretation and patient management of home
INR testing for a patient with mechanical heart valve(s) who meets other
coverage criteria............................................................................................. 367
G0328-Colorectal cancer screening; fecal occult blood test, immunoassay,
1-3 simultaneous determinations ................................................................. 368



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             NATIONAL COVERAGE DETERMINATION
                                       TABLE OF CONTENTS
G0394-Blood occult test (e.g., guaiac), feces, for single determination for
colorectal neoplasm....................................................................................... 369
P3000-Screening pap smear, cervical or vaginal, up to three smears, by
technician under physician supervision ...................................................... 382
P3001-Screening pap smear, cervical or vaginal, up to three smears,
requiring interpretation by physician ........................................................... 383
Q0091-Screening pap smear, obtaining, preparing and conveyance or
cervical or vaginal smear to laboratory........................................................ 384




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NATIONAL COVERAGE DETERMINATION                                                                                  Lipid Panels


NATIONAL COVERAGE DETERMINATION
Lipid Panels
80061, 82465, 83718, 84478-Lipid Panels




CPT CODE: 80061, 82465, 83718, 84478



CPT CODE DESCRIPTOR:

                                          80061 Lipid Panel

                                          82465 Cholesterol, serum or whole blood, total

                                          83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)

                                          84478 Triglycerides



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                          When monitoring long term anti-lipid dietary or pharmacologic therapy and when
                                          following patients with borderline high total or LDL cholesterol levels, it is
                                          reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a
                                          yearly interval will usually be adequate while measurement of the serum total
                                          cholesterol (CPT code 82465) or a measured LDL (CPT code 83721) should suffice
                                          for interim visits if the patient does not have hypertriglyceridemia (for example,
                                          ICD-9-CM code 272.1, Pure hyperglyceridemia).

                                          Any one component of the panel or a measured LDL may be medically necessary
                                          up to six times the first year for monitoring dietary or pharmacologic therapy. More
                                          frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing
                                          may be indicated for marked elevations or for changes to anti-lipid therapy due to
                                          inadequate initial patient response to dietary or pharma-cologic therapy. The LDL
                                          cholesterol or total cholesterol may be measured three times yearly after treatment
                                          goals have been achieved. If no dietary or pharmacological therapy is advised,
                                          monitoring is not necessary.

                                          When evaluating non-specific chronic abnormalities of the liver (for example,
                                          elevations of transaminase, alkaline phosphatase, abnormal imaging studies, etc.),
                                          a lipid panel would generally not be indicated more than twice per year.



COVERED ICD-9 CODES:
242.00 Toxic diffuse goiter without thyrotoxic crisis or storm
242.01 Toxic diffuse goiter with thyrotoxic crisis or storm
242.10 Toxic uninodular goiter without thyrotoxic crisis or storm
242.11 Toxic uninodular goiter with thyrotoxic crisis or storm
242.20 Toxic multinodular goiter without thyrotoxic crisis or storm
242.21 Toxic multinodular goiter with thyrotoxic crisis or storm
242.30 Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm
242.31 Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40 Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41 Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
242.80 Thyrotoxicosis of other specified origin without thyrotoxic crisis or storm


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NATIONAL COVERAGE DETERMINATION                                                        Lipid Panels

242.81   Thyrotoxicosis of other specified origin with thyrotoxic crisis or storm
242.90   Thyrotoxicosis without of goiter or other cause without thyrotoxic crisis or storm
242.91   Thyrotoxicosis without goiter or other cause with mention of thyrotoxic crisis or storm
243      Congenital hypothyroidism
244.0    Postsurgical hypothyroidism
244.1    Other postablative hypothyroidism
244.2    Iodine hypothyroidism
244.3    Other iatrogenic hypothyroidism
244.8    Other specified acquired hypothyroidism
244.9    Unspecified hypothyroidism
245.0    Acute thyroiditis
245.1    Subacute thyroiditis
245.2    Chronic lymphocytic thyroiditis
245.3    Chronic fibrous thyroiditis
245.4    Iatrogenic thyroiditis
245.8    Other and unspecified chronic thyroiditis
245.9    Thyroiditis, unspecified
250.00   Diabetes mellitus without complication, type II or unspecified type, not stated as
         uncontrolled
250.01   Diabetes mellitus without complication, type I, not stated as uncontrolled
250.02   Diabetes mellitus without complication, type II or unspecified type, uncontrolled
250.03   Diabetes mellitus without complication, type I, uncontrolled
250.10   Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
250.11   Diabetes with ketoacidosis, type I, not stated as uncontrolled
250.12   Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13   Diabetes with ketoacidosis, type I, uncontrolled
250.20   Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
250.21   Diabetes with hyperosmolarity, type I, not stated as uncontrolled
250.22   Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23   Diabetes with hyperosmolarity, type I, uncontrolled
250.30   Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
250.31   Diabetes with other coma, type I, not stated as uncontrolled
250.32   Diabetes with other coma, type II or unspecified type, uncontrolled
250.33   Diabetes with other coma type I, uncontrolled
250.40   Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41   Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42   Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43   Diabetes with renal manifestations, type I, uncontrolled
250.50   Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
         uncontrolled
250.51   Diabetes with ophthalmic manifestations, type I, not stated as uncontrolled
250.52   Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53   Diabetes with ophthalmic manifestations, type I, uncontrolled
250.60   Diabetes with neurological manifestations, type II or unspecified type, not stated as
         uncontrolled
250.61   Diabetes with neurological manifestations, type I, not stated as uncontrolled
250.62   Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
250.63   Diabetes with neurological manifestations, type I, uncontrolled
250.70   Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
         uncontrolled
250.71   Diabetes with peripheral circulatory disorders, type I, not stated as uncontrolled
250.72   Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
250.73   Diabetes with peripheral circulatory disorders, type I, uncontrolled



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NATIONAL COVERAGE DETERMINATION                                                      Lipid Panels

250.80 Diabetes with other specified manifestations, type II or unspecified type, not stated as
       uncontrolled
250.81 Diabetes with other specified manifestations, type I, not stated as uncontrolled
250.82 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
250.83 Diabetes with other specified manifestations, type I uncontrolled
250.90 Diabetes with unspecified complication, type II or unspecified type, not stated as
       uncontrolled
250.91 Diabetes with unspecified complication, type I, not stated as uncontrolled
250.92 Diabetes with unspecified complication, type II or unspecified type, uncontrolled
250.93 Diabetes with unspecified complication, type I, uncontrolled
255.0 Cushing's syndrome
260    Kwashiorkor
261    Nutritional marasmus
262    Other severe protein-calorie malnutrition
263.0 Malnutrition of moderate degree
263.1 Malnutrition of mild degree
263.8 Other protein-calorie malnutrition
263.9 Unspecified protein-calorie malnutrition
270.0 Disturbances of amino-acid transport
271.1 Galactosemia
272.0 Pure hypercholesterolemia
272.1 Pure hyperglyceridemia
272.2 Mixed hyperlipidemia
272.3 Hyperchylomicronemia
272.4 Other and unspecified hyperlipidemia
272.5 Lipoprotein deficiencies
272.6 Lipodystrophy
272.7 Lipidoses
272.8 Other disorders of lipoid metabolism
272.9 Unspecified disorder of lipoid metabolism
277.30 Amyloidosis, unspecified
277.31 Familial Mediterranean fever
277.39 Other amyloidosis
278.00 Obesity, unspecified
278.01 Morbid obesity
278.02 Overweight
303.90 Other and unspecified alcohol dependence, unspecified
303.91 Other and unspecified alcohol dependence, continuous
303.92 Other and unspecified alcohol dependence, episodic
362.10 Background retinopathy, unspecified
362.11 Hypertensive retinopathy
362.12 Exudative retinopathy
362.13 Changes in vascular appearance
362.14 Retinal microaneurysms
362.15 Retinal telangiectasia
362.16 Retinal neovascularization
362.30 Retinal vascular occlusion, unspecified
362.31 Central retinal artery occlusion
362.32 Arterial branch occlusion
362.33 Partial arterial occlusion
362.34 Transient arterial occlusion
362.82 Retinal exudates and deposits
371.41 Senile corneal changes



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NATIONAL COVERAGE DETERMINATION                                                     Lipid Panels

374.51   Xanthelasma
379.22   Crystalline deposits in vitreous
388.00   Degenerative and vascular disorders, unspecified
388.02   Transient ischemic deafness
401.0    Malignant hypertension
401.1    Benign hypertension
401.9    Unspecified hypertension
402.00   Malignant hypertension without congestive heart failure
402.01   Malignant hypertension with congestive heart failure
402.10   Benign hypertension without congestive heart failure
402.11   Benign hypertension with congestive heart failure
402.90   Unspecified hypertension without congestive heart failure
402.91   Unspecified hypertension with congestive heart failure
403.00   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I
         through stage IV, or unspecified
403.01   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or
         end stage renal disease
403.10   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through
         stage IV, or unspecified
403.11   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end
         stage renal disease
403.90   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I
         through stage IV, or unspecified
403.91   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or
         end stage renal disease
404.00   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.01   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.02   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.03   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.10   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.11   Hypertensive heart and chronic kidney disease, benign, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.12   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.13   Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic
         kidney disease stage V or end stage renal disease
404.90   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage I through stage IV, or unspecified
404.91   Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.92   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage V or end stage renal disease
404.93   Hypertensive heart and chronic kidney disease, unspecified, with heart failure and
         chronic kidney disease stage V or end stage renal disease
405.01   Renovascular hypertensive heart and renal disease
405.09   Other hypertensive heart and renal disease
405.11   Renovascular hypertensive heart and renal disease
405.19   Other hypertensive heart and renal disease



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NATIONAL COVERAGE DETERMINATION                                                     Lipid Panels

405.91   Renovascular hypertensive heart and renal disease
405.99   Other hypertensive heart and renal disease
410.00   Infarction of anterolateral wall, episode of care unspecified
410.01   Infarction of anterolateral wall, initial episode of care
410.02   Infarction of anterolateral wall, subsequent episode of care
410.10   Infarction of other anterior wall, episode of care unspecified
410.11   Infarction of other anterior wall, initial episode of care
410.12   Infarction of other anterior wall, subsequent episode of care
410.20   Infarction of inferolateral wall, episode of care unspecified
410.21   Infarction of inferolateral wall, initial episode of care
410.22   Infarction of inferolateral wall, subsequent episode of care
410.30   Infarction of inferoposterior wall, episode of care unspecified
410.31   Infarction of inferoposterior wall, initial episode of care
410.32   Infarction of inferoposterior wall,subsequent episode of care
410.40   Infarction of other inferior wall, episode of care unspecified
410.41   Infarction of other inferior wal, initial episode of care
410.42   Infarction of other inferior wall, subsequent episode of care
410.50   Infarction of other lateral wall, episode of care unspecified
410.51   Infarction of other lateral wall, initial episode of care
410.52   Infarction of other lateral wall, subsequent episode of care
410.60   True posterior wall infarction, episode of care unspecified
410.61   True posterior wall infarction, initial episode of care
410.62   True posterior wall infarction, subsequent episode of care
410.70   Subendocardial infarction, episode of care unspecified
410.71   Subendocardial infarction, initial episode of care
410.72   Subendocardial infarction, subsequent episode of care
410.80   Infarction of other specified sites, episode of care unspecified
410.81   Infarction of other specified sites, initial episode of care
410.82   Infarction of other specified sites, subsequent episode of care
410.90   Infarction, unspecified site, episode of care unspecified
410.91   Infarction, unspecified site, initial episode of care
410.92   Infarction, unspecified site, subsequent episode of care
411.0    Postmyocardial infarction syndrome
411.1    Intermediate coronary syndrome
411.81   Coronary occlusion without myocardial infarction
411.89   Other ischemic heart disease
412      Old myocardial infarction
413.0    Angina decubitus
413.1    Prinzmetal angina
413.9    Other and unspecified angina pectoris
414.00   Coronary atherosclerosis of unspecified vessel
414.01   Coronary atherosclerosis of native coronary artery
414.02   Coronary atherosclerosis of autologous biological bypass graft
414.03   Coronary atherosclerosis of nonautologous biological bypass graft
414.04   Coronary atherosclerosis of artery bypass graft
414.05   Coronary atherosclerosis of unspecified bypass graft
414.06   Coronary atherosclerosis of native coronary artery of transplanted heart
414.07   Coronary atherosclerosis, of bypass graft of transplanted heart
414.10   Aneurysm of heart (wall)
414.11   Aneurysm of coronary vessels
414.12   Dissection of coronary artery
414.19   Aneurysm, other
414.8    Other specified forms of chronic ischemic heart disease



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NATIONAL COVERAGE DETERMINATION                                                       Lipid Panels

414.9    Chronic ischemic heart disease, unspecified
428.0    Congestive heart failure
428.1    Left heart failure
428.20   Systolic heart failure, unspecified
428.21   Systolic heart failure, acute
428.22   Systolic heart failure, chronic
428.23   Systolic heart failure, acute on chronic
428.30   Diastolic heart failure, unspecified
428.31   Diastolic heart failure, acute
428.32   Diastolic heart failure, chronic
428.33   Diastolic heart failure, acute on chronic
428.40   Combined systolic and diastolic heart failure, unspecified
428.41   Combined systolic and diastolic heart failure, acute
428.42   Combined systolic and diastolic heart failure, chronic
428.43   Combined systolic and diastolic heart failure, acute on chronic
428.9    Heart failure, unspecified
429.2    Cardiovascular disease, unspecified
429.9    Heart disease, unspecified
431      Intracerebral hemorrhage
433.00   Occlusion and stenosis, basilar artery without cerebral infarction
433.01   Occlusion and stenosis, basilar artery with cerebral infarction
433.10   Occlusion and stenosis, carotid artery without cerebral infarction
433.11   Occlusion and stenosis, carotid artery with cerebral infarction
433.20   Occlusion and stenosis, vertebral artery without cerebral infarction
433.21   Occlusion and stenosis, vertebral artery with cerebral infarction
433.30   Occlusion and stenosis, multiple and bilateral without cerebral infarction
433.31   Occlusion and stenosis, multiple and bilateral with cerebral infarction
433.80   Occlusion and stenosis, other specified precerebral artery without cerebral infarction
433.81   Occlusion and stenosis, with cerebral infarction
433.90   Occlusion and stenosis, unspecified precerebral artery without cerebral infarction
433.91   Occlusion and stenosis, unspecified precerebral artery with cerebral infarction
434.00   Cerebral thrombosis without cerebral infarction
434.01   Cerebral thrombosis with cerebral infarction
434.10   Cerebral embolism without cerebral infarction
434.11   Cerebral embolism with cerebral infarction
434.90   Cerebral artery occlusion, unspecified without cerebral infarction
434.91   Cerebral artery occlusion, unspecified with cerebral infarction
435.0    Basilar artery syndrome
435.1    Vertebral artery syndrome
435.2    Subclavian steal syndrome
435.3    Vertebrobasilar artery syndrome
435.8    Other specified transient cerebral ischemias
435.9    Unspecified transient cerebral ischemia
437.0    Cerebral atherosclerosis
437.1    Other generalized ischemic cerebrovascular disease
437.5    Moyamoya disease
438.0    Late effects of cerebrovascular disease, cognitive defects
438.10   Late effects of cerebrovascular disease, speech/language unspecified
438.11   Late effects of cerebrovascular disease, aphasia
438.12   Late effects of cerebrovascular disease, dysphasia
438.19   Late effects of cerebrovascular disease, other speech/language defects
438.20   Late effects of cerebrovascular disease, hemiplegia, unspecified side
438.21   Late effects of cerebrovascular disease, hemiplegia, dominant side



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NATIONAL COVERAGE DETERMINATION                                                     Lipid Panels

438.22   Late effects of cerebrovascular disease, hemiplegia, non-dominant side
438.30   Late effects of cerebrovascular disease, monoplegia, upper limb, unspecified
438.31   Late effects of cerebrovascular disease, monoplegia, upper limb, dominant side
438.32   Late effects of cerebrovascular disease, monoplegia, upper limb, non-dominant side
438.40   Late effects of cerebrovascular disease, monoplegia, lower limb, unspecified
438.41   Late effects of cerebrovascular disease, monoplegia, lower limb, dominant side
438.42   Late effects of cerebrovascular disease, monoplegia, lower limb, non-dominant side
438.50   Late effects of cerebrovascular disease, other paralytic syndrome, unspecified
438.51   Late effects of cerebrovascular disease, other paralytic syndrome, dominant side
438.52   Late effects of cerebrovascular disease, other paralytic syndrome, non-dominant side
438.53   Late effects of cerebrovascular disease, other paralytic syndrome, bilateral
438.6    Alterations of sensations
438.7    Disturbances of vision
438.81   Late effects of cerebrovascular disease, aproxia
438.82   Late effects of cerebrovascular disease, dysphagia
438.83   Late effects of cerebrovascular disease, facial weakness
438.84   Late effects of cerebrovascular disease, ataxia
438.85   Late effects of cerebrovascular disease, vertigo
438.89   Late effects of cerebrovascular disease, other
438.9    Late effects of cerebrovascular disease, unspecified
440.0    Atherosclerosis of aorta
440.1    Atherosclerosis of renal artery
440.20   Atherosclerosis of the extremities, unspecified
440.21   Atherosclerosis of the extremities with intermittent claudication
440.22   Atherosclerosis of the extremities with rest pain
440.23   Atherosclerosis of the extremities with ulceration
440.24   Atherosclerosis of the extremities with gangrene
440.29   Other atherosclerosis of the extremities
440.30   Atherosclerosis of unspecified graft
440.31   Atherosclerosis of autologous vein bypass graft
440.32   Atherosclerosis of nonautologous vein bypass graft
440.4    Chronic total occlusion of artery of the extremities
440.8    Atherosclerosis of other specified arteries
440.9    Generalized and unspecified atherosclerosis
441.00   Dissection of aorta, unspecified site
441.01   Dissection of aorta, thoracic
441.02   Dissection of aorta, abdominal
441.03   Dissection of aorta, thoracoabdominal
441.1    Thoracic aneurysm, ruptured
441.2    Thoracic aneurysm without rupture
441.3    Abdominal aneurysm, ruptured
441.4    Abdominal aneurysm without rupture
441.5    Aortic aneurysm of unspecified site, ruptured
441.6    Thoracoabdominal aneurysm, ruptured
441.7    Thoracoabdominal aneurysm, without rupture
441.9    Aortic aneurysm of unspecified site without rupture
442.0    Aneurysm of artery of upper extremity
442.1    Aneurysm of renal artery
442.2    Aneurysm of iliac artery
444.0    Arterial embolism and thrombosis of abdominal aorta
444.1    Arterial embolism and thrombosis of thoracic aorta
444.21   Arterial embolism and thrombosis, upper extremity
444.22   Arterial embolism and thrombosis, lower extremity



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NATIONAL COVERAGE DETERMINATION                                                      Lipid Panels

444.81   Arterial embolism and thrombosis, iliac artery
444.89   Arterial embolism and thrombosis, other
444.9    Arterial embolism and thrombosis of unspecified artery
557.1    Chronic vascular insufficiency of intestine
571.8    Other chronic nonalcoholic liver disease
571.9    Unspecified chronic liver disease without mention of
573.8    Other specified disorders of liver
573.9    Unspecified disorder of liver
577.0    Acute pancreatitis
577.1    Chronic pancreatitis
577.2    Cyst and pseudocyst of pancreas
577.8    Other specified diseases of pancreas
577.9    Unspecified disease of pancreas
579.3    Other and unspecified postsurgical nonabsorption
579.8    Other specified intestinal malabsorption
581.0    Nephrotic syndrome with lesion of proliferative glomerulonephritis
581.1    Nephrotic syndrome with lesion of membranous glomerulonephritis
581.2    Nephrotic syndrome with lesion of membranoproliferative glomerulonephritis
581.3    Nephrotic syndrome with lesion of minimal change glomerulonephritis
581.81   Nephrotic syndrome in diseases classified elsewhere
581.89   Other nephrotic syndrome
581.9    Nephrotic syndrome with unspecified pathological lesion in
584.5    Acute renal failure with lesion of tubular necrosis
585.4    Chronic kidney disease, Stage IV (severe)
585.5    Chronic kidney disease, Stage V
585.6    End stage renal disease
585.9    Chronic kidney disease, unspecified
588.0    Renal osteodystrophy
588.1    Nephrogenic diabetes insipidus
588.81   Secondary hyperparathyroidism (of renal origin)
588.89   Other specified disorders resulting from impaired renal function
588.9    Unspecified disorder resulting from impaired renal function
607.84   Impotence of organic origin
646.70   Liver disorders in pregnancy, unspecified episode of care
646.71   Liver disorders in pregnancy, delivered, with or without antepartum condition
646.73   Liver disorders in pregnancy, antepartum condition or complication defects
648.10   Other conditions of mother complicating pregnancy, thyroid dysfunction, unspecified
         episode of care
648.11   Other conditions of mother complicating pregnancy, thyroid dysfunction, delivered, with or
         without antepartum condition
648.12   Other conditions of mother complicating pregnancy, thyroid dysfunction, delivered, with
         postpartum complication
648.13   Other conditions of mother complicating pregnancy, thyroid dysfunction, antepartum
         condition or complication
648.14   Other conditions of mother complicating pregnancy, thyroid dysfunction, postpartum
         condition or complication
696.0    Psoriatic arthropathy
696.1    Other psoriasis
751.61   Biliary atresia
764.10   Light-for-dates with signs of fetal malnutrition, unspecified [weight]
764.11   Light-for-dates with signs of fetal malnutrition less than 500 grams
764.12   Light-for-dates with signs of fetal malnutrition 500-749 grams
764.13   Light-for-dates with signs of fetal malnutrition 750-999 grams



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NATIONAL COVERAGE DETERMINATION                                                  Lipid Panels

764.14   Light-for-dates with signs of fetal malnutrition 1,000-1,249 grams
764.15   Light-for-dates with signs of fetal malnutrition 1,250-1,499 grams
764.16   Light-for-dates with signs of fetal malnutrition 1,500-1,749 grams
764.17   Light-for-dates with signs of fetal malnutrition 1,750-1,999 grams
764.18   Light-for-dates with signs of fetal malnutrition 2,000-2,499 grams
764.19   Light-for-dates with signs of fetal malnutrition 2,500 grams and over
786.50   Chest pain, unspecified
786.51   Precordial pain
786.59   Other chest pain
789.1    Hepatomegaly
790.4    Nonspecific elevation transaminase or lactic acid dehydrogenase [LDH]
790.5    Other nonspecific abnormalserum enzyme levels
790.6    Other abnormal blood chemistry
793.4    Abnormal radiologiocal findings, gastrointestinal tract
987.9    Toxic effect of unspecified gas, fume, or vapor
996.81   Complications, transplanted kidney
V42.0    Organ or tissue replaced by transplant, kidney
V42.7    Organ or tissue replaced by transplant, liver
V58.63   Long-term (current) use of antiplatelet/antithrombotic
V58.64   Long-term (current) use of non-steroidal anti-inflammatories
V58.69   Long-term (current) use of other medications
V81.0    Special screening for ischemic heart disease
V81.1    Special screening for hypertension
V81.2    Special screening for other and unspecified cardiovascular conditions




                                                                                     Page 12
NATIONAL COVERAGE DETERMINATION                                                                               80074


NATIONAL COVERAGE DETERMINATION
80074
80074-Acute hepatitis panel




CPT CODE: 80074



CPT CODE DESCRIPTOR: Acute hepatitis panel



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                              After a hepatitis diagnosis has been established, only individual tests, rather than
                              the entire panel, are needed.



COVERED ICD-9 CODES:
070.0 Viral hepatitis A with hepatic coma
070.1 Viral hepatitis A without hepatic coma
070.20 Viral hepatitis B with hepatic coma, acute or unspecified, without hepatitis delta
070.21 Viral hepatitis B with hepatic coma, acute or unspecified, with hepatitis delta
070.22 Viral hepatitis B with hepatic coma, chronic, without hepatitis delta
070.23 Viral hepatitis B with hepatic coma, chronic, with hepatitis delta
070.30 Viral hepatitis B without hepatic coma, acute or unspecified, without hepatitis delta
070.31 Viral hepatitis B without hepatic coma, acute or unspecified, with hepatitis delta
070.32 Viral hepatitis B without hepatic coma, chronic, without hepatitis delta
070.33 Viral hepatitis B without hepatic coma, chronic, with hepatitis delta
070.41 Acute hepatitis C with hepatic coma
070.42 Hepatitis delta without active hepatitis B disease with hepatic coma
070.43 Hepatitis E with hepatic coma
070.44 Chronic hepatitis C with hepatic coma
070.49 Other specified viral hepatitis with hepatic coma
070.51 Acute hepatitis C without mention of hepatic coma
070.52 Hepatitis delta without active hepatitis B disease or hepatic coma
070.53 Hepatitis E without hepatic coma
070.54 Chronic hepatitis C without hepatic coma
070.59 Other specified viral hepatitis without hepatic coma
070.6 Unspecified viral hepatitis with hepatic coma
070.70 Unspecified viral hepatitis C without hepatic coma
070.71 Unspecified viral hepatitis C with hepatic coma
070.9 Unspecified viral hepatitis without hepatic coma
456.0 Esophageal varices with bleeding
456.1 Esophageal varices without bleeding
456.20 Esophageal varices in diseases classified elsewhere with bleeding
456.21 Esophageal varices in diseases classified elsewhere without bleeding
570    Acute and subacute necrosis of liver
571.5 Cirrhosis of liver without mention of alcohol
572.0 Abscess of liver
572.1 Portal pyemia
572.2 Hepatic coma
572.3 Portal hypertension
572.4 Hepatorenal syndrome
572.8 Other sequelae of chronic liver disease
573.3 Hepatitis, unspecified


                                                                                                            Page 13
NATIONAL COVERAGE DETERMINATION                                                        80074

780.31   Febrile convulsions (simple), unspecified
780.32   Complex febrile convulsions
780.71   Chronic fatigue syndrome
780.79   Other malaise and fatigue
782.4    Jaundice, unspecified, not of newborn
783.0    Anorexia
783.1    Abnormal weight gain
783.21   Abnormal loss of weight
783.22   Underweight
783.3    Feeding difficulties and mismanagement
783.40   Lack of expected normal physiological development, unspecified
783.41   Failure to thrive
783.42   Delayed milestones
783.43   Short status
783.5    Polydipsia
783.6    Polyphagia
787.01   Nausea with vomiting
787.02   Nausea alone
787.03   Vomiting alone
789.00   Abdominal pain, unspecified site
789.01   Abdominal pain, right upper quadrant
789.02   Abdominal pain, left upper quadrant
789.03   Abdominal pain, right lower quadrant
789.04   Abdominal pain, left lower quadrant
789.05   Abdominal pain, periumbilic
789.06   Abdominal pain, epigastric
789.07   Abdominal pain, generalized
789.09   Abdominal pain, other specified site
789.1    Hepatomegaly
789.61   Abdominal tenderness, right upper quadrant
790.4    Nonspecific elevation transaminase or lactic acid dehydrogenase [LDH]
794.8    Abnormal results of function studies, liver
996.82   Complications, transplanted liver
999.31   Infection due to central venous catheter
999.39   Infection following other infusion, injection, transfusion, or vaccination
V72.85   Other specified examination




                                                                                      Page 14
NATIONAL COVERAGE DETERMINATION                                                              80162


NATIONAL COVERAGE DETERMINATION
80162
80162-Digoxin




CPT CODE: 80162



CPT CODE DESCRIPTOR: Digoxin



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS: None



COVERED ICD-9 CODES:
242.00 Toxic diffuse goiter without thyrotoxic crisis or storm
242.01 Toxic diffuse goiter with thyrotoxic crisis or storm
242.10 Toxic uninodular goiter without thyrotoxic crisis or storm
242.11 Toxic uninodular goiter with thyrotoxic crisis or storm
242.20 Toxic multinodular goiter without thyrotoxic crisis or storm
242.21 Toxic multinodular goiter with thyrotoxic crisis or storm
242.30 Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm
242.31 Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40 Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41 Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
242.80 Thyrotoxicosis of other specified origin without thyrotoxic crisis or storm
242.81 Thyrotoxicosis of other specified origin with thyrotoxic crisis or storm
242.90 Thyrotoxicosis without of goiter or other cause without thyrotoxic crisis or storm
242.91 Thyrotoxicosis without goiter or other cause with mention of thyrotoxic crisis or storm
243    Congenital hypothyroidism
244.0 Postsurgical hypothyroidism
244.1 Other postablative hypothyroidism
244.2 Iodine hypothyroidism
244.3 Other iatrogenic hypothyroidism
244.8 Other specified acquired hypothyroidism
244.9 Unspecified hypothyroidism
245.0 Acute thyroiditis
245.1 Subacute thyroiditis
245.2 Chronic lymphocytic thyroiditis
245.3 Chronic fibrous thyroiditis
245.4 Iatrogenic thyroiditis
245.8 Other and unspecified chronic thyroiditis
245.9 Thyroiditis, unspecified
275.2 Disorders of magnesium metabolism
275.40 Disorders of calcium metabolism, unspecified
275.41 Hypocalcemia
275.42 Hypercalcemia
275.49 Other disorders of calcium metabolism
276.0 Hyperosmolality and/or hypernatremia
276.1 Hyposmolality and/or hyponatremia
276.2 Acidosis
276.3 Alkalosis
276.4 Mixed acid-base balance disorder
276.50 Volume depletion, unspecified
276.51 Dehydration


                                                                                           Page 15
NATIONAL COVERAGE DETERMINATION                                                            80162

276.52   Hypovolemia
276.6    Fluid overload
276.7    Hyperpotassemia
276.8    Hypopotassemia
276.9    Electrolyte and fluid disorders not elsewhere classified
293.0    Delirium due to conditions classified elsewhere
293.1    Subacute delirium
307.47   Other dysfunctions of sleep stages or arousal from sleep
368.16   Psychophysical visual disturbances
368.8    Other specified visual disturbances
368.9    Unspecified visual disturbance
397.9    Rheumatic diseases of endocardium, valve unspecified
398.0    Rheumatic myocarditis
398.91   Rheumatic heart failure (congestive)
402.01   Malignant hypertension with congestive heart failure
402.11   Benign hypertension with congestive heart failure
402.91   Unspecified hypertension with congestive heart failure
403.00   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I
         through stage IV, or unspecified
403.01   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or
         end stage renal disease
403.10   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through
         stage IV, or unspecified
403.11   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end
         stage renal disease
403.90   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I
         through stage IV, or unspecified
403.91   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or
         end stage renal disease
404.00   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.01   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.02   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.03   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.10   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.11   Hypertensive heart and chronic kidney disease, benign, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.12   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.13   Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic
         kidney disease stage V or end stage renal disease
404.90   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage I through stage IV, or unspecified
404.91   Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.92   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage V or end stage renal disease
404.93   Hypertensive heart and chronic kidney disease, unspecified, with heart failure and
         chronic kidney disease stage V or end stage renal disease



                                                                                          Page 16
NATIONAL COVERAGE DETERMINATION                                              80162

410.00   Infarction of anterolateral wall, episode of care unspecified
410.01   Infarction of anterolateral wall, initial episode of care
410.02   Infarction of anterolateral wall, subsequent episode of care
410.10   Infarction of other anterior wall, episode of care unspecified
410.11   Infarction of other anterior wall, initial episode of care
410.12   Infarction of other anterior wall, subsequent episode of care
410.20   Infarction of inferolateral wall, episode of care unspecified
410.21   Infarction of inferolateral wall, initial episode of care
410.22   Infarction of inferolateral wall, subsequent episode of care
410.30   Infarction of inferoposterior wall, episode of care unspecified
410.31   Infarction of inferoposterior wall, initial episode of care
410.32   Infarction of inferoposterior wall,subsequent episode of care
410.40   Infarction of other inferior wall, episode of care unspecified
410.41   Infarction of other inferior wal, initial episode of care
410.42   Infarction of other inferior wall, subsequent episode of care
410.50   Infarction of other lateral wall, episode of care unspecified
410.51   Infarction of other lateral wall, initial episode of care
410.52   Infarction of other lateral wall, subsequent episode of care
410.60   True posterior wall infarction, episode of care unspecified
410.61   True posterior wall infarction, initial episode of care
410.62   True posterior wall infarction, subsequent episode of care
410.70   Subendocardial infarction, episode of care unspecified
410.71   Subendocardial infarction, initial episode of care
410.72   Subendocardial infarction, subsequent episode of care
410.80   Infarction of other specified sites, episode of care unspecified
410.81   Infarction of other specified sites, initial episode of care
410.82   Infarction of other specified sites, subsequent episode of care
410.90   Infarction, unspecified site, episode of care unspecified
410.91   Infarction, unspecified site, initial episode of care
410.92   Infarction, unspecified site, subsequent episode of care
411.0    Postmyocardial infarction syndrome
411.1    Intermediate coronary syndrome
411.81   Coronary occlusion without myocardial infarction
411.89   Other ischemic heart disease
413.0    Angina decubitus
413.1    Prinzmetal angina
413.9    Other and unspecified angina pectoris
422.0    Acute myocarditis in diseases classified elsewhere
422.90   Acute myocarditis, unspecified
422.91   Idiopathic myocarditis
422.92   Septic myocarditis
422.93   Toxic myocarditis
422.99   Other myocarditis
425.0    Endomyocardial fibrosis
425.1    Hypertrophic obstructive cardiomyopathy
425.2    Obscure cardiomyopathy of Africa
425.3    Endocardial fibroelastosis
425.4    Other primary cardiomyopathies
425.5    Alcoholic cardiomyopathy
425.7    Nutritional and metabolic cardiomyopathy
425.8    Cardiomyopathy in other diseases classified elsewhere
425.9    Secondary cardiomyopathy, unspecified
426.0    Atrioventricular block, complete



                                                                            Page 17
NATIONAL COVERAGE DETERMINATION                                             80162

426.10   Atrioventricular block, unspecified
426.11   First degree atrioventricular block
426.12   Mobitz (type) II atrioventricular block
426.13   Other second degree atrioventricular block
426.2    Left bundle branch hemiblock
426.3    Other left bundle branch block
426.4    Right bundle branch block
426.50   Bundle branch block, unspecified
426.51   Right bundle branch block and left posterior fascicular block
426.52   Right bundle branch block and left anterior fascicular block
426.53   Other bilateral bundle branch block
426.54   Trifascicular block
426.6    Other heart block
426.7    Anomalous atrioventricular excitation
426.81   Lown-Ganong-Levine syndrome
426.82   Long QT syndrome
426.89   Other conductive disorders
426.9    Conduction disorder, unspecified
427.0    Paroxysmal supraventricular tachycardia
427.1    Paroxysmal ventricular tachycardia
427.2    Paroxysmal tachycardia, unspecified
427.31   Atrial fibrillation
427.32   Atrial flutter
427.41   Ventricular fibrillation
427.42   Ventricular flutter
427.5    Cardiac arrest
427.60   Premature beats, unspecified
427.61   Supraventricular premature beats
427.69   Other Premature beats
427.81   Sinoatrial node dysfunction
427.89   Other node dysfunction
427.9    Cardiac dysrhythmia, unspecified
428.0    Congestive heart failure
428.1    Left heart failure
428.20   Systolic heart failure, unspecified
428.21   Systolic heart failure, acute
428.22   Systolic heart failure, chronic
428.23   Systolic heart failure, acute on chronic
428.30   Diastolic heart failure, unspecified
428.31   Diastolic heart failure, acute
428.32   Diastolic heart failure, chronic
428.33   Diastolic heart failure, acute on chronic
428.40   Combined systolic and diastolic heart failure, unspecified
428.41   Combined systolic and diastolic heart failure, acute
428.42   Combined systolic and diastolic heart failure, chronic
428.43   Combined systolic and diastolic heart failure, acute on chronic
428.9    Heart failure, unspecified
429.2    Cardiovascular disease, unspecified
429.4    Functional disturbances following cardiac surgery
429.5    Rupture of chordae tendineae
429.6    Rupture of papillary muscle
429.71   Acquired cardiac septal defect
514      Pulmonary congestion and hypostasis



                                                                           Page 18
NATIONAL COVERAGE DETERMINATION                                                            80162

579.9  Unspecified intestinal malabsorption
584.5  Acute renal failure with lesion of tubular necrosis
584.6  Acute renal failure with lesion of renal cortical necrosis
584.7  Acute renal failure with lesion of renal medullary [papillary] necrosis
584.8  Acute renal failure with other specified pathological lesion in kidney
584.9  Acute renal failure, unspecified
585.1  Chronic kidney disease, Stage I
585.2  Chronic kidney disease, Stage II (mild)
585.3  Chronic kidney disease, Stage III (moderate)
585.4  Chronic kidney disease, Stage IV (severe)
585.5  Chronic kidney disease, Stage V
585.6  End stage renal disease
585.9  Chronic kidney disease, unspecified
586    Renal failure, unspecified
587    Renal sclerosis, unspecified
588.0  Renal osteodystrophy
588.1  Nephrogenic diabetes insipidus
588.81 Secondary hyperparathyroidism (of renal origin)
588.89 Other specified disorders resulting from impaired renal function
588.9  Unspecified disorder resulting from impaired renal function
780.01 Coma
780.02 Transient alteration of awareness
780.09 Other alteration of awareness
780.1  Hallucinations
780.2  Syncope and collapse
780.4  Dizziness and giddiness
780.71 Chronic fatigue syndrome
780.79 Other malaise and fatigue
783.0  Anorexia
784.0  Headache
787.01 Nausea with vomiting
787.02 Nausea alone
787.03 Vomiting alone
787.91 Diarrhea
794.31 Abnormal electrocardiogram [ECG] [EKG]
799.2  Nervousness
972.0  Poisoning by cardiac rhythm regulators
972.1  Poisoning by cardiotonic glycosides and drugs of similar action
995.20 Unspecified adverse effect of unspecified drug, medicinal and biological substance
995.21 Arthus phenomenon
995.27 Other drug allergy
995.29 Unspecified adverse effect of other drug, medicinal and biological substance
E942.1 Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic
       use
V58.69 Long-term (current) use of other medications




                                                                                         Page 19
NATIONAL COVERAGE DETERMINATION                                                    82105


NATIONAL COVERAGE DETERMINATION
82105
82105-Alpha-fetoprotein; serum




CPT CODE: 82105



CPT CODE DESCRIPTOR: Alpha-fetoprotein; serum



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS: None



COVERED ICD-9 CODES:
070.22 Viral hepatitis B with hepatic coma, chronic, without hepatitis delta
070.23 Viral hepatitis B with hepatic coma, chronic, with hepatitis delta
070.32 Viral hepatitis B without hepatic coma, chronic, without hepatitis delta
070.33 Viral hepatitis B without hepatic coma, chronic, with hepatitis delta
070.44 Chronic hepatitis C with hepatic coma
070.54 Chronic hepatitis C without hepatic coma
095.3 Syphilis of liver
121.1 Clonorchiasis
121.3 Fascioliasis
155.0 Malignant neoplasm, liver, primary
155.1 Malignant neoplasm, intrahepatic bile ducts
155.2 Malignant neoplasm, liver, not specified as primary or
164.2 Malignant neoplasm of anterior mediastinum
164.3 Malignant neoplasm of posterior mediastinum
164.8 Other malignant neoplasm of thymus, heart, and mediastinum
164.9 Malignant neoplasm of mediastinum, part unspecified
183.0 Malignant neoplasm of ovary
186.0 Malignant neoplasm of undescended testis
186.9 Malignant neoplasm of other and unspecified testis
197.1 Secondary malignant neoplasm of mediastinum
197.7 Secondary malignant neoplasm of liver, specified as secondary
198.6 Secondary malignant neoplasm of ovary
198.82 Secondary malignant neoplasm of genital organs
211.5 Benign neoplasm of liver and biliary passages
235.3 Neoplasm of uncertain behavior of liver and biliary passages
272.2 Mixed hyperlipidemia
273.4 Alpha-1-antitrypsin deficiency
275.0 Disorders of iron metabolism
275.1 Disorders of copper metabolism
277.00 Cystic fibrosis without meconium ileus
277.03 Cystic fibrosis with gastrointestinal manifestations
277.6 Other deficiencies of circulating enzymes
285.0 Sideroblastic anemia
338.3 Neoplasm related pain (acute) (chronic)
571.2 Alcoholic cirrhosis of liver
571.40 Chronic hepatitis, unspecified
571.41 Chronic persistent hepatitis
571.49 Other chronic hepatitis
571.5 Cirrhosis of liver without mention of alcohol
608.89 Other Vascular disorders of male genital orga


                                                                                  Page 20
NATIONAL COVERAGE DETERMINATION                                                        82105

793.1    Abnormal radiologiocal findings, lung field
793.2    Abnormal radiologiocal findings, other intrathoracic organ
793.3    Abnormal radiologiocal findings, biliary tract
793.6    Abnormal radiologiocal findings, abdominal area, including retroperitoneum
795.89   Other abnormal tumor markers
V10.07   Personal history of malignant neoplasm, liver
V10.43   Personal history of malignant neoplasm, ovary
V10.47   Personal history of malignant neoplasm, testis
V86.0    Estrogen receptor positive status [ER+]
V86.1    Estrogen receptor negative status [ER-]




                                                                                      Page 21
NATIONAL COVERAGE DETERMINATION                                                                                                                                                                                                                                       82270


NATIONAL COVERAGE DETERMINATION
82270
82270-Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided three cards or single triple card for consecutive collection)




CPT CODE: 82270



CPT CODE DESCRIPTOR: Blood, occult, by peroxidase activity (eg, guaiac), qualitative;
      feces, consecutive collected specimens with single determination, for colorectal
      neoplasm screening (ie, patient was provided three cards or single triple card for
      consecutive collection)



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                             Screening fecal occult blood tests are covered at a frequency of once every 12
                                             months for beneficiaries who have attained age 50. A written order from the
                                             beneficiary's attending physician is required. Attending physician means a doctor
                                             or medicine or osteopathy who is fully knowledgeable about the beneficiary's
                                             medical condition, and who would be responsible for using the test results in the
                                             overall management of the beneficiary's specific medical problem.



COVERED ICD-9 CODES:
XXX.XX      Contact local Medicare Contractor for guidance




                                                                                                                                                                                                                                                                     Page 22
NATIONAL COVERAGE DETERMINATION                                                                                                  82272


NATIONAL COVERAGE DETERMINATION
82272
82272-Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, single specimen ( eg, from digital rectal exam)




CPT CODE: 82272



CPT CODE DESCRIPTOR: Blood, occult, by peroxidase activity (eg, guaiac), qualitative,
      feces, single specimen (eg, from digital rectal exam)



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                             Patients who are taking non-steroidal anti-inflammatory drugs and have a history
                                             of GI bleeding but no other signs, symptoms, or complaints associated with GI
                                             blood loss: once every 3 months



COVERED ICD-9 CODES:
003.0 Salmonella gastroenteritis
003.1 Salmonella septicemia
004.0 Shigella dysenteriae, infection by group A Shigella
004.1 Shigella flexneri, infection by group B Shigella
004.2 Shigella boydii, infection by group C Shigella
004.3 Shigella sonnei, infection by group D Shigella
004.8 Other specified shigella infections
004.9 Shigellosis, unspecified
005.0 Staphylococcal food poisoning
005.1 Botulism food poisoning
005.2 Food poisoning due to Clostridium perfringens [C. welchii]
005.3 Food poisoning due to other Clostridia
005.4 Food poisoning due to Vibrio parahaemolyticus
005.81 Food poisoning due to Vibrio vulnificus
005.89 Other bacterial food poisoning
005.9 Food poisoning, unspecified
006.0 Acute amebic dysentery without abscess
006.1 Chronic intestinal amebiasis without abscess
006.2 Amebic nondysenteric colitis
006.3 Amebic liver abscess
006.4 Amebic lung abscess
006.5 Amebic brain abscess
006.6 Amebic skin ulceration
006.8 Amebic infection of other sites
006.9 Amebiasis, unspecified
007.0 Food poisoning due to Balantidiasis
007.1 Food poisoning due to Giardiasis
007.2 Food poisoning due to Coccidiosis
007.3 Food poisoning due to intestinal trichomoniasis
007.4 Cryptosporidiosis
007.5 Cyclosporiasis
007.8 Food poisoning due to other specified protozoal intestinal diseases
007.9 Unspecified protozoal intestinal disease
008.41 Food poisoning due to Staphylococcus
008.42 Food poisoning due to Pseudomonas


                                                                                                                                Page 23
NATIONAL COVERAGE DETERMINATION                                                               82272

008.43   Food poisoning due to Campylobacter
008.44   Food poisoning due to Yersinia enterocolitica
008.45   Food poisoning due to Clostridium difficile
008.46   Food poisoning due to other anaerobes
008.47   Food poisoning due to other gram-negative bacteria
008.49   Food poisoning due to other specified bacteria
009.0    Infectious colitis, enteritis, and gastroenteritis
009.1    Colitis, enteritis, gastroenteritis of presumed infectious origin
009.2    Infectious diarrhea
009.3    Diarrhea of presumed infectious origin
014.00   Tuberculous peritonitis, unspecified
014.01   Tuberculous peritonitis, bacteriological or histological examination not done
014.02   Tuberculous peritonitis, bacteriological or histological examination unknown (at present)
014.03   Tuberculous peritonitis, tubercle bacilli found (in sputum) by microscopy
014.04   Tuberculous peritonitis, tubercle bacilli not found (in sputum) by microscopy, but found by
         bacterial culture
014.05   Tuberculous peritonitis, tubercle bacilli not found by bacteriological examination, but
         tuberculosis confirmed histologically
014.06   Tuberculous peritonitis, tubercle bacilli not found by bacteriological or histological
         examination, but tuberculosis confirmed by other methods
014.80   Other tuberculosis, unspecified
014.81   Other tuberculosis, bacteriological or histological examination not done
014.82   Other tuberculosis, bacteriological or histological examination unknown (at present)
014.83   Other tuberculosis, tubercle bacilli found (in sputum) by microscopy
014.84   Other tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found by
         bacterial culture
014.85   Other tuberculosis, tubercle bacilli not found by bacteriological examination, but
         tuberculosis confirmed histologically
014.86   Other tuberculosis, tubercle bacilli not found by bacteriological or histological
         examination, but tuberculosis confirmed by other methods
040.2    Whipple's disease
095.2    Syphilitic peritonitis
095.3    Syphilis of liver
098.0    Gonococcal infections, acute, of lower genitourinary tract
098.7    Gonococcal infection of anus and rectum
098.84   Gonococcal endocarditis
123.0    Taenia solium infection, intestinal form
123.1    Cysticercosis
123.2    Taenia saginata infection
123.3    Taeniasis, unspecified
123.4    Diphyllobothriasis, intestinal
123.5    Sparganosis [larval diphyllobothriasis]
123.6    Hymenolepiasis
123.8    Other specified cestode infection
123.9    Cestode infection, unspecified
124      Trichinosis
127.0    Ascariasis
127.1    Anisakiasis
127.2    Strongyloidiasis
127.3    Trichuriasis
127.4    Enterobiasis
127.5    Capillariasis
127.6    Trichostrongyliasis



                                                                                            Page 24
NATIONAL COVERAGE DETERMINATION                                                    82272

127.7   Other specified intestinal helminthiasis
127.8   Mixed intestinal helminthiasis
127.9   Intestinal helminthiasis, unspecified
139.8   Late effects of other and unspecified infectious and parasitic diseases
150.0   Malignant neoplasm of cervical esophagus
150.1   Malignant neoplasm of thoracic esophagus
150.2   Malignant neoplasm of abdominal esophagus
150.3   Malignant neoplasm of uUpper third of esophagus
150.4   Malignant neoplasm of middle third of esophagus
150.5   Malignant neoplasm of lower third of esophagus
150.8   Malignant neoplasm of other specified part of esophagus
150.9   Malignant neoplasm of esophagus, unspecified
151.0   Malignant neoplasm of cardia
151.1   Malignant neoplasm of pylorus
151.2   Malignant neoplasm of pyloric antrum
151.3   Malignant neoplasm of fundus of stomach
151.4   Malignant neoplasm of body of stomach
151.5   Malignant neoplasm of lesser curvature, unspecified
151.6   Malignant neoplasm of greater curvature of stomach, unspecified
151.8   Malignant neoplasm of other specified sites of stomach
151.9   Malignant neoplasm of stomach, unspecified
152.0   Malignant neoplasm of duodenum
152.1   Malignant neoplasm of jejunum
152.2   Malignant neoplasm of ileum
152.3   Malignant neoplasm of meckel's diverticulum
152.8   Malignant neoplasm of other specified sites of small intestine
152.9   Malignant neoplasm of small intestine, unspecified
153.0   Malignant neoplasm of hepatic flexure of colon
153.1   Malignant neoplasm, transverse colon
153.2   Malignant neoplasm, descending colon
153.3   Malignant neoplasm, sigmoid colon
153.4   Malignant neoplasm, cecum
153.5   Malignant neoplasm, appendix
153.6   Malignant neoplasm, ascending colon
153.7   Malignant neoplasm, splenic flexure
153.8   Malignant neoplasm, other specified sites of large intestine
153.9   Malignant neoplasm, colon, unspecified
154.0   Malignant neoplasm, rectosigmoid junction
154.1   Malignant neoplasm, rectum
154.2   Malignant neoplasm, anal canal
154.3   Malignant neoplasm, anus, unspecified
154.8   Malignant neoplasm, other
155.0   Malignant neoplasm, liver, primary
155.1   Malignant neoplasm, intrahepatic bile ducts
155.2   Malignant neoplasm, liver, not specified as primary or
156.0   Malignant neoplasm, gallbladder
156.1   Malignant neoplasm, extrahepatic bile ducts
156.2   Malignant neoplasm, ampulla of Vater
156.8   Malignant neoplasm, other specified sites of gallbladder
156.9   Malignant neoplasm, biliary tract, part unspecified
157.0   Malignant neoplasm, head of pancreas
157.1   Malignant neoplasm, body of pancreas
157.2   Malignant neoplasm, tail of pancreas



                                                                                  Page 25
NATIONAL COVERAGE DETERMINATION                                                 82272

157.3    Malignant neoplasm, pancreatic duct
157.4    Malignant neoplasm, islets of Langerhans
157.8    Malignant neoplasm, other specified sites of pancreas
157.9    Malignant neoplasm, pancreas, part unspecified
159.0    Malignant neoplasm, intestinal tract, part unspecified
159.1    Malignant neoplasm, spleen, not elsewhere classified
159.8    Malignant neoplasm, other sites of digestive system
159.9    Malignant neoplasm, ill-defined sites of digestive system
176.3    Kaposi's sarcoma, gastrointestinal sites
197.4    Secondary malignant neoplasm of small intestine, including duodenum
197.5    Secondary malignant neoplasm of large intestine and rectum
197.8    Secondary malignant neoplasm of other digestive organs and spleen
199.0    Malignant neoplasm without specification of site, Disseminated
204.00   Acute lymphoid leukemia without remission
204.01   Acute lymphoid leukemia in remission
204.10   Chronic lymphoid leukemia without remission
204.11   Chronic lymphoid leukemia in remission
204.20   Subacute lymphoid leukemia without remission
204.21   Subacute lymphoid leukemia in remission
204.80   Other lymphoid leukemia without remission
204.81   Other lymphoid leukemia in remission
204.90   Unspecified lymphoid leukemia without remission
204.91   Unspecified lymphoid leukemia in remission
205.00   Acute myeloid leukemia without remission
205.01   Acute myeloid leukemia in remission
205.10   Chronic myeloid leukemia without remission
205.11   Chronic myeloid leukemia in remission
205.20   Subacute myeloid sarcoma, without remission
205.21   Subacute myeloid sarcoma in remission
205.30   Myeloid sarcoma without remission
205.31   Myeloid sarcoma in remission
205.80   Other myeloid leukemia without remission
205.81   Other myeloid leukemia in remission
205.90   Unspecified myeloid leukemia without remission
205.91   Unspecified myeloid leukemia in remission
206.00   Acute monocytic leukemia without remission
206.01   Acute monocytic leukemia in remission
206.10   Chronic monocytic leukemia without remission
206.11   Chronic monocytic leukemia in remission
206.20   Subacute monocytic leukemia without remission
206.21   Subacute monocytic leukemia in remission
206.80   Other monocytic leukemia without remission
206.81   Other monocytic leukemia in remission
206.90   Unspecified monocytic leukemia without remission
206.91   Unspecified monocytic leukemia in remission
207.00   Acute erythremia and erythroleukemia without remission
207.01   Acute erythremia and erythroleukemia in remission
207.10   Chronic erythremia without remission
207.11   Chronic erythremia in remission
207.20   Megakaryocytic leukemia without remission
207.21   Megakaryocytic leukemia in remission
207.80   Other specified leukemia without remission
207.81   Other specified leukemia in remission



                                                                               Page 26
NATIONAL COVERAGE DETERMINATION                                                      82272

208.00   Acute leukemia of unspecified cell type without remission
208.01   Acute leukemia of unspecified cell type in remission
208.10   Chronic leukemia of unspecified cell type without remission
208.11   Chronic leukemia of unspecified cell type in remission
208.20   Subacute leukemia of unspecified cell type without remission
208.21   Subacute leukemia of unspecified cell type in remission
208.80   Other leukemia of unspecified cell type without remission
208.81   Other leukemia of unspecified cell type in remission
208.90   Unspecified leukemia without remission
208.91   Unspecified leukemia in remission
211.0    Benign neoplasm of esophagus
211.1    Benign neoplasm of stomach
211.2    Benign neoplasm of duodenum, jejunum, and ileum
211.3    Benign neoplasm of colon
211.4    Benign neoplasm of rectum and anal canal
211.5    Benign neoplasm of liver and biliary passages
211.6    Benign neoplasm of pancreas, except islets of Langerhans
211.7    Benign neoplasm of islets of Langerhans
211.8    Benign neoplasm of retroperitoneum and peritoneum
211.9    Benign neoplasm of other and unspecified site
228.04   Hemangioma, of intra-abdominal structures
230.2    Carcinoma in situ of stomach
230.3    Carcinoma in situ of colon
230.4    Carcinoma in situ of rectum
230.5    Carcinoma in situ of anal canal
230.6    Carcinoma in situ of anus, unspecified
230.7    Carcinoma in situ of other and unspecified parts of intestine
230.8    Carcinoma in situ of liver and biliary system
230.9    Carcinoma in situ of other and unspecified digestive organs
235.2    Neoplasm of uncertain behavior of stomach, intestines, and rectum
235.5    Neoplasm of uncertain behavior of other and unspecified digestive organs
239.0    Neoplasms of unspecified nature of digestive system
280.0    Iron deficiency anemia, unspecified
280.1    Iron deficiency anemia, secondary to inadequate dietary iron intake
280.8    Other specified iron deficiency anemias
280.9    Iron deficiency anemia, unspecified
284.2    Myelophthisis
285.0    Sideroblastic anemia
285.1    Acute posthemorrhagic anemia
285.21   Anemia in chronic kidney disease
285.22   Anemia in neoplastic disease
285.29   Anemia of other chronic disease
285.8    Other specified anemias
285.9    Anemia, unspecified
286.0    Congenital factor VIII disorder
286.1    Congenital factor IX disorder
286.2    Congenital factor XI deficiency
286.3    Congenital deficiency of other clotting factors
286.4    von Willebrand's disease
286.5    Hemorrhagic disorder due to circulating anticoagulants
286.6    Defibrination syndrome
286.7    Acquired coagulation factor deficiency
286.9    Other and unspecified coagulation defects



                                                                                    Page 27
NATIONAL COVERAGE DETERMINATION                                                       82272

287.0    Allergic purpura
287.1    Qualitative platelet defects
287.2    Other nonthrombocytopenic purpuras
287.30   Primary thrombocytopenia, unspecified
287.31   Immune thrombocytopenic purpura
287.32   Evans' syndrome
287.33   Congenital and hereditary thrombocytopenic purpura
287.39   Other primary thrombocytopenia
287.4    Secondary thrombocytopenia
287.5    Thrombocytopenia, unspecified
287.8    Other specified hemorrhagic conditions
287.9    Unspecified hemorrhagic conditions
338.3    Neoplasm related pain (acute) (chronic)
448.0    Hereditary hemorrhagic telangiectasia
455.0    Internal hemorrhoids without complication
455.1    Internal thrombosed hemorrhoids
455.2    Internal hemorrhoids with other complication
455.3    External hemorrhoids without complication
455.4    External thrombosed hemorrhoids
455.5    External hemorrhoids with other complication
455.6    Unspecified hemorrhoids without complication
455.7    Unspecified thrombosed hemorrhoids
455.8    Unspecified hemorrhoids with other complication
456.0    Esophageal varices with bleeding
456.1    Esophageal varices without bleeding
456.20   Esophageal varices in diseases classified elsewhere with bleeding
456.21   Esophageal varices in diseases classified elsewhere without bleeding
530.10   Esophagitis, unspecified
530.11   Reflux esophagitis
530.12   Acute esophagitis
530.19   Other esophagitis
530.20   Ulcer of esophagus without bleeding
530.21   Ulcer of esophagus with bleeding
530.3    Stricture and stenosis of esophagus
530.4    Perforation of esophagus
530.5    Dyskinesia of esophagus
530.6    Diverticulum of esophagus, acquired
530.7    Gastroesophageal laceration-hemorrhage syndrome
530.81   Esophageal reflux
530.82   Esophageal hemorrhage
530.83   Esophageal leukoplakia
530.84   Tracheoesophageal fistula
530.85   Barrett's esophagus
530.89   Other specified disorders of esophagus
530.9    Unspecified disorder of esophagus
531.00   Peptic ulcer, acute with hemorrhage without obstruction
531.01   Peptic ulcer, acute with hemorrhage with obstruction
531.10   Peptic ulcer, acute with perforation without obstruction
531.11   Peptic ulcer, acute with perforation with obstruction
531.20   Peptic ulcer, acute with hemorrhage and perforation without obstruction
531.21   Peptic ulcer, acute with hemorrhage and perforation with obstruction
531.30   Peptic ulcer, acute without hemorrhage or perforation without obstruction
531.31   Peptic ulcer, acute without hemorrhage or perforation with obstruction



                                                                                     Page 28
NATIONAL COVERAGE DETERMINATION                                                              82272

531.40   Peptic ulcer, chronic or unspecified with hemorrhage without obstruction
531.41   Peptic ulcer, chronic or unspecified with hemorrhage with obstruction
531.50   Peptic ulcer, chronic or unspecified with perforation without obstruction
531.51   Peptic ulcer, chronic or unspecified with perforation with obstruction
531.60   Peptic ulcer, chronic or unspecified with hemorrhage and perforation without obstruction
531.61   Peptic ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
531.70   Peptic ulcer, chronic without hemorrhage or perforation without obstruction
531.71   Peptic ulcer, chronic without hemorrhage or perforation with obstruction
531.90   Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation without
         obstruction
531.91   Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation with
         obstruction
532.00   Peptic ulcer, acute with hemorrhage without obstruction
532.01   Peptic ulcer, acute with hemorrhage with obstruction
532.10   Peptic ulcer, acute with perforation without obstruction
532.11   Peptic ulcer, acute with perforation with obstruction
532.20   Peptic ulcer, acute with hemorrhage and perforation without obstruction
532.21   Peptic ulcer, acute with hemorrhage and perforation with obstruction
532.30   Peptic ulcer, acute without hemorrhage or perforation without obstruction
532.31   Peptic ulcer, acute without hemorrhage or perforation with obstruction
532.40   Peptic ulcer, chronic or unspecified with hemorrhage without obstruction
532.41   Peptic ulcer, chronic or unspecified with hemorrhage with obstruction
532.50   Peptic ulcer, chronic or unspecified with perforation without obstruction
532.51   Peptic ulcer, chronic or unspecified with perforation with obstruction
532.60   Peptic ulcer, chronic or unspecified with hemorrhage and perforation without obstruction
532.61   Peptic ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
532.70   Peptic ulcer, chronic without hemorrhage or perforation without obstruction
532.71   Peptic ulcer, chronic without hemorrhage or perforation with obstruction
532.90   Peptic ulcer, unspecified as acute or chronic without obstruction
532.91   Peptic ulcer, unspecified as acute or chronic with obstruction hemorrhage or perforation
533.00   Peptic ulcer, acute with hemorrhage without obstruction
533.01   Peptic ulcer, acute with hemorrhage with obstruction
533.10   Peptic ulcer, acute with perforation without obstruction
533.11   Peptic ulcer, acute with perforation with obstruction
533.20   Peptic ulcer, acute with hemorrhage and perforation without obstruction
533.21   Peptic ulcer, acute with hemorrhage and perforation with obstruction
533.30   Peptic ulcer, acute without hemorrhage and perforation without obstruction
533.31   Peptic ulcer, acute without hemorrhage and perforation with obstruction
533.40   Peptic ulcer, chronic or unspecified with hemorrhage without obstruction
533.41   Peptic ulcer, chronic or unspecified with hemorrhage with obstruction
533.50   Peptic ulcer, chronic or unspecified with perforation without obstruction
533.51   Peptic ulcer, chronic or unspecified with perforation with obstruction
533.60   Peptic ulcer, chronic or unspecified with hemorrhage and perforation without obstruction
533.61   Peptic ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
533.70   Peptic ulcer, chronic without hemorrhage or perforation without obstruction
533.71   Peptic ulcer, chronic without hemorrhage or perforation with obstruction
533.90   Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation without
         obstruction
533.91   Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation with
         obstruction
534.00   Gastrojejunal ulcer, acute with hemorrhage without obstruction
534.01   Gastrojejunal ulcer, acute with hemorrhage with obstruction
534.10   Gastrojejunal ulcer, acute with perforation without obstruction



                                                                                           Page 29
NATIONAL COVERAGE DETERMINATION                                                              82272

534.11   Gastrojejunal ulcer, acute with perforation with obstruction
534.20   Gastrojejunal ulcer, acute with hemorrhage and perforation without obstruction
534.21   Gastrojejunal ulcer, acute with hemorrhage and perforation with obstruction
534.30   Gastrojejunal ulcer, acute without hemorrhage or perforation without obstruction
534.31   Gastrojejunal ulcer, acute without hemorrhage or perforation with obstruction
534.40   Gastrojejunal ulcer, chronic or unspecified with hemorrhage without obstruction
534.41   Gastrojejunal ulcer, chronic or unspecified with hemorrhage with obstruction
534.50   Gastrojejunal ulcer, chronic or unspecified with perforation without obstruction
534.51   Gastrojejunal ulcer, chronic or unspecified with perforation with obstruction
534.60   Gastrojejunal ulcer, chronic or unspecified with hemorrhage and perforation without
         obstruction
534.61   Gastrojejunal ulcer, chronic or unspecified with hemorrhage and perforation with
         obstruction
534.70   Gastrojejunal ulcer, chronic without hemorrhage or perforation without mention of
         obstruction
534.71   Gastrojejunal ulcer, chronic without hemorrhage or perforation with obstruction
534.90   Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
         without obstruction
534.91   Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
         with obstruction
535.00   Acute gastritis without hemorrhage
535.01   Acute gastritis with hemorrhage
535.10   Atrophic gastritis without hemorrhage
535.11   Atrophic gastritis with hemorrhage
535.20   Gastric mucosal hypertrophy without hemorrhage
535.21   Gastric mucosal hypertrophy with hemorrhage
535.30   Alcoholic gastritis without hemorrhage
535.31   Alcoholic gastritis with hemorrhage
535.40   Other specified gastritis without hemorrhage
535.41   Other specified gastritis with hemorrhage
535.50   Unspecified gastritis and gastroduodenitis without hemorrhage
535.51   Unspecified gastritis and gastroduodenitis with hemorrhage
535.60   Duodenitis without hemorrhage
535.61   Duodenitis with hemorrhage
536.2    Persistent vomiting
536.8    Dyspepsia and other specified disorders of function of stomach
536.9    Unspecified functional disorder of stomach
537.0    Acquired hypertrophic pyloric stenosis
537.1    Gastric diverticulum
537.2    Chronic duodenal ileus
537.3    Other obstruction of duodenum
537.4    Fistula of stomach or duodenum
537.82   Angiodysplasia of stomach and duodenum without hemorrhage
537.83   Angiodysplasia of stomach and duodenum with hemorrhage
537.84   Dieulafoy lesion (hemorrhagic) of stomach and duodeum
537.89   Other disorder of stomach and duodenum
555.0    Regional enteritis, small intestine
555.1    Regional enteritis, large intestine
555.2    Regional enteritis, small intestine with large intestine
555.9    Regional enteritis, unspecified site
556.0    Ulcerative (chronic) enterocolitis
556.1    Ulcerative (chronic) ileocolitis
556.2    Ulcerative (chronic) proctitis



                                                                                           Page 30
NATIONAL COVERAGE DETERMINATION                                             82272

556.3    Ulcerative (chronic) proctosigmoiditis
556.4    Pseudopolyposis of colon
556.5    Left-sided ulcerative (chronic) colitis
556.6    Universal ulcerative (chronic) colitis
556.8    Other ulcerative colitis
556.9    Ulcerative colitis, unspecified
557.0    Acute vascular insufficiency of intestine
557.1    Chronic vascular insufficiency of intestine
557.9    Unspecified vascular insufficiency of intestine
558.1    Gastroenteritis and colitis due to radiation
558.2    Toxic gastroenteritis and colitis
558.3    Allergic gastroenteritis and colitis
558.9    Other and unspecified noninfectious gastroenteritis and colitis
560.0    Intussusception
560.1    Paralytic ileus
560.2    Volvulus
560.30   Impaction of intestine, unspecified
560.31   Gallstone ileus
560.39   Other intestinal obstruction
562.10   Diverticulosis of colon without hemorrhage
562.11   Diverticulitis of colon without hemorrhage
562.12   Diverticulosis of colon with hemorrhage
562.13   Diverticulitis of colon with hemorrhage
564.00   Constipation, unspecified
564.01   Slow transit constipation
564.02   Outlet dysfunction constipation
564.09   Other constipation
564.1    Irritable colon
564.2    Postgastric surgery syndromes
564.3    Vomiting following gastrointestinal surgery
564.4    Other postoperative functional disorders
564.5    Functional diarrhea
564.6    Anal spasm
564.7    Megacolon, other than Hirschsprung's
564.81   Neurogenic bowel
564.89   Other functional disorders of intestine
564.9    Unspecified functional disorder of intestine
565.0    Anal fissure
565.1    Anal fistula
569.0    Anal and rectal polyp
569.1    Rectal prolapse
569.3    Hemorrhage of rectum and anus
569.41   Ulcer of anus and rectum
569.42   Anal or rectal pain
569.43   Anal sphincter tear (healed) (old)
569.49   Other disorder or rectum and anus
569.82   Ulceration of intestine
569.83   Perforation of intestine
569.84   Angiodysplasia of intestine without hemorrhage
569.85   Angiodysplasia of intestine with hemorrhage
569.86   Dieulafoy lesion (hemorrhagic) of intestine
571.0    Alcoholic fatty liver
571.1    Acute alcoholic hepatitis



                                                                           Page 31
NATIONAL COVERAGE DETERMINATION                                               82272

571.2    Alcoholic cirrhosis of liver
571.3    Alcoholic liver damage, unspecified
571.40   Chronic hepatitis, unspecified
571.41   Chronic persistent hepatitis
571.49   Other chronic hepatitis
571.5    Cirrhosis of liver without mention of alcohol
571.6    Biliary cirrhosis
571.8    Other chronic nonalcoholic liver disease
571.9    Unspecified chronic liver disease without mention of
577.0    Acute pancreatitis
577.1    Chronic pancreatitis
577.2    Cyst and pseudocyst of pancreas
577.8    Other specified diseases of pancreas
577.9    Unspecified disease of pancreas
578.0    Hematemesis
578.1    Blood in stool
578.9    Hemorrhage of gastrointestinal tract, unspecified
579.0    Celiac disease
579.8    Other specified intestinal malabsorption
596.1    Intestinovesical fistula
617.5    Endometriosis of intestine
780.71   Chronic fatigue syndrome
780.79   Other malaise and fatigue
783.0    Anorexia
783.21   Abnormal loss of weight
787.01   Nausea with vomiting
787.02   Nausea alone
787.03   Vomiting alone
787.1    Heartburn
787.20   Dysphagia, unspecified
787.21   Dysphagia, oral phase
787.22   Dysphagia, oropharyngeal phase
787.23   Dysphagia, pharyngeal phase
787.24   Dysphagia, pharyngoesophageal phase
787.29   Other dysphagia
787.7    Abnormal feces
787.91   Diarrhea
787.99   Other bowel symptoms
789.00   Abdominal pain, unspecified site
789.01   Abdominal pain, right upper quadrant
789.02   Abdominal pain, left upper quadrant
789.03   Abdominal pain, right lower quadrant
789.04   Abdominal pain, left lower quadrant
789.05   Abdominal pain, periumbilic
789.06   Abdominal pain, epigastric
789.07   Abdominal pain, generalized
789.09   Abdominal pain, other specified site
789.30   Abdominal or pelvic swelling, mass, or lump, unspecified site
789.31   Abdominal or pelvic swelling, mass, or lump, right upper quadrant
789.32   Abdominal or pelvic swelling, mass, or lump, left upper quadrant
789.33   Abdominal or pelvic swelling, mass, or lump, right lower quadrant
789.34   Abdominal or pelvic swelling, mass, or lump, left lower quadrant
789.35   Abdominal or pelvic swelling, mass, or lump, periumbilic



                                                                             Page 32
NATIONAL COVERAGE DETERMINATION                                                                82272

789.36   Abdominal or pelvic swelling, mass, or lump, epigastric
789.37   Abdominal or pelvic swelling, mass, or lump, generalized
789.39   Abdominal or pelvic swelling, mass, or lump, other specified site
789.40   Abdominal rigidity, unspecified site
789.41   Abdominal rigidity, right upper quadrant
789.42   Abdominal rigidity, left upper quadrant
789.43   Abdominal rigidity, right lower quadrant
789.44   Abdominal rigidity, left lower quadrant
789.45   Abdominal rigidity, periumbilic
789.46   Abdominal rigidity, epigastric
789.47   Abdominal rigidity, generalized
789.49   Abdominal rigidity, other specified site
789.51   Malignant ascites
789.59   Other ascites
789.60   Abdominal tenderness, unspecified site
789.61   Abdominal tenderness, right upper quadrant
789.62   Abdominal tenderness, left upper quadrant
789.63   Abdominal tenderness, right lower quadrant
789.64   Abdominal tenderness, left lower quadrant
789.65   Abdominal tenderness, periumbilic
789.66   Abdominal tenderness, epigastric
789.67   Abdominal tenderness, generalized
789.69   Abdominal tenderness, other specified site
790.92   Abnormal coagulation profile
792.1    Other nonspecific findings on examination of stool contents
793.6    Abnormal radiologiocal findings, abdominal area, including retroperitoneum
794.8    Abnormal results of function studies, liver
863.0    Injury to stomach, without open wound into cavity
863.1    Injury to stomach, with open wound into cavity into cavity
863.20   Injury to small intestine, without open wound into cavity, unspecified site
863.21   Injury to duodenum without open wound into cavity
863.29   Injury to other digestive tract organ without open wound into cavity
863.30   Injury to small intestine, unspecified site, with open wound into cavity
863.31   Injury to duodenum with open wound into cavity
863.39   Injury to other digestive tract organ with open wound into cavity
863.40   Injury to colon, unspecified site, without open wound into cavity
863.41   Injury to ascending [right] colon without open wound into cavity
863.42   Injury to transverse colon without open wound into cavity
863.43   Injury to descending [left] colon without open wound into cavity
863.44   Injury to sigmoid colon without open wound into cavity
863.45   Injury to rectum without open wound into
863.46   Injury to multiple sites in colon and rectum without open wound into cavity
863.49   Injury to other colon or rectum site without open wound into cavity
863.50   Injury to colon, unspecified site, with open wound into cavity
863.51   Injury to ascending [right] colon with open wound into cavity
863.52   Injury to transverse colon with open wound into cavity
863.53   Injury to descending [left] colon with open wound into cavity
863.54   Injury to sigmoid colon with open wound into cavity
863.55   Injury to rectum with open wound into cavity
863.56   Injury to multiple sites in colon and rectum with open wound into cavity
863.59   Injury to other sites in colon and rectum with open wound into cavity
863.80   Injury to gastrointestinal tract, unspecified site, without open wound into cavity
863.81   Injury to pancreas, head, without open wound into cavity



                                                                                              Page 33
NATIONAL COVERAGE DETERMINATION                                                             82272

863.82   Injury to pancreas, body. without open wound into cavity
863.83   Injury to pancreas, tail, without open wound into cavity
863.84   Injury to pancreas, multiple and unspecified sites, without open wound into cavity
863.85   Injury to appendix without open wound into cavity
863.89   Injury to other gastrointestinal sites, without open wound into cavity
863.90   Injury to gastrointestinal tract, unspecified site, with open wound into cavity
863.91   Injury to pancreas, head, with open wound into cavity
863.92   Injury to pancreas, body, with open wound into cavity
863.93   Injury to pancreas, tail, with open wound into cavity
863.94   Injury to pancreas, multiple and unspecified sites, with open wound into cavity
863.95   Injury to appendix with open wound into cavity
863.99   Injury to other gastrointestinal tract sites with open wound into cavity
864.00   Injury to liver without open wound into cavity, unspecified injury
864.01   Injury to liver without open wound into cavity, hematoma and contusion
864.02   Injury to liver without open wound into cavity, laceration, minor
864.03   Injury to liver without open wound into cavity, laceration, moderate
864.04   Injury to liver without open wound into cavity, laceration, major
864.05   Injury to liver without open wound into cavity, laceration, unspecified
864.09   Injury to liver without open wound into cavity, other
864.11   Injury to liver with open wound into cavity, hematoma and contusion
864.12   Injury to liver with open wound into cavity, laceration, minor
864.13   Injury to liver with open wound into cavity, laceration, moderate
864.14   Injury to liver with open wound into cavity, laceration, major
864.15   Injury to liver with open wound into cavity, laceration, unspecified
864.19   Injury to liver with open wound into cavity, other
866.00   Injury to kidney without open wound into cavity, unspecified injury
866.01   Injury to kidney without open wound into cavity, hematoma without rupture of capsule
866.02   Injury to kidney without open wound into cavity, laceration
866.03   Injury to kidney without open wound into cavity, complete disruption of kidney
         parenchyma
866.10   Injury to kidney with open wound into cavity, unspecified injury
866.11   Injury to kidney with open wound into cavity, hematoma without rupture of capsule
866.12   Injury to kidney with open wound into cavity, laceration
866.13   Injury to kidney with open wound into cavity, complete disruption of kidney parenchyma
902.0    Injury to abdominal aorta
902.10   Injury to inferior vena cava, unspecified
902.11   Injury to hepatic veins
902.19   Injury to other blood vessels of abdomen and pelvis
902.20   Injury to celiac and mesenteric arteries, unspecified
902.21   Injury to gastric artery
902.22   Injury to hepatic artery
902.23   Injury to splenic artery
902.24   Injury to other specified branches of celiac axis
902.25   Injury to superior mesenteric artery (trunk)
902.26   Injury to primary branches of superior mesenteric artery
902.27   Injury to inferior mesenteric artery
902.29   Injury to other celiac and mesenteric arteries
902.31   Injury to superior mesenteric vein and primary
902.32   Injury to inferior mesenteric vein
902.33   Injury to portal vein
902.34   Injury to splenic vein
902.39   Injury to other portal and splenic veins
902.40   Injury to renal vessel(s), unspecified



                                                                                          Page 34
NATIONAL COVERAGE DETERMINATION                                                            82272

902.41   Injury to renal artery
902.42   Injury to renal vein
902.49   Injury to other renal blood vessels
902.50   Injury to iliac vessel(s), unspecified
902.51   Injury to hypogastric artery
902.52   Injury to hypogastric vein
902.53   Injury to iliac artery
902.54   Injury to iliac vein
902.55   Injury to uterine artery
902.56   Injury to uterine vein
902.59   Injury to other iliac blood vessels
902.81   Injury to ovarian artery
902.82   Injury to ovarian vein
902.87   Injury to multiple blood vessels of abdomen and pelvis
902.89   Injury to other specified blood vessels of abdomen and pelvis
902.9    Injury to unspecified blood vessel of abdomen and pelvis
926.11   Crushing injury of back
926.12   Crushing injury of buttock
926.19   Crushing injury, other
926.8    Crushing injury of multiple sites of trunk
926.9    Crushing injury of unspecified site
964.2    Poisoning by anticoagulants
995.20   Unspecified adverse effect of unspecified drug, medicinal and biological substance
V10.00   Personal history of malignant neoplasm, gastrointestinal tract, unspecified
V10.01   Personal history of malignant neoplasm, tongue
V10.02   Personal history of malignant neoplasm, other and unspecified oral cavity and pharynx
V10.03   Personal history of malignant neoplasm, esophagus
V10.04   Personal history of malignant neoplasm, stomach
V10.05   Personal history of malignant neoplasm, large intestine
V10.06   Personal history of malignant neoplasm, rectum, rectosigmoid junction, and anus
V10.07   Personal history of malignant neoplasm, liver
V10.09   Personal history of malignant neoplasm, other
V12.00   Personal history of unspecified infectious and parasitic disease
V12.72   Personal history of colonic polyps
V58.61   Long-term (current) use of anticoagulants
V58.63   Long-term (current) use of antiplatelet/antithrombotic
V58.64   Long-term (current) use of non-steroidal anti-inflammatories
V58.65   Long-term (current) use of steroids
V58.66   Long-term (current) use of aspirin
V58.69   Long-term (current) use of other medications
V67.51   Follow-up examination following completed treatment with high-risk medication, not
         elsewhere classified




                                                                                         Page 35
NATIONAL COVERAGE DETERMINATION                                                                                      82378


NATIONAL COVERAGE DETERMINATION
82378
82378-Carcinoembryonic antigen (CEA)




CPT CODE: 82378



CPT CODE DESCRIPTOR: Carcinoembryonic antigen (CEA)



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                       Serum CEA determinations are generally not indicated more frequently than once
                                       per chemotherapy treatment cycle for patients with metastatic solid tumors which
                                       express CEA or every two months post-surgical treatment for patients who have
                                       had colorectal carcinoma. It may be proper to order the test more frequently when
                                       there has been a significant change from prior CEA level or a significant change in
                                       patient status which could reflect disease progression or recurrence. Testing with
                                       a diagnosis of an in situ carcinoma is not reasonably done more frequently than
                                       once, unless the result is abnormal, in which case the test may be repeated once.



COVERED ICD-9 CODES:
150.0 Malignant neoplasm of cervical esophagus
150.1 Malignant neoplasm of thoracic esophagus
150.2 Malignant neoplasm of abdominal esophagus
150.3 Malignant neoplasm of uUpper third of esophagus
150.4 Malignant neoplasm of middle third of esophagus
150.5 Malignant neoplasm of lower third of esophagus
150.8 Malignant neoplasm of other specified part of esophagus
150.9 Malignant neoplasm of esophagus, unspecified
151.0 Malignant neoplasm of cardia
151.1 Malignant neoplasm of pylorus
151.2 Malignant neoplasm of pyloric antrum
151.3 Malignant neoplasm of fundus of stomach
151.4 Malignant neoplasm of body of stomach
151.5 Malignant neoplasm of lesser curvature, unspecified
151.6 Malignant neoplasm of greater curvature of stomach, unspecified
151.8 Malignant neoplasm of other specified sites of stomach
151.9 Malignant neoplasm of stomach, unspecified
152.0 Malignant neoplasm of duodenum
152.1 Malignant neoplasm of jejunum
152.2 Malignant neoplasm of ileum
152.3 Malignant neoplasm of meckel's diverticulum
152.8 Malignant neoplasm of other specified sites of small intestine
152.9 Malignant neoplasm of small intestine, unspecified
153.0 Malignant neoplasm of hepatic flexure of colon
153.1 Malignant neoplasm, transverse colon
153.2 Malignant neoplasm, descending colon
153.3 Malignant neoplasm, sigmoid colon
153.4 Malignant neoplasm, cecum
153.5 Malignant neoplasm, appendix
153.6 Malignant neoplasm, ascending colon
153.7 Malignant neoplasm, splenic flexure


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NATIONAL COVERAGE DETERMINATION                                                             82378

153.8    Malignant neoplasm, other specified sites of large intestine
153.9    Malignant neoplasm, colon, unspecified
154.0    Malignant neoplasm, rectosigmoid junction
154.1    Malignant neoplasm, rectum
154.2    Malignant neoplasm, anal canal
154.3    Malignant neoplasm, anus, unspecified
154.8    Malignant neoplasm, other
157.0    Malignant neoplasm, head of pancreas
157.1    Malignant neoplasm, body of pancreas
157.2    Malignant neoplasm, tail of pancreas
157.3    Malignant neoplasm, pancreatic duct
157.4    Malignant neoplasm, islets of Langerhans
157.8    Malignant neoplasm, other specified sites of pancreas
157.9    Malignant neoplasm, pancreas, part unspecified
159.0    Malignant neoplasm, intestinal tract, part unspecified
162.0    Malignant neoplasm of trachea
162.2    Malignant neoplasm of main bronchus
162.3    Malignant neoplasm of upper lobe, bronchus or lung
162.4    Malignant neoplasm of middle lobe, bronchus or lung
162.5    Malignant neoplasm of lower lobe, bronchus or lung
162.8    Malignant neoplasm of other parts of bronchus or lung
162.9    Malignant neoplasm of bronchus and lung, unspecified
174.0    Malignant neoplasm of nipple and areola of female breast
174.1    Malignant neoplasm of central portion of breast
174.2    Upper-inner quadrant of female breast
174.3    Lower-inner quadrant of female breast
174.4    Upper-outer quadrant of female breast
174.5    Lower-outer quadrant of female breast
174.6    Axillary tail of female breast
174.8    Other specified sites of female breast
174.9    Malignant neoplasm of breast (female), unspecified
175.0    Malignant neoplasm of nipple and areola of male breast
175.9    Malignant neoplasm, other and unspecified sites of male breast
183.0    Malignant neoplasm of ovary
197.0    Secondary malignant neoplasm of lung
197.4    Secondary malignant neoplasm of small intestine, including duodenum
197.5    Secondary malignant neoplasm of large intestine and rectum
230.3    Carcinoma in situ of colon
230.4    Carcinoma in situ of rectum
230.7    Carcinoma in situ of other and unspecified parts of intestine
230.9    Carcinoma in situ of other and unspecified digestive organs
235.2    Neoplasm of uncertain behavior of stomach, intestines, and rectum
338.3    Neoplasm related pain (acute) (chronic)
790.99   Other abnormal blood test
795.81   Elevated carcinoembryonic antigen [CEA]
795.89   Other abnormal tumor markers
V10.00   Personal history of malignant neoplasm, gastrointestinal tract, unspecified
V10.05   Personal history of malignant neoplasm, large intestine
V10.06   Personal history of malignant neoplasm, rectum, rectosigmoid junction, and anus
V10.11   Personal history of malignant neoplasm, bronchus and lung
V10.3    Personal history of malignant neoplasm, breast
V10.43   Personal history of malignant neoplasm, ovary
V67.2    Follow-up examination following chemotherapy



                                                                                           Page 37
NATIONAL COVERAGE DETERMINATION    82378




                                  Page 38
NATIONAL COVERAGE DETERMINATION                                                                                        82523


NATIONAL COVERAGE DETERMINATION
82523
82523-Collagen cross links, any method




CPT CODE: 82523



CPT CODE DESCRIPTOR: Collagen cross links, any method



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                         Current recommendations for appropriate utilization include: one or two base-line
                                         assays from specified urine collections on separate days; followed by a repeat
                                         assay about three months after starting anti-resorptive therapy; followed by a
                                         repeat assay in 12 months after the three-month assay; and thereafter not more
                                         than annually, unless there is a change in therapy in which circumstance an
                                         additional test may be indicated three months after the initiation of new therapy.



COVERED ICD-9 CODES:
242.00 Toxic diffuse goiter without thyrotoxic crisis or storm
242.01 Toxic diffuse goiter with thyrotoxic crisis or storm
242.10 Toxic uninodular goiter without thyrotoxic crisis or storm
242.11 Toxic uninodular goiter with thyrotoxic crisis or storm
242.20 Toxic multinodular goiter without thyrotoxic crisis or storm
242.21 Toxic multinodular goiter with thyrotoxic crisis or storm
242.30 Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm
242.31 Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40 Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41 Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
242.80 Thyrotoxicosis of other specified origin without thyrotoxic crisis or storm
242.81 Thyrotoxicosis of other specified origin with thyrotoxic crisis or storm
242.90 Thyrotoxicosis without of goiter or other cause without thyrotoxic crisis or storm
242.91 Thyrotoxicosis without goiter or other cause with mention of thyrotoxic crisis or storm
245.2 Chronic lymphocytic thyroiditis
246.9 Unspecified disorder of thyroid
252.00 Hyperparathyroidism, unspecified
252.01 Primary hyperparathyroidism
252.02 Secondary hyperparathyroidism, non-renal
252.08 Other hyperparathyroidism
256.2 Postablative ovarian failure
256.31 Premature menopause
256.39 Other ovarian failure
256.8 Other ovarian dysfunction
256.9 Unspecified ovarian dysfunction
268.9 Unspecified vitamin D deficiency
269.3 Mineral deficiency, not elsewhere classified
627.0 Premenopausal menorrhagia
627.1 Postmenopausal bleeding
627.2 Menopausal or female climacteric states
627.4 States associated with artificial menopause
627.8 Other specified menopausal and postmenopausal disorders
627.9 Unspecified menopausal and postmenopausal ydisorder


                                                                                                                     Page 39
NATIONAL COVERAGE DETERMINATION                                                          82523

731.0    Osteitis deformans without bone tumor
733.00   Osteoporosis, unspecified
733.01   Senile osteoporosis
733.02   Idiopathic osteoporosis
733.03   Disuse osteoporosis
733.09   Other osteoporosis
733.10   Pathologic fracture, unspecified site
733.11   Pathologic fracture of humerus
733.12   Pathologic fracture of distal radius and ulna
733.13   Pathologic fracture of vertebrae
733.14   Pathologic fracture of neck of femur
733.15   Pathologic fracture of other specified part of femur
733.16   Pathologic fracture of tibia and fibula
733.19   Pathologic fracture of other specified site
733.90   Disorder of bone and cartilage, unspecified
805.8    Fracture of vertebral column without spinal cord injury, unspecified, closed
V58.65   Long-term (current) use of steroids
V58.69   Long-term (current) use of other medications




                                                                                        Page 40
NATIONAL COVERAGE DETERMINATION                                                                          Serum Iron Studies


NATIONAL COVERAGE DETERMINATION
Serum Iron Studies
82728, 83540, 83550, 84466-Serum Iron Studies




CPT CODE: 82728, 83540, 83550, 84466



CPT CODE DESCRIPTOR:

                                         82728 Ferritin

                                         83540 Iron

                                         83550 Iron binding capacity

                                         84466 Transferrin



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                         If a normal serum ferritin level is documented, repeat testing would not ordinarily
                                         be medically necessary unless there is a change in the patient's condition, and
                                         ferritin assessment is needed for the ongoing management of the patient.

                                         When an End Stage Renal Disease (ESRD) patient is tested for ferritin, testing
                                         more frequently than every three months (the frequency authorized by 3167.3,
                                         Fiscal Intermediary manual) requires documentation of medical necessity [e.g.,
                                         other than Chronic Renal Failure (ICD-9-CM 585) or Renal Failure, Unspecified
                                         (ICD-9-CM 586)].



COVERED ICD-9 CODES:
002.0 Typhoid fever
002.1 Paratyphoid fever A
002.2 Paratyphoid fever B
002.3 Paratyphoid fever C
002.9 Paratyphoid fever, unspecified
003.0 Salmonella gastroenteritis
003.1 Salmonella septicemia
003.20 Localized salmonella infection, unspecified
003.21 Salmonella meningitis
003.22 Salmonella pneumonia
003.23 Salmonella arthritis
003.24 Salmonella osteomyelitis
003.29 Other localized salmonella infection
003.8 Other specified salmonella infections
003.9 Salmonella infection, unspecified
006.0 Acute amebic dysentery without abscess
006.1 Chronic intestinal amebiasis without abscess
006.2 Amebic nondysenteric colitis
006.3 Amebic liver abscess
006.4 Amebic lung abscess
006.5 Amebic brain abscess
006.6 Amebic skin ulceration


                                                                                                                       Page 41
NATIONAL COVERAGE DETERMINATION                                               Serum Iron Studies

006.8    Amebic infection of other sites
006.9    Amebiasis, unspecified
007.0    Food poisoning due to Balantidiasis
007.1    Food poisoning due to Giardiasis
007.2    Food poisoning due to Coccidiosis
007.3    Food poisoning due to intestinal trichomoniasis
007.4    Cryptosporidiosis
007.5    Cyclosporiasis
007.8    Food poisoning due to other specified protozoal intestinal diseases
007.9    Unspecified protozoal intestinal disease
008.00   Food poisoning due to E. coli, unspecified
008.01   Food poisoning due to enteropathogenic E. coli
008.02   Food poisoning due to enterotoxigenic E. coli
008.03   Food poisoning due to enteroinvasive E. coli
008.04   Food poisoning due to enterohemorrhagic E. coli
008.09   Food poisoning due to other intestinal E. coli infections
008.1    Food poisoning due to Arizona group of paracolon bacilli
008.2    Food poisoning due to Aerobacter aerogenes
008.3    Food poisoning due to Proteus (mirabilis) (morganii)
008.41   Food poisoning due to Staphylococcus
008.42   Food poisoning due to Pseudomonas
008.43   Food poisoning due to Campylobacter
008.44   Food poisoning due to Yersinia enterocolitica
008.45   Food poisoning due to Clostridium difficile
008.46   Food poisoning due to other anaerobes
008.47   Food poisoning due to other gram-negative bacteria
008.49   Food poisoning due to other specified bacteria
008.5    Bacterial enteritis, unspecified
008.61   Enteritis due to Rotavirus
008.62   Enteritis due to Adenovirus
008.63   Enteritis due to Norwalk virus
008.64   Enteritis due to other small round viruses [SRV's]
008.65   Enteritis due to Calcivirus
008.66   Enteritis due to Astrovirus
008.67   Enteritis due to enterovirus not elsewhere classified
008.69   Other viral enteritis
008.8    Enteritis due to other organism, not elsewhere classified
009.0    Infectious colitis, enteritis, and gastroenteritis
009.1    Colitis, enteritis, gastroenteritis of presumed infectious origin
009.2    Infectious diarrhea
009.3    Diarrhea of presumed infectious origin
011.50   Tuberculous bronchiectasis, unspecified
011.51   Tuberculous bronchiectasis, bacteriological or histological examination not done
011.52   Tuberculous bronchiectasis, bacteriological or histological examination unknown (at
         present)
011.53   Tuberculous bronchiectasis, tubercle bacilli found (in sputum) by microscopy
011.54   Tuberculous bronchiectasis, tubercle bacilli not found (in sputum) by microscopy, but
         found by bacterial culture
011.55   Tuberculous bronchiectasis, tubercle bacilli not found by bacteriological examination, but
         tuberculosis confirmed histologically
011.56   Tuberculous bronchiectasis, tubercle bacilli not found by bacteriological or histological
         examination, but tuberculosis confirmed by other methods
014.00   Tuberculous peritonitis, unspecified



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NATIONAL COVERAGE DETERMINATION                                                Serum Iron Studies

014.01   Tuberculous peritonitis, bacteriological or histological examination not done
014.02   Tuberculous peritonitis, bacteriological or histological examination unknown (at present)
014.03   Tuberculous peritonitis, tubercle bacilli found (in sputum) by microscopy
014.04   Tuberculous peritonitis, tubercle bacilli not found (in sputum) by microscopy, but found by
         bacterial culture
014.05   Tuberculous peritonitis, tubercle bacilli not found by bacteriological examination, but
         tuberculosis confirmed histologically
014.06   Tuberculous peritonitis, tubercle bacilli not found by bacteriological or histological
         examination, but tuberculosis confirmed by other methods
014.80   Other tuberculosis, unspecified
014.81   Other tuberculosis, bacteriological or histological examination not done
014.82   Other tuberculosis, bacteriological or histological examination unknown (at present)
014.83   Other tuberculosis, tubercle bacilli found (in sputum) by microscopy
014.84   Other tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found by
         bacterial culture
014.85   Other tuberculosis, tubercle bacilli not found by bacteriological examination, but
         tuberculosis confirmed histologically
014.86   Other tuberculosis, tubercle bacilli not found by bacteriological or histological
         examination, but tuberculosis confirmed by other methods
015.00   Tuberculosis, vertebral column, unspecified
015.01   Tuberculosis, vertebral column, bacteriological or histological exam not done
015.02   Tuberculosis, vertebral column, bacteriological or histological exam unknown (at present)
015.03   Tuberculosis, vertebral column, tubercle bacilli found (in sputum) by microscopy
015.04   Tuberculosis, Vertebral column, tubercle bacilli not found (in sputum) by microscopy, but
         found by bacterial culture
015.05   Tuberculosis, vertebral column, tubercle bacilli not found by bacteriological exam, but
         tuberculosis confirmed histologically
015.06   Tuberculosis, vertebral column, tubercle bacilli not found by bacteriological or histological
         exam, but tuberculosis confirmed by other methods
015.10   Tuberculosis, hip, unspecified
015.11   Tuberculosis, hip, bacteriological or histological exam not done
015.12   Tuberculosis, hip, bacteriological or histological exam unknown (at present)
015.13   Tuberculosis, hip, tubercle bacilli found (in sputum) by microscopy
015.14   Tuberculosis, hip, tubercle bacilli not found (in sputum) by microscopy, but found by
         bacterial culture
015.15   Tuberculosis, hip, tubercle bacilli not found by bacteriological exam, but tuberculosis
         confirmed histologically
015.16   Tuberculosis, hip, tubercle bacilli not found by bacteriological or histological exam, but
         tuberculosis confirmed by other methods
015.20   Tuberculosis, knee, unspecified
015.21   Tuberculosis, knee, bacteriological or histological exam not done
015.22   Tuberculosis, knee, bacteriological or histological exam unknown (at present)
015.23   Tuberculosis, knee, tubercle bacilli found (in sputum) by microscopy
015.24   Tuberculosis, knee, tubercle bacilli not found (in sputum) by microscopy, but found by
         bacterial culture
015.25   Tuberculosis, knee, tubercle bacilli not found by bacteriological exam, but tuberculosis
         confirmed histologically
015.26   Tuberculosis, knee, tubercle bacilli not found by bacteriological or histological exam, but
         tuberculosis confirmed by other methods
015.50   Tuberculosis, limb bones, unspecified
015.51   Tuberculosis, limb bones, bacteriological or histological exam not done
015.52   Tuberculosis, limb bones, bacteriological or histological exam unknown (at present)
015.53   Tuberculosis, limb bones, tubercle bacilli found (in sputum) by microscopy



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NATIONAL COVERAGE DETERMINATION                                              Serum Iron Studies

015.54 Tuberculosis, limb bones, tubercle bacilli not found (in sputum) by microscopy, but found
       by bacterial culture
015.55 Tuberculosis, limb bones, tubercle bacilli not found by bacteriological exam, but
       tuberculosis confirmed histologically
015.56 Tuberculosis, limb bones, tubercle bacilli not found by bacteriological or histological
       exam, but tuberculosis confirmed by other methods
015.60 Tuberculosis, mastoid, unspecified
015.61 Tuberculosis, mastoid, bacteriological or histological exam not done
015.62 Tuberculosis, mastoid, bacteriological or histological exam unknown (at present)
015.63 Tuberculosis, mastoid, tubercle bacilli found (in sputum) by microscopy
015.64 Tuberculosis, mastoid, tubercle bacilli not found (in sputum) by microscopy, but found by
       bacterial culture
015.65 Tuberculosis, mastoid, tubercle bacilli not found by bacteriological exam, but tuberculosis
       confirmed histologically
015.66 Tuberculosis, mastoid, tubercle bacilli not found by bacteriological or histological exam,
       but tuberculosis confirmed by other methods
015.70 Tuberculosis, other specified bone, unspecified
015.71 Tuberculosis, other specified bone, bacteriological or histological exam not done
015.72 Tuberculosis, other specified bone, bacteriological or histological examination unknown
       (at present)
015.73 Tuberculosis, other specified bone, tubercle bacilli found (in sputum) by microscopy
015.74 Tuberculosis, other specified bone, tubercle bacilli not found (in sputum) by microscopy,
       but found by bacterial culture
015.75 Tuberculosis, other specified bone, tubercle bacilli not found by bacteriological
       examination, but tuberculosis confirmed histologically
015.76 Tuberculosis, other specified bone, tubercle bacilli not found by bacteriological or
       histological examination, but tuberculosis confirmed by other methods
015.80 Tuberculosis, other specified joint, unspecified
015.81 Tuberculosis, other specified joint, bacteriological or histological examination not done
015.82 Tuberculosis, other specified joint, bacteriological or histological examination unknown (at
       present)
015.83 Tuberculosis, other specified joint, tubercle bacilli found (in sputum) by microscopy
015.84 Tuberculosis, other specified joint, tubercle bacilli not found (in sputum) by microscopy,
       but found by bacterial culture
015.85 Tuberculosis, other specified joint, tubercle bacilli not found by bacteriological
       examination, but tuberculosis confirmed histologically
015.86 Tuberculosis, other specified joint, tubercle bacilli not found by bacteriological or
       histological examination, but tuberculosis confirmed by other methods
015.90 Tuberculosis of unspecified bones and joints, unspecified
015.91 Tuberculosis of unspecified bones and joints, o bacteriological or histological examination
       not done
015.92 Tuberculosis of unspecified bones and joints, bacteriological or histological examination
       unknown (at present)
015.93 Tuberculosis of unspecified bones and joints, tubercle bacilli found (in sputum) by
       microscopy
015.94 Tuberculosis of unspecified bones and joints, tubercle bacilli not found (in sputum) by
       microscopy, but found by bacterial culture
015.95 Tuberculosis of unspecified bones and joints, tubercle bacilli not found by bacteriological
       examination, but tuberculosis confirmed histologically
015.96 Tuberculosis of unspecified bones and joints, tubercle bacilli not found by bacteriological
       or histological examination, but tuberculosis confirmed by other methods
016.00 Tuberculosis, kidney, unspecified
016.01 Tuberculosis, kidney, bacteriological or histological exam not done



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NATIONAL COVERAGE DETERMINATION                                               Serum Iron Studies

016.02 Tuberculosis, kidney, bacteriological or histological exam unknown (at present)
016.03 Tuberculosis, kidney, tubercle bacilli found (in sputum) by microscopy
016.04 Tuberculosis, kidney, tubercle bacilli not found (in sputum) by microscopy, but found by
       bacterial culture
016.05 Tuberculosis, kidney, tubercle bacilli not found by bacteriological exam, but tuberculosis
       confirmed histologically
016.06 Tuberculosis, kidney, tubercle bacilli not found by bacteriological or histological exam, but
       tuberculosis confirmed by other methods
016.10 Tuberculosis, bladder, unspecified
016.11 Tuberculosis, bladder, bacteriological or histological exam not done
016.12 Tuberculosis, bladder, bacteriological or histological exam unknown (at present)
016.13 Tuberculosis, bladder, tubercle bacilli found (in sputum) by microscopy
016.14 Tuberculosis, bladder, tubercle bacilli not found (in sputum) by microscopy, but found by
       bacterial culture
016.15 Tuberculosis, bladder, tubercle bacilli not found by bacteriological exam, but tuberculosis
       confirmed histologically
016.16 Tuberculosis, bladder, tubercle bacilli not found by bacteriological or histological exam,
       but tuberculosis confirmed by other methods
016.20 Tuberculosis, ureter, unspecified
016.21 Tuberculosis, ureter, bacteriological or histological exam not done
016.22 Tuberculosis, ureter, bacteriological or histological exam unknown (at present)
016.23 Tuberculosis, ureter, tubercle bacilli found (in sputum) by microscopy
016.24 Tuberculosis, ureter, tubercle bacilli not found (in sputum) by microscopy, but found by
       bacterial culture
016.25 Tuberculosis, ureter, tubercle bacilli not found by bacteriological exam, but tuberculosis
       confirmed histologically
016.26 Tuberculosis, ureter, tubercle bacilli not found by bacteriological or histological exam, but
       tuberculosis confirmed by other methods
016.30 Tuberculosis, other urinary organs, unspecified
016.31 Tuberculosis, Other urinary organs, bacteriological or histological exam not done
016.32 Tuberculosis, other urinary organs, bacteriological or histological exam unknown (at
       present)
016.33 Tuberculosis, other urinary organs, tubercle bacilli found (in sputum) by microscopy
016.34 Tuberculosis, other urinary organs, tubercle bacilli not found (in sputum) by microscopy,
       but found by bacterial culture
016.35 Tuberculosis, other urinary organs, tubercle bacilli not found by bacteriological exam, but
       tuberculosis confirmed histologically
016.36 Tuberculosis, other urinary organs, tubercle bacilli not found by bacteriological or
       histological exam, but tuberculosis confirmed by other methods
042    Human immunodeficiency virus [HIV] disease
070.0 Viral hepatitis A with hepatic coma
070.1 Viral hepatitis A without hepatic coma
070.20 Viral hepatitis B with hepatic coma, acute or unspecified, without hepatitis delta
070.21 Viral hepatitis B with hepatic coma, acute or unspecified, with hepatitis delta
070.22 Viral hepatitis B with hepatic coma, chronic, without hepatitis delta
070.23 Viral hepatitis B with hepatic coma, chronic, with hepatitis delta
070.30 Viral hepatitis B without hepatic coma, acute or unspecified, without hepatitis delta
070.31 Viral hepatitis B without hepatic coma, acute or unspecified, with hepatitis delta
070.32 Viral hepatitis B without hepatic coma, chronic, without hepatitis delta
070.33 Viral hepatitis B without hepatic coma, chronic, with hepatitis delta
070.41 Acute hepatitis C with hepatic coma
070.42 Hepatitis delta without active hepatitis B disease with hepatic coma
070.43 Hepatitis E with hepatic coma



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NATIONAL COVERAGE DETERMINATION                                                Serum Iron Studies

070.44   Chronic hepatitis C with hepatic coma
070.49   Other specified viral hepatitis with hepatic coma
070.51   Acute hepatitis C without mention of hepatic coma
070.52   Hepatitis delta without active hepatitis B disease or hepatic coma
070.53   Hepatitis E without hepatic coma
070.54   Chronic hepatitis C without hepatic coma
070.59   Other specified viral hepatitis without hepatic coma
070.6    Unspecified viral hepatitis with hepatic coma
070.70   Unspecified viral hepatitis C without hepatic coma
070.71   Unspecified viral hepatitis C with hepatic coma
070.9    Unspecified viral hepatitis without hepatic coma
140.0    Malignant neoplasm, upper lip, vermilion border
140.1    Malignant neoplasm, lower lip, vermilion border
140.3    Malignant neoplasm, upper lip, inner aspect
140.4    Malignant neoplasm, lower lip, inner aspect
140.5    Malignant neoplasm, lip, unspecified, inner aspect
140.6    Malignant neoplasm, commissure of lip
140.8    Malignant neoplasm, other sites of lip
140.9    Malignant neoplasm, lip, unspecified, vermilion border
141.0    Malignant neoplasm, base of tongue
141.1    Malignant neoplasm, dorsal surface of tongue
141.2    Malignant neoplasm, tip and lateral border of tongue
141.3    Malignant neoplasm, ventral surface of tongue
141.4    Malignant neoplasm, anterior two-thirds of tongue, part unspecified
141.5    Malignant neoplasm, junctional zone of tongue
141.6    Malignant neoplasm, lingual tonsil
141.8    Malignant neoplasm, other sites of tongue
141.9    Malignant neoplasm, tongue, unspecified
142.0    Malignant neoplasm, parotid gland
142.1    Malignant neoplasm, submandibular gland
142.2    Malignant neoplasm, sublingual gland
142.8    Malignant neoplasm, other major salivary glands
142.9    Malignant neoplasm, salivary gland, unspecified
143.0    Malignant neoplasm, upper gum
143.1    Malignant neoplasm, lower gum
143.8    Malignant neoplasm, other sites of gum
143.9    Malignant neoplasm, gum, unspecified
144.0    Malignant neoplasm of floor of mouth Anterior portion
144.1    Malignant neoplasm of floor of mouth Lateral portion
144.8    Malignant neoplasm, other sites of floor of mouth
144.9    Malignant neoplasm, floor of mouth, part unspecified
145.0    Malignant neoplasm, cheek mucosa
145.1    Malignant neoplasm, vestibule of mouth
145.2    Malignant neoplasm, hard palate
145.3    Malignant neoplasm, soft palate
145.4    Malignant neoplasm, uvula
145.5    Malignant neoplasm, palate, unspecified
145.6    Malignant neoplasm, retromolar area
145.8    Malignant neoplasm, other specified parts of mouth
145.9    Malignant neoplasm, mouth, unspecified
146.0    Malignant neoplasm, tonsil
146.1    Malignant neoplasm, tonsillar fossa
146.2    Malignant neoplasm, tonsillar pillars (anterior) (posterior)



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NATIONAL COVERAGE DETERMINATION                                             Serum Iron Studies

146.3   Malignant neoplasm, vallecula
146.4   Malignant neoplasm, anterior aspect of epiglottis
146.5   Malignant neoplasm, junction of the free margin of the
146.6   Malignant neoplasm, lateral wall of oropharynx
146.7   Malignant neoplasm, posterior wall of oropharynx
146.8   Malignant neoplasm, other specified sites of oropharynx
146.9   Malignant neoplasm, oropharynx, unspecified
147.0   Malignant neoplasm, superior wall of nasopharynx
147.1   Malignant neoplasm, posterior wall of nasopharynx
147.2   Malignant neoplasm, lateral wall of nasopharynx
147.3   Malignant neoplasm, anterior wall of nasopharynx
147.8   Malignant neoplasm, other specified sites of nasopharynx
147.9   Malignant neoplasm, nasopharynx, unspecified
148.0   Malignant neoplasm, postcricoid region
148.1   Malignant neoplasm, pyriform sinus
148.2   Malignant neoplasm, aryepiglottic fold, hypopharyngeal aspect
148.3   Malignant neoplasm, posterior hypopharyngeal wall
148.8   Malignant neoplasm, other specified sites of hypopharynx
148.9   Malignant neoplasm, hypopharynx, unspecified
149.0   Malignant neoplasm, pharynx, unspecified
149.1   Malignant neoplasm, Waldeyer's ring
149.8   Malignant neoplasm, other
149.9   Malignant neoplasm, lip, oral cavity, phyarynx, ill-defined sites
150.0   Malignant neoplasm of cervical esophagus
150.1   Malignant neoplasm of thoracic esophagus
150.2   Malignant neoplasm of abdominal esophagus
150.3   Malignant neoplasm of uUpper third of esophagus
150.4   Malignant neoplasm of middle third of esophagus
150.5   Malignant neoplasm of lower third of esophagus
150.8   Malignant neoplasm of other specified part of esophagus
150.9   Malignant neoplasm of esophagus, unspecified
151.0   Malignant neoplasm of cardia
151.1   Malignant neoplasm of pylorus
151.2   Malignant neoplasm of pyloric antrum
151.3   Malignant neoplasm of fundus of stomach
151.4   Malignant neoplasm of body of stomach
151.5   Malignant neoplasm of lesser curvature, unspecified
151.6   Malignant neoplasm of greater curvature of stomach, unspecified
151.8   Malignant neoplasm of other specified sites of stomach
151.9   Malignant neoplasm of stomach, unspecified
152.0   Malignant neoplasm of duodenum
152.1   Malignant neoplasm of jejunum
152.2   Malignant neoplasm of ileum
152.3   Malignant neoplasm of meckel's diverticulum
152.8   Malignant neoplasm of other specified sites of small intestine
152.9   Malignant neoplasm of small intestine, unspecified
153.0   Malignant neoplasm of hepatic flexure of colon
153.1   Malignant neoplasm, transverse colon
153.2   Malignant neoplasm, descending colon
153.3   Malignant neoplasm, sigmoid colon
153.4   Malignant neoplasm, cecum
153.5   Malignant neoplasm, appendix
153.6   Malignant neoplasm, ascending colon



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153.7   Malignant neoplasm, splenic flexure
153.8   Malignant neoplasm, other specified sites of large intestine
153.9   Malignant neoplasm, colon, unspecified
154.0   Malignant neoplasm, rectosigmoid junction
154.1   Malignant neoplasm, rectum
154.2   Malignant neoplasm, anal canal
154.3   Malignant neoplasm, anus, unspecified
154.8   Malignant neoplasm, other
155.0   Malignant neoplasm, liver, primary
155.1   Malignant neoplasm, intrahepatic bile ducts
155.2   Malignant neoplasm, liver, not specified as primary or
156.0   Malignant neoplasm, gallbladder
156.1   Malignant neoplasm, extrahepatic bile ducts
156.2   Malignant neoplasm, ampulla of Vater
156.8   Malignant neoplasm, other specified sites of gallbladder
156.9   Malignant neoplasm, biliary tract, part unspecified
157.0   Malignant neoplasm, head of pancreas
157.1   Malignant neoplasm, body of pancreas
157.2   Malignant neoplasm, tail of pancreas
157.3   Malignant neoplasm, pancreatic duct
157.4   Malignant neoplasm, islets of Langerhans
157.8   Malignant neoplasm, other specified sites of pancreas
157.9   Malignant neoplasm, pancreas, part unspecified
158.0   Malignant neoplasm, retroperitoneum
158.8   Malignant neoplasm, specified parts of peritoneum
158.9   Malignant neoplasm, peritoneum, unspecified
159.0   Malignant neoplasm, intestinal tract, part unspecified
159.1   Malignant neoplasm, spleen, not elsewhere classified
159.8   Malignant neoplasm, other sites of digestive system
159.9   Malignant neoplasm, ill-defined sites of digestive system
160.0   Malignant neoplasm of nasal cavities
160.1   Malignant neoplasm of auditory tube, middle ear, and mastoid air cells
160.2   Malignant neoplasm of maxillary sinus
160.3   Malignant neoplasm of ethmoidal sinus
160.4   Malignant neoplasm of frontal sinus
160.5   Malignant neoplasm of sphenoidal sinus
160.8   Malignant neoplasm of other
160.9   Malignant neoplasm of accessory sinus, unspecified
161.0   Malignant neoplasm of glottis
161.1   Malignant neoplasm of supraglottis
161.2   Malignant neoplasm of subglottis
161.3   Malignant neoplasm of laryngeal cartilages
161.8   Malignant neoplasm of other specified sites of larynx
161.9   Malignant neoplasm of larynx, unspecified
162.0   Malignant neoplasm of trachea
162.2   Malignant neoplasm of main bronchus
162.3   Malignant neoplasm of upper lobe, bronchus or lung
162.4   Malignant neoplasm of middle lobe, bronchus or lung
162.5   Malignant neoplasm of lower lobe, bronchus or lung
162.8   Malignant neoplasm of other parts of bronchus or lung
162.9   Malignant neoplasm of bronchus and lung, unspecified
163.0   Malignant neoplasm of parietal pleura
163.1   Malignant neoplasm of visceral pleura



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163.8   Malignant neoplasm of other specified sites of pleura
163.9   Malignant neoplasm of pleura, unspecified
164.0   Malignant neoplasm of thymus
164.1   Malignant neoplasm of heart
164.2   Malignant neoplasm of anterior mediastinum
164.3   Malignant neoplasm of posterior mediastinum
164.8   Other malignant neoplasm of thymus, heart, and mediastinum
164.9   Malignant neoplasm of mediastinum, part unspecified
165.0   Malignant neoplasm of upper respiratory tract, part unspecified
165.8   Malignant neoplasm of other part of thymus, heart, and mediastinum
165.9   Malignant neoplasm of ill-defined sites within the respiratory system
170.0   Malignant neoplasm of bones of skull and face, except
170.1   Malignant neoplasm of mandible
170.2   Malignant neoplasm of vertebral column, excluding sacrum
170.3   Malignant neoplasm of ribs, sternum, and clavicle
170.4   Malignant neoplasm of scapula and long bones of upper
170.5   Malignant neoplasm of short bones of upper limb
170.6   Malignant neoplasm of pelvic bones, sacrum, and coccyx
170.7   Malignant neoplasm of long bones of lower limb
170.8   Malignant neoplasm of short bones of lower limb
170.9   Malignant neoplasm of bone and articular cartilage, site
171.0   Malignant neoplasm of head, face, and neck
171.2   Malignant neoplasm of upper limb, including shoulder
171.3   Malignant neoplasm of lower limb, including hip
171.4   Malignant neoplasm of thorax
171.5   Malignant neoplasm of abdomen
171.6   Malignant neoplasm of pelvis
171.7   Malignant neoplasm of trunk, unspecified
171.8   Malignant neoplasm of connective/soft tissue, other sites
171.9   Malignant neoplasm of connective and other soft tissue,
172.0   Malignant neoplasm of lip
172.1   Malignant neoplasm of eyelid, including canthus
172.2   Malignant neoplasm of ear and external auditory canal
172.3   Malignant neoplasm of other and unspecified parts of face
172.4   Malignant melanoma of skin, scalp and neck
172.5   Malignant melanoma of skin, trunk, except scrotum
172.6   Malignant neoplasm of upper limb, including shoulder
172.7   Malignant neoplasm of lower limb, including hip
172.8   Malignant neoplasm of other specified sites of skin
172.9   Malignant neoplasm of melanoma of skin, site unspecified
173.0   Malignant neoplasm of skin of lip
173.1   Malignant neoplasm of eyelid, including canthus
173.2   Malignant neoplasm of skin of ear and external auditory
173.3   Malignant neoplasm of skin of other and unspecified parts
173.4   Malignant neoplasm of scalp and skin of neck
173.5   Malignant neoplasm of skin of trunk, except scrotum
173.6   Malignant neoplasm of skin of upper limb, including
173.7   Skin of lower limb, including hip
173.8   Malignant neoplasm of other specified sites of skin
173.9   Malignant neoplasm of skin, site unspecified
174.0   Malignant neoplasm of nipple and areola of female breast
174.1   Malignant neoplasm of central portion of breast
174.2   Upper-inner quadrant of female breast



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174.3   Lower-inner quadrant of female breast
174.4   Upper-outer quadrant of female breast
174.5   Lower-outer quadrant of female breast
174.6   Axillary tail of female breast
174.8   Other specified sites of female breast
174.9   Malignant neoplasm of breast (female), unspecified
175.0   Malignant neoplasm of nipple and areola of male breast
175.9   Malignant neoplasm, other and unspecified sites of male breast
176.0   Kaposi's sarcoma skin
176.1   Kaposi's sarcoma soft tissue
176.2   Kaposi's sarcoma, palate
176.3   Kaposi's sarcoma, gastrointestinal sites
176.4   Kaposi's sarcoma, lung
176.5   Kaposi's sarcoma, lymph nodes
176.8   Kaposi's sarcoma, other specified sites
176.9   Kaposi's sarcoma, unspecified
179     Malignant neoplasm of uterus, part unspecified
180.0   Malignant neoplasm of endocervix
180.1   Malignant neoplasm of exocervix
180.8   Malignant neoplasm of other specified sites of cervix
180.9   Malignant neoplasm of cervix uteri, unspecified
181     Malignant neoplasm of placenta
182.0   Malignant neoplasm of corpus uteri, except isthmus
182.1   Malignant neoplasm of uterus, isthmus
182.8   Malignant neoplasm, other specified sites, body of uterus
183.0   Malignant neoplasm of ovary
183.2   Malignant neoplasm of fallopian tube
183.3   Malignant neoplasm of broad ligament
183.4   Malignant neoplasm of parametrium
183.5   Malignant neoplasm of round ligament
183.8   Malignant neoplasm of other specified sites of uterine adnexa
183.9   Malignant neoplasm of uterine adnexa, unspecified
184.0   Malignant neoplasm of vagina
184.1   Malignant neoplasm of labia majora
184.2   Malignant neoplasm of labia minora
184.3   Malignant neoplasm of clitoris
184.4   Malignant neoplasm of vulva, unspecified
184.8   Malignant neoplasm of other specified sites of female genital organs
184.9   Malignant neoplasm of female genital organ, site unspecified
185     Malignant neoplasm of prostate
186.0   Malignant neoplasm of undescended testis
186.9   Malignant neoplasm of other and unspecified testis
187.1   Malignant neoplasm of prepuce
187.2   Malignant neoplasm of glans penis
187.3   Malignant neoplasm of body of penis
187.4   Malignant neoplasm of penis, part unspecified
187.5   Malignant neoplasm of epididymis
187.6   Malignant neoplasm of spermatic cord
187.7   Malignant neoplasm of scrotum
187.8   Malignant neoplasm of other specified sites of male genital organs
187.9   Malignant neoplasm of male genital organ, site unspecified
188.0   Malignant neoplasm of trigone of urinary bladder
188.1   Malignant neoplasm of dome of urinary bladder



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188.2   Malignant neoplasm of lateral wall of urinary bladder
188.3   Malignant neoplasm, anterior wall of urinary bladder
188.4   Malignant neoplasm, posterior wall of urinary bladder
188.5   Malignant neoplasm of bladder neck
188.6   Malignant neoplasm of ureteric orifice
188.7   Malignant neoplasm of urachus
188.8   Malignant neoplasm of other specified sites of bladder
188.9   Malignant neoplasm of bladder, part unspecified
189.0   Malignant neoplasm of kidney, except pelvis
189.1   Malignant neoplasm of renal pelvis
189.2   Malignant neoplasm of ureter
189.3   Malignant neoplasm of urethra
189.4   Malignant neoplasm of paraurethral glands
189.8   Malignant neoplasm of other specified sites of urinary organs
189.9   Malignant neoplasm of urinary organ, site unspecified
190.0   Malignant neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid
190.1   Malignant neoplasm of orbit
190.2   Malignant neoplasm of lacrimal gland
190.3   Malignant neoplasm of conjunctiva
190.4   Malignant neoplasm of cornea
190.5   Malignant neoplasm of retina
190.6   Malignant neoplasm of choroid
190.7   Malignant neoplasm of lacrimal duct
190.8   Malignant neoplasm of other specified sites of eye
190.9   Malignant neoplasm of eye, part unspecified
191.0   Malignant neoplasm of cerebrum, except lobes and ventricles
191.1   Malignant neoplasm of frontal lobe of brain
191.2   Malignant neoplasm of temporal lobe of brain
191.3   Malignant neoplasm of parietal lobe
191.4   Malignant neoplasm of occipital lobe
191.5   Malignant neoplasm of ventricles of brain
191.6   Malignant neoplasm of cerebellum not otherwise specified
191.7   Malignant neoplasm of brain stem
191.8   Malignant neoplasm of other parts of brain
191.9   Malignant neoplasm of brain, unspecified
192.0   Malignant neoplasm of cranial nerves
192.1   Malignant neoplasm of cerebral meninges
192.2   Malignant neoplasm of spinal cord
192.3   Malignant neoplasm of spinal meninges
192.8   Malignant neoplasm of other specified sites of nervous system
192.9   Malignant neoplasm of nervous system, part unspecified
193     Malignant neoplasm of thyroid gland
194.0   Malignant neoplasm of adrenal gland
194.1   Malignant neoplasm of parathyroid gland
194.3   Malignant neoplasm of pituitary gland and craniopharyngeal duct
194.4   Malignant neoplasm of pineal gland
194.5   Malignant neoplasm of carotid body
194.6   Malignant neoplasm of aortic body and other paraganglia
194.8   Malignant neoplasm of other endocrine gland
194.9   Malignant neoplasm of endocrine gland, site unspecified
195.0   Malignant neoplasm of head, face, and neck
195.1   Malignant neoplasm of thorax
195.2   Malignant neoplasm of abdomen



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195.3    Malignant neoplasm of pelvis
195.4    Malignant neoplasm of upper limb
195.5    Malignant neoplasm of lower limb
195.8    Malignant neoplasm of other specified sites
196.0    Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck
196.1    Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes
196.2    Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
196.3    Secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb
196.5    Secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and
         lower limb
196.6    Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes
196.8    Secondary and unspecified malignant neoplasm, lymph nodes of multiple sites
196.9    Secondary and unspecified malignant neoplasm, site unspecified
197.0    Secondary malignant neoplasm of lung
197.1    Secondary malignant neoplasm of mediastinum
197.2    Secondary malignant neoplasm of pleura
197.3    Secondary malignant neoplasm of other respiratory organs
197.4    Secondary malignant neoplasm of small intestine, including duodenum
197.5    Secondary malignant neoplasm of large intestine and rectum
197.6    Secondary malignant neoplasm of retroperitoneum and peritoneum
197.7    Secondary malignant neoplasm of liver, specified as secondary
197.8    Secondary malignant neoplasm of other digestive organs and spleen
198.0    Secondary malignant neoplasm of kidney
198.1    Secondary malignant neoplasm of other urinary organs
198.2    Secondary malignant neoplasm of skin
198.3    Secondary malignant neoplasm of brain and spinal cord
198.4    Secondary malignant neoplasm of other parts of nervous system
198.5    Secondary malignant neoplasm of bone and bone marrow
198.6    Secondary malignant neoplasm of ovary
198.7    Secondary malignant neoplasm of adrenal gland
198.81   Secondary malignant neoplasm of breast
198.82   Secondary malignant neoplasm of genital organs
198.89   Secondary malignant neoplasm of other sites
199.0    Malignant neoplasm without specification of site, Disseminated
199.1    Malignant neoplasm without specification of site, other
200.00   Reticulosarcoma, unspecified site, extranodal and solid organ sites
200.01   Reticulosarcoma of lymph nodes of head, face, and neck
200.02   Reticulosarcoma of intrathoracic lymph nodes
200.03   Reticulosarcoma of intra-abdominal lymph nodes
200.04   Reticulosarcoma of lymph nodes of axilla and upper limb
200.05   Reticulosarcoma of lymph nodes of inguinal region and lower limb
200.06   Reticulosarcoma of intrapelvic lymph nodes
200.07   Reticulosarcoma of spleen
200.08   Reticulosarcoma, lymph nodes of multiple sites
200.10   Lymphosarcoma, unspecified site, extranodal and solid organ sites
200.11   Lymphosarcoma of lymph nodes of head, face, and neck
200.12   Lymphosarcoma of intrathoracic lymph nodes
200.13   Lymphosarcoma of intra-abdominal lymph nodes
200.14   Lymphosarcoma of lymph nodes of axilla and upper limb
200.15   Lymphosarcoma of lymph nodes of inguinal region and lower limb
200.16   Lymphosarcoma of intrapelvic lymph nodes
200.17   Lymphosarcoma of spleen
200.18   Lymphosarcoma, lymph nodes of multiple sites



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200.20   Burkitt's tumor or lymphoma, unspecified site, extranodal and solid organ sites
200.21   Burkitt's tumor or lymphoma of lymph nodes of head, face, and neck
200.22   Burkitt's tumor or lymphoma of intrathoracic lymph nodes
200.23   Burkitt's tumor or lymphoma of intra-abdominal lymph nodes
200.24   Burkitt's tumor or lymphoma of lymph nodes of axilla and upper limb
200.25   Burkitt's tumor or lymphoma of lymph nodes of inguinal region and lower limb
200.26   Burkitt's tumor or lymphoma of intrapelvic lymph nodes
200.27   Burkitt's tumor or lymphoma of spleen
200.28   Burkitt's tumor or lymphoma, lymph nodes of multiple sites
200.30   Marginal zone lymphoma, unspecified site, extranodal and solid organ sites
200.31   Marginal zone lymphoma, lymph nodes of head, face, and neck
200.32   Marginal zone lymphoma, intrathoracic lymph nodes
200.33   Marginal zone lymphoma, intraabdominal lymph nodes
200.34   Marginal zone lymphoma, lymph nodes of axilla and upper limb
200.35   Marginal zone lymphoma, lymph nodes of inguinal region and lower limb
200.36   Marginal zone lymphoma, intrapelvic lymph nodes
200.37   Marginal zone lymphoma, spleen
200.38   Marginal zone lymphoma, lymph nodes of multiple sites
200.40   Mantle cell lymphoma, unspecified site, extranodal and solid organ sites
200.41   Mantle cell lymphoma, lymph nodes of head, face, and neck
200.42   Mantle cell lymphoma, intrathoracic lymph nodes
200.43   Mantle cell lymphoma, intra-abdominal lymph nodes
200.44   Mantle cell lymphoma, lymph nodes of axilla and upper limb
200.45   Mantle cell lymphoma, lymph nodes of inguinal region and lower limb
200.46   Mantle cell lymphoma, intrapelvic lymph nodes
200.47   Mantle cell lymphoma, spleen
200.48   Mantle cell lymphoma, lymph nodes of multiple sites
200.50   Primary central nervous system lymphoma, unspecified site, extranodal and solid organ
         sites
200.51   Primary central nervous system lymphoma, lymph nodes of head, face, and neck
200.52   Primary central nervous system lymphoma, intrathoracic lymph nodes
200.53   Primary central nervous system lymphoma, intra-abdominal lymph nodes
200.54   Primary central nervous system lymphoma, lymph nodes of axilla and upper limb
200.55   Primary central nervous system lymphoma, lymph nodes of inguinal region and lower
         limb
200.56   Primary central nervous system lymphoma, intrapelvic lymph nodes
200.57   Primary central nervous system lymphoma, spleen
200.58   Primary central nervous system lymphoma, lymph nodes of multiple sites
200.60   Anaplastic large cell lymphoma, unspecified site, extranodal and solid organ sites
200.61   Anaplastic large cell lymphoma, lymph nodes of head, face, and neck
200.62   Anaplastic large cell lymphoma, intrathoracic lymph nodes
200.63   Anaplastic large cell lymphoma, intra-abdominal lymph nodes
200.64   Anaplastic large cell lymphoma, lymph nodes of axilla and upper limb
200.65   Anaplastic large cell lymphoma, lymph nodes of inguinal region and lower limb
200.66   Anaplastic large cell lymphoma, intrapelvic lymph nodes
200.67   Anaplastic large cell lymphoma, spleen
200.68   Anaplastic large cell lymphoma, lymph nodes of multiple sites
200.70   Large cell lymphoma, unspecified site, extranodal and solid organ sites
200.71   Large cell lymphoma, lymph nodes of head, face, and neck
200.72   Large cell lymphoma, intrathoracic lymph nodes
200.73   Large cell lymphoma, intra-abdominal lymph nodes
200.74   Large cell lymphoma, lymph nodes of axilla and upper limb
200.75   Large cell lymphoma, lymph nodes of inguinal region and lower limb



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200.76   Large cell lymphoma, intrapelvic lymph nodes
200.77   Large cell lymphoma, spleen
200.78   Large cell lymphoma, lymph nodes of multiple sites
200.80   Other named variants of lymphosarcoma and reticulosarcoma, unspecified site,
         extranodal and solid organ sites
200.81   Other named variants of lymphosarcoma and reticulosarcoma of lymph nodes of head,
         face, and neck
200.82   Other named variants of lymphosarcoma and reticulosarcoma of intrathoracic lymph
         nodes
200.83   Other named variants of lymphosarcoma and reticulosarcoma of intra-abdominal lymph
         nodes
200.84   Other named variants of lymphosarcoma and reticulosarcoma of lymph nodes of axilla
         and upper limb
200.85   Other named variants of lymphosarcoma and reticulosarcoma of lymph nodes of inguinal
         region and lower limb
200.86   Other named variants of lymphosarcoma and reticulosarcoma of intrapelvic lymph nodes
200.87   Other named variants of lymphosarcoma and reticulosarcoma of spleen
200.88   Other named variants of lymphosarcoma and reticulosarcoma of lymph nodes, multiple
         sites
201.00   Hodgkin's paragranuloma, unspecified site, extranodal and solid organ sites
201.01   Hodgkin's paragranuloma of lymph nodes of head, face, and neck
201.02   Hodgkin's paragranuloma of intrathoracic lymph nodes
201.03   Hodgkin's paragranuloma of intra-abdominal lymph nodes
201.04   Hodgkin's paragranuloma of lymph nodes of axilla and upper limb
201.05   Hodgkin's paragranuloma of lymph nodes of inguinal region and lower limb
201.06   Hodgkin's paragranuloma of intrapelvic lymph nodes
201.07   Hodgkin's paragranuloma of spleen
201.08   Hodgkin's paragranuloma, lymph nodes at multiple sites
201.10   Hodgkin's granuloma, unspecified site, extranodal and solid organ sites
201.11   Hodgkin's granuloma of lymph nodes of head, face, and neck
201.12   Hodgkin's granuloma of intrathoracic lymph nodes
201.13   Hodgkin's granuloma of intra-abdominal lymph nodes
201.14   Hodgkin's granuloma of lymph nodes of axilla and upper limb
201.15   Hodgkin's granuloma of lymph nodes of inguinal region and lower limb
201.16   Hodgkin's granuloma of intrapelvic lymph nodes
201.17   Hodgkin's granuloma of spleen
201.18   Hodgkin's granuloma of lymph nodes at multiple sites
201.20   Hodgkin's sarcoma, unspecified site, extranodal and solid organ sites
201.21   Hodgkin's sarcoma of lymph nodes of head, face, and neck
201.22   Hodgkin's sarcoma of intrathoracic lymph nodes
201.23   Hodgkin's sarcoma of intra-abdominal lymph nodes
201.24   Hodgkin's sarcoma of lymph nodes of axilla and upper limb
201.25   Hodgkin's sarcoma of lymph nodes of inguinal region and lower limb
201.26   Hodgkin's sarcoma of intrapelvic lymph nodes
201.27   Hodgkin's sarcoma of spleen
201.28   Hodgkin's sarcoma of lymph nodes, multiple sites
201.40   Hodgkin's disease, lymphocytic-histiocytic predominance, unspecified site, extranodal
         and solid organ sites
201.41   Hodgkin's disease, lymphocytic-histiocytic predominance, lymph nodes of head, face,
         and neck
201.42   Hodgkin's disease, lymphocytic-histiocytic predominance, intrathoracic lymph nodes
201.43   Hodgkin's disease, lymphocytic-histiocytic predominance, intra-abdominal lymph nodes




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201.44 Hodgkin's disease, lymphocytic-histiocytic predominance, lymph nodes of axilla and
       upper limb
201.45 Hodgkin's disease, lymphocytic-histiocytic predominance, lymph nodes of inguinal region
       and lower limb
201.46 Hodgkin's disease, lymphocytic-histiocytic predominance, intrapelvic lymph nodes
201.47 Hodgkin's disease, lymphocytic-histiocytic predominance, spleen
201.48 Hodgkin's disease, lymphocytic-histiocytic predominance, lymph nodes of multiple sites
201.50 Hodgkin's disease, nodular sclerosis, unspecified site, extranodal and solid organ sites
201.51 Hodgkin's disease, nodular sclerosis lymph nodes of head, face, and neck
201.52 Hodgkin's disease, nodular sclerosis of intrathoracic lymph nodes
201.53 Hodgkin's disease, nodular sclerosis of intra-abdominal lymph nodes
201.54 Hodgkin's disease, nodular sclerosis of lymph nodes of axilla and upper limb
201.55 Hodgkin's disease, nodular sclerosis of lymph nodes of inguinal region and lower limb
201.56 Hodgkin's disease, nodular sclerosis of intrapelvic lymph nodes
201.57 Hodgkin's disease, nodular sclerosis of spleen
201.58 Hodgkin's disease, nodular sclerosis of lymph nodes of multiple sites
201.60 Hodgkin's disease, mixed cellularity, unspecified site, extranodal and solid organ sites
201.61 Hodgkin's disease, mixed cellularity of lymph nodes of head, face, and neck
201.62 Hodgkin's disease, mixed cellularity of intrathoracic lymph nodes
201.63 Hodgkin's disease, mixed cellularity of intra-abdominal lymph nodes
201.64 Hodgkin's disease, mixed cellularity of lymph nodes of axilla and upper limb
201.65 Hodgkin's disease, mixed cellularity of lymph nodes of inguinal region and lower limb
201.66 Hodgkin's disease, mixed cellularity of intrapelvic lymph nodes
201.67 Hodgkin's disease, mixed cellularity of spleen
201.68 Hodgkin's disease, mixed cellularity, lymph nodes of multiple sites
201.70 Hodgkin's disease, lymphocytic depletion, unspecified site, extranodal and solid organ
       sites
201.71 Hodgkin's disease, lymphocytic depletion, lymph nodes of head, face, and neck
201.72 Hodgkin's disease, lymphocytic depletion, intrathoracic lymph nodes
201.73 Hodgkin's disease, lymphocytic depletion, intra-abdominal lymph nodes
201.74 Hodgkin's disease, lymphocytic depletion, lymph nodes of axilla and upper limb
201.75 Hodgkin's disease, lymphocytic depletion, lymph nodes of inguinal region and lower limb
201.76 Hodgkin's disease, lymphocytic depletion, intrapelvic lymph nodes
201.77 Hodgkin's disease, lymphocytic depletion, spleen
201.78 Hodgkin's disease, lymphocytic depletion, lymph nodes of multiple sites
201.90 Unspecified Hodgkin's disease, unspecified site, extranodal and solid organ sites
201.91 Hodgkin's disease, unspecified lymph nodes of head, face, and neck
201.92 Hodgkin's disease, unspecified intrathoracic lymph nodes
201.93 Hodgkin's disease, unspecified intra-abdominal lymph nodes
201.94 Hodgkin's disease, unspecified lymph nodes of axilla and upper limb
201.95 Hodgkin's disease, unspecified lymph nodes of inguinal region and lower limb
201.96 Hodgkin's disease, unspecified intrapelvic lymph nodes
201.97 Hodgkin's disease, unspecified spleen
201.98 Hodgkin's disease, unspecified lymph nodes of multiple sites
202.00 Nodular lymphoma, unspecified site, extranodal and solid organ sites
202.01 Nodular lymphoma, lymph nodes of head, face, and neck
202.02 Nodular lymphoma, intrathoracic lymph nodes
202.03 Nodular lymphoma, intra-abdominal lymph nodes
202.04 Nodular lymphoma, lymph nodes of axilla and upper limb
202.05 Nodular lymphoma, lymph nodes of inguinal region and lower limb
202.06 Nodular lymphoma, intrapelvic lymph nodes
202.07 Nodular lymphoma, spleen
202.08 Nodular lymphoma, lymph nodes of multiple sites



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202.10   Mycosis fungoides, unspecified site, extranodal and solid organ sites
202.11   Mycosis fungoides, lymph nodes of head, face, and neck
202.12   Mycosis fungoides, intrathoracic lymph nodes
202.13   Mycosis fungoides, intra-abdominal lymph nodes
202.14   Mycosis fungoides, lymph nodes of axilla and upper limb
202.15   Mycosis fungoides, lymph nodes of inguinal region and lower limb
202.16   Mycosis fungoides, intrapelvic lymph nodes
202.17   Mycosis fungoides, spleen
202.18   Mycosis fungoides, lymph nodes of multiple sites
202.20   Sézary's disease, unspecified site, extranodal and solid organ sites
202.21   Sézary's disease, lymph nodes of head, face, and neck
202.22   Sézary's disease, intrathoracic lymph nodes
202.23   Sézary's disease, intra-abdominal lymph nodes
202.24   Sézary's disease, lymph nodes of axilla and upper limb
202.25   Sézary's disease, lymph nodes of inguinal region and lower limb
202.26   Sézary's disease, intrapelvic lymph nodes
202.27   Sézary's disease, spleen
202.28   Sézary's disease, lymph nodes of multiple sites
202.30   Malignant histiocytosis, unspecified site, extranodal and solid organ sites
202.31   Malignant histiocytosis, lymph nodes of head, face, and neck
202.32   Malignant histiocytosis, intrathoracic lymph nodes
202.33   Malignant histiocytosis, intra-abdominal lymph nodes
202.34   Malignant histiocytosis, lymph nodes of axilla and upper limb
202.35   Malignant histiocytosis, lymph nodes of inguinal region and lower limb
202.36   Malignant histiocytosis, intrapelvic lymph nodes
202.37   Malignant histiocytosis, spleen
202.38   Malignant histiocytosis, lymph nodes of multiple sites
202.40   Leukemic reticuloendotheliosis, unspecified site, extranodal and solid organ sites
202.41   Leukemic reticuloendotheliosis, lymph nodes of head, face, and neck
202.42   Leukemic reticuloendotheliosis, intrathoracic lymph nodes
202.43   Leukemic reticuloendotheliosis, intra-abdominal lymph nodes
202.44   Leukemic reticuloendotheliosis, lymph nodes of axilla and upper limb
202.45   Leukemic reticuloendotheliosis, lymph nodes of inguinal region and lower limb
202.46   Leukemic reticuloendotheliosis, intrapelvic lymph nodes
202.47   Leukemic reticuloendotheliosis, spleen
202.48   Leukemic reticuloendotheliosis, lymph nodes of multiple sites
202.50   Letterer-Siwe disease, unspecified site, extranodal and solid organ sites
202.51   Letterer-Siwe disease, lymph nodes of head, face, and neck
202.52   Letterer-Siwe disease, intrathoracic lymph nodes
202.53   Letterer-Siwe disease, intra-abdominal lymph nodes
202.54   Letterer-Siwe disease, lymph nodes of axilla and upper limb
202.55   Letterer-Siwe disease, lymph nodes of inguinal region and lower limb
202.56   Letterer-Siwe disease, intrapelvic lymph nodes
202.57   Letterer-Siwe disease, spleen
202.58   Letterer-Siwe disease, lymph nodes of multiple sites
202.60   Malignant mast cell tumors, unspecified site, extranodal and solid organ sites
202.61   Malignant mast cell tumors, lymph nodes of head, face, and neck
202.62   Malignant mast cell tumors, intrathoracic lymph nodes
202.63   Malignant mast cell tumors, intra-abdominal lymph nodes
202.64   Malignant mast cell tumors, lymph nodes of axilla and upper limb
202.65   Malignant mast cell tumors, lymph nodes of inguinal region and lower limb
202.66   Malignant mast cell tumors, intrapelvic lymph nodes
202.67   Malignant mast cell tumors, spleen



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202.68   Malignant mast cell tumors, lymph nodes of multiple sites
202.70   Peripheral T cell lymphoma, unspecified site, extranodal and solid organ sites
202.71   Peripheral T cell lymphoma, lymph nodes of head, face, and neck
202.72   Peripheral T cell lymphoma, intrathoracic lymph nodes
202.73   Peripheral T cell lymphoma, intra-abdominal lymph nodes
202.74   Peripheral T cell lymphoma, lymph nodes of axilla and upper limb
202.75   Peripheral T cell lymphoma, lymph nodes of inguinal region and lower limb
202.76   Peripheral T cell lymphoma, intrapelvic lymph nodes
202.77   Peripheral T cell lymphoma, spleen
202.78   Peripheral T cell lymphoma, lymph nodes of multiple sites
202.80   Other lymphomas, unspecified site, extranodal and solid organ sites
202.81   Other lymphomas, lymph nodes of head, face, and neck
202.82   Other lymphomas, intrathoracic lymph nodes
202.83   Other lymphomas, intra-abdominal lymph nodes
202.84   Other lymphomas, lymph nodes of axilla and upper limb
202.85   Other lymphomas, lymph nodes of inguinal region and lower limb
202.86   Other lymphomas, intrapelvic lymph nodes
202.87   Other lymphomas, spleen
202.88   Other lymphomas, lymph nodes of multiple sites
202.90   Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue,
         unspecified site, extranodal and solid organ sites
202.91   Other and unspecified malignant neoplasms, lymph nodes of head, face, and neck
202.92   Other and unspecified malignant neoplasms, intrathoracic lymph nodes
202.93   Other and unspecified malignant neoplasms, intra-abdominal lymph nodes
202.94   Other and unspecified malignant neoplasms, lymph nodes of axilla and upper limb
202.95   Other and unspecified malignant neoplasms, lymph nodes of inguinal region and lower
         limb
202.96   Other and unspecified malignant neoplasms, intrapelvic lymph nodes
202.97   Other and unspecified malignant neoplasms, spleen
202.98   Other and unspecified malignant neoplasms, lymph nodes of multiple sites
203.00   Multiple myeloma without remission
203.01   Multiple myeloma in remission
203.10   Plasma cell leukemia without remission
203.11   Plasma cell leukemia in remission
203.80   Other immunoproliferative neoplasms without remission
203.81   Other immunoproliferative neoplasms in remission
204.00   Acute lymphoid leukemia without remission
204.01   Acute lymphoid leukemia in remission
204.10   Chronic lymphoid leukemia without remission
204.11   Chronic lymphoid leukemia in remission
204.20   Subacute lymphoid leukemia without remission
204.21   Subacute lymphoid leukemia in remission
204.80   Other lymphoid leukemia without remission
204.81   Other lymphoid leukemia in remission
204.90   Unspecified lymphoid leukemia without remission
204.91   Unspecified lymphoid leukemia in remission
205.00   Acute myeloid leukemia without remission
205.01   Acute myeloid leukemia in remission
205.10   Chronic myeloid leukemia without remission
205.11   Chronic myeloid leukemia in remission
205.20   Subacute myeloid sarcoma, without remission
205.21   Subacute myeloid sarcoma in remission
205.30   Myeloid sarcoma without remission



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205.31   Myeloid sarcoma in remission
205.80   Other myeloid leukemia without remission
205.81   Other myeloid leukemia in remission
205.90   Unspecified myeloid leukemia without remission
205.91   Unspecified myeloid leukemia in remission
206.00   Acute monocytic leukemia without remission
206.01   Acute monocytic leukemia in remission
206.10   Chronic monocytic leukemia without remission
206.11   Chronic monocytic leukemia in remission
206.20   Subacute monocytic leukemia without remission
206.21   Subacute monocytic leukemia in remission
206.80   Other monocytic leukemia without remission
206.81   Other monocytic leukemia in remission
206.90   Unspecified monocytic leukemia without remission
206.91   Unspecified monocytic leukemia in remission
207.00   Acute erythremia and erythroleukemia without remission
207.01   Acute erythremia and erythroleukemia in remission
207.10   Chronic erythremia without remission
207.11   Chronic erythremia in remission
207.20   Megakaryocytic leukemia without remission
207.21   Megakaryocytic leukemia in remission
207.80   Other specified leukemia without remission
207.81   Other specified leukemia in remission
208.00   Acute leukemia of unspecified cell type without remission
208.01   Acute leukemia of unspecified cell type in remission
208.10   Chronic leukemia of unspecified cell type without remission
208.11   Chronic leukemia of unspecified cell type in remission
208.20   Subacute leukemia of unspecified cell type without remission
208.21   Subacute leukemia of unspecified cell type in remission
208.80   Other leukemia of unspecified cell type without remission
208.81   Other leukemia of unspecified cell type in remission
208.90   Unspecified leukemia without remission
208.91   Unspecified leukemia in remission
210.0    Benign neoplasm of lip
210.1    Benign neoplasm of tongue
210.2    Benign neoplasm of major salivary glands
210.3    Benign neoplasm of floor of mouth
210.4    Benign neoplasm of other and unspecified parts of mouth
210.5    Benign neoplasm of tonsil
210.6    Benign neoplasm of other parts of oropharynx
210.7    Benign neoplasm of nasopharynx
210.8    Benign neoplasm of hypopharynx
210.9    Benign neoplasm of pharynx, unspecified
211.0    Benign neoplasm of esophagus
211.1    Benign neoplasm of stomach
211.2    Benign neoplasm of duodenum, jejunum, and ileum
211.3    Benign neoplasm of colon
211.4    Benign neoplasm of rectum and anal canal
211.5    Benign neoplasm of liver and biliary passages
211.6    Benign neoplasm of pancreas, except islets of Langerhans
211.7    Benign neoplasm of islets of Langerhans
211.8    Benign neoplasm of retroperitoneum and peritoneum
211.9    Benign neoplasm of other and unspecified site



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212.0   Benign neoplasm of nasal cavities, middle ear
212.1   Benign neoplasm of larynx
212.2   Benign neoplasm of trachea
212.3   Benign neoplasm of bronchus and lung
212.4   Benign neoplasm of pleura
212.5   Benign neoplasm of mediastinum
212.6   Benign neoplasm of thymus
212.7   Benign neoplasm of heart
212.8   Benign neoplasm of other specified sites
212.9   Benign neoplasm of unspecified site
213.0   Benign neoplasm of bones of skull and face
213.1   Benign neoplasm of lower jaw bone
213.2   Benign neoplasm of vertebral column, excluding sacrum and coccyx
213.3   Benign neoplasm of ribs, sternum, and clavicle
213.4   Benign neoplasm of scapula and long bones of upper limb
213.5   Benign neoplasm of short bones of upper limb
213.6   Benign neoplasm of pelvic bones, sacrum, and coccyx
213.7   Benign neoplasm of long bones of lower limb
213.8   Benign neoplasm of short bones of lower limb
213.9   Benign neoplasm of bone and articular cartilage, site unspecified
214.0   Lipoma, skin and subcutaneous tissue of face
214.1   Lipoma, other skin and subcutaneous tissue
214.2   Lipoma, intrathoracic organs
214.3   Lipoma, intra-abdominal organs
214.4   Lipoma, spermatic cord
214.8   Lipoma, other specified sites
214.9   Lipoma, unspecified site
215.0   Other benign neoplasm, connective and soft tissue of head, face, and neck
215.2   Other benign neoplasm, connective and soft tissue of upper limb, including shoulder
215.3   Other benign neoplasm, connective and soft tissue of lower limb, including hip
215.4   Other benign neoplasm, connective and soft tissue of thorax
215.5   Other benign neoplasm, connective and soft tissue of abdomen
215.6   Other benign neoplasm, connective and soft tissue of pelvis
215.7   Other benign neoplasm, connective and soft tissue of trunk, unspecified
215.8   Other benign neoplasm, connective and soft tissue of other specified sites
215.9   Other benign neoplasm, connective and soft tissue, unspecified site
216.0   Benign neoplasm of skin of lip
216.1   Benign neoplasm of eyelid, including canthus
216.2   Benign neoplasm of Ear and external auditory canal
216.3   Benign neoplasm of skin of other and unspecified parts of face
216.4   Benign neoplasm of scalp and skin of neck
216.5   Benign neoplasm of skin of trunk, except scrotum
216.6   Benign neoplasm of skin of upper limb, including shoulder
216.7   Benign neoplasm of skin of lower limb, including hip
216.8   Benign neoplasm of other specified sites of skin
216.9   Benign neoplasm of skin, site unspecified
217     Benign neoplasm of breast
218.0   Submucous leiomyoma of uterus
218.1   Intramural leiomyoma of uterus
218.2   Subserous leiomyoma of uterus
218.9   Leiomyoma of uterus, unspecified
219.0   Other benign neoplasm cervix uteri
219.1   Other benign neoplasm corpus uteri



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219.8    Other benign neoplasm, other specified parts of uterus
219.9    Other benign neoplasm of uterus, part unspecified
220      Benign neoplasm of ovary
221.0    Benign neoplasm of fallopian tube and uterine ligaments
221.1    Benign neoplasm of vagina
221.2    Benign neoplasm of vulva
221.8    Benign neoplasm of other specified sites of female genital organs
221.9    Benign neoplasm of female genital organ, site unspecified
222.0    Benign neoplasm of testis
222.1    Benign neoplasm of penis
222.2    Benign neoplasm of prostate
222.3    Benign neoplasm of epididymis
222.4    Benign neoplasm of scrotum
222.8    Benign neoplasm of other specified sites of male genital organs
222.9    Benign neoplasm of male genital organ, site unspecified
223.0    Benign neoplasm of kidney, except pelvis
223.1    Benign neoplasm of renal pelvis
223.2    Benign neoplasm of ureter
223.3    Benign neoplasm of bladder
223.81   Benign neoplasm of urethra
223.89   Benign neoplasm of other sites of urinary organs
223.9    Urinary organ, site unspecified
224.0    Benign neoplasm of eyeball, except conjunctiva, cornea,
224.1    Benign neoplasm of orbit
224.2    Benign neoplasm of lacrimal gland
224.3    Benign neoplasm of conjunctiva
224.4    Benign neoplasm of cornea
224.5    Benign neoplasm of retina
224.6    Benign neoplasm of choroid
224.7    Benign neoplasm of lacrimal duct
224.8    Benign neoplasm of other specified parts of eye
224.9    Benign neoplasm of eye, part unspecified
225.0    Benign neoplasm of brain
225.1    Benign neoplasm of cranial nerves
225.2    Benign neoplasm of cerebral meninges
225.3    Benign neoplasm of spinal cord
225.4    Benign neoplasm of spinal meninges
225.8    Benign neoplasm of other specified sites of nervous system
225.9    Benign neoplasm of nervous system, part unspecified
226      Benign neoplasm of thyroid glands
227.0    Benign neoplasm of adrenal gland
227.1    Benign neoplasm of parathyroid gland
227.3    Benign neoplasm of pituitary gland and craniopharyngeal
227.4    Benign neoplasm of pineal gland
227.5    Benign neoplasm of carotid body
227.6    Benign neoplasm of aortic body and other paraganglia
227.8    Benign neoplasm of other endocrine glands and related structures
227.9    Benign neoplasm of endocrine gland, site unspecified
228.00   Hemangioma, of unspecified site
228.01   Hemangioma, of skin and subcutaneous tissue
228.02   Hemangioma, of intracranial structures
228.03   Hemangioma, of retina
228.04   Hemangioma, of intra-abdominal structures



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228.09   Hemangioma, of other sites
228.1    Lymphangioma, any site
229.0    Benign neoplasm of lymph nodes
229.8    Benign neoplasm of other specified sites
229.9    Benign neoplasm of site unspecified
230.0    Carcinoma in situ of lip, oral cavity, and pharynx
230.1    Carcinoma in situ of esophagus
230.2    Carcinoma in situ of stomach
230.3    Carcinoma in situ of colon
230.4    Carcinoma in situ of rectum
230.5    Carcinoma in situ of anal canal
230.6    Carcinoma in situ of anus, unspecified
230.7    Carcinoma in situ of other and unspecified parts of intestine
230.8    Carcinoma in situ of liver and biliary system
230.9    Carcinoma in situ of other and unspecified digestive organs
231.0    Carcinoma in situ of larynx
231.1    Carcinoma in situ of trachea
231.2    Carcinoma in situ of bronchus and lung
231.8    Carcinoma in situ of other specified parts of respiratory system
231.9    Carcinoma in situ of respiratory system, part unspecified
232.0    Carcinoma in situ of skin of lip
232.1    Carcinoma in situ of eyelid, including canthus
232.2    Carcinoma in situ of ear and external auditory canal
232.3    Carcinoma in situ of skin of other and unspecified parts of face
232.4    Carcinoma in situ of scalp and skin of neck
232.5    Carcinoma in situ of skin of trunk, except scrotum
232.6    Carcinoma in situ of skin of upper limb, including shoulder
232.7    Carcinoma in situ of skin of lower limb, including hip
232.8    Carcinoma in situ of other specified sites of skin
232.9    Carcinoma in situ of skin, site unspecified
233.0    Carcinoma in situ of breast
233.1    Carcinoma in situ of cervix uteri
233.2    Carcinoma in situ of other and unspecified parts of uterus
233.30   Carcinoma in situ, unspecified female genital organ
233.31   Carcinoma in situ,vagina
233.32   Carcinoma in situ,vulva
233.39   Carcinoma in situ, other female genital organ
233.4    Carcinoma in situ of prostate
233.5    Carcinoma in situ of penis
233.6    Carcinoma in situ of other and unspecified male genital organs
233.7    Carcinoma in situ of bladder
233.9    Carcinoma in situ of other and unspecified urinary organs
234.0    Carcinoma in situ of eye
234.8    Carcinoma in situ of other specified sites
234.9    Carcinoma in situ of unspecified site
235.0    Neoplasm of uncertain behavior of major salivary glands
235.1    Neoplasm of uncertain behavior of lip, oral cavity, and pharynx
235.2    Neoplasm of uncertain behavior of stomach, intestines, and rectum
235.3    Neoplasm of uncertain behavior of liver and biliary passages
235.4    Neoplasm of uncertain behavior of retroperitoneum and peritoneum
235.5    Neoplasm of uncertain behavior of other and unspecified digestive organs
235.6    Neoplasm of uncertain behavior of larynx
235.7    Neoplasm of uncertain behavior of trachea, bronchus, and lung



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235.8  Neoplasm of uncertain behavior of pleura, thymus, and mediastinum
235.9  Neoplasm of uncertain behavior of other and unspecified respiratory organs
236.0  Neoplasm of uncertain behavior of uterus
236.1  Neoplasm of uncertain behavior of placenta
236.2  Neoplasm of uncertain behavior of ovary
236.3  Neoplasm of uncertain behavior of other and unspecified female genital organs
236.4  Neoplasm of uncertain behavior of testis
236.5  Neoplasm of uncertain behavior of prostate
236.6  Neoplasm of uncertain behavior of other and unspecified male genital organs
236.7  Neoplasm of uncertain behavior of bladder
236.90 Neoplasm of uncertain behavior of urinary organs unspecified
236.91 Neoplasm of uncertain behavior of kidney and ureter
236.99 Neoplasm of uncertain behavior of other urinary organs
237.0  Neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct
237.1  Neoplasm of uncertain behavior of pineal gland
237.2  Neoplasm of uncertain behavior of adrenal gland
237.3  Paraganglia
237.4  Neoplasm of uncertain behavior of other and unspecified endocrine glands
237.5  Neoplasm of uncertain behavior of brain and spinal cord
237.6  Neoplasm of uncertain behavior of meninges
237.70 Neurofibromatosis, unspecified
237.71 Neurofibromatosis, type 1 [von Recklinghausen's disease]
237.72 Neurofibromatosis, type 2 [acoustic neurofibromatosis]
237.9  Other and unspecified parts of nervous system
238.0  Neoplasm of uncertain behavior of bone and articular cartilage
238.1  Neoplasm of uncertain behavior of connective and other soft tissue
238.2  Neoplasm of uncertain behavior of skin
238.3  Neoplasm of uncertain behavior of breast
238.4  Polycythemia vera
238.5  Histiocytic and mast cells
238.6  Plasma cells
238.71 Essential thrombocythemia
238.72 Low grade myelodysplastic syndrome lesions
238.73 High grade myelodysplastic syndrome lesions
238.74 Myelodysplastic syndrome with 5q deletion
238.75 Myelodysplastic syndrome, unspecified
238.76 Myelofibrosis with myeloid metaplasia
238.79 Other lymphatic and hematopoietic tissues
238.8  Neoplasm of uncertain behavior of other specified sites
238.9  Neoplasm of uncertain behavior, site unspecified
239.0  Neoplasms of unspecified nature of digestive system
239.1  Neoplasms of unspecified nature of respiratory system
239.2  Neoplasms of unspecified nature of bone, soft tissue, and skin
239.3  Neoplasms of unspecified nature of breast
239.4  Neoplasms of unspecified nature of bladder
239.5  Neoplasms of unspecified nature of other genitourinary organs
239.6  Neoplasms of unspecified nature of brain
239.7  Neoplasms of unspecified nature of endocrine glands and other parts of nervous system
239.8  Neoplasms of unspecified nature, other specified sites
239.9  Neoplasms of unspecified nature, site unspecified
250.00 Diabetes mellitus without complication, type II or unspecified type, not stated as
       uncontrolled
250.01 Diabetes mellitus without complication, type I, not stated as uncontrolled



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NATIONAL COVERAGE DETERMINATION                                               Serum Iron Studies

250.02   Diabetes mellitus without complication, type II or unspecified type, uncontrolled
250.03   Diabetes mellitus without complication, type I, uncontrolled
250.10   Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
250.11   Diabetes with ketoacidosis, type I, not stated as uncontrolled
250.12   Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13   Diabetes with ketoacidosis, type I, uncontrolled
250.20   Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
250.21   Diabetes with hyperosmolarity, type I, not stated as uncontrolled
250.22   Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23   Diabetes with hyperosmolarity, type I, uncontrolled
250.30   Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
250.31   Diabetes with other coma, type I, not stated as uncontrolled
250.32   Diabetes with other coma, type II or unspecified type, uncontrolled
250.33   Diabetes with other coma type I, uncontrolled
250.40   Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41   Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42   Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43   Diabetes with renal manifestations, type I, uncontrolled
250.50   Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
         uncontrolled
250.51   Diabetes with ophthalmic manifestations, type I, not stated as uncontrolled
250.52   Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53   Diabetes with ophthalmic manifestations, type I, uncontrolled
250.60   Diabetes with neurological manifestations, type II or unspecified type, not stated as
         uncontrolled
250.61   Diabetes with neurological manifestations, type I, not stated as uncontrolled
250.62   Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
250.63   Diabetes with neurological manifestations, type I, uncontrolled
250.70   Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
         uncontrolled
250.71   Diabetes with peripheral circulatory disorders, type I, not stated as uncontrolled
250.72   Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
250.73   Diabetes with peripheral circulatory disorders, type I, uncontrolled
250.80   Diabetes with other specified manifestations, type II or unspecified type, not stated as
         uncontrolled
250.81   Diabetes with other specified manifestations, type I, not stated as uncontrolled
250.82   Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
250.83   Diabetes with other specified manifestations, type I uncontrolled
250.90   Diabetes with unspecified complication, type II or unspecified type, not stated as
         uncontrolled
250.91   Diabetes with unspecified complication, type I, not stated as uncontrolled
250.92   Diabetes with unspecified complication, type II or unspecified type, uncontrolled
250.93   Diabetes with unspecified complication, type I, uncontrolled
253.2    Panhypopituitarism
253.7    Iatrogenic pituitary disorders
253.8    Other disorders of the pituitary gland
256.31   Premature menopause
256.39   Other ovarian failure
257.2    Other testicular hypofunction
260      Kwashiorkor
261      Nutritional marasmus
262      Other severe protein-calorie malnutrition
263.0    Malnutrition of moderate degree



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263.1    Malnutrition of mild degree
263.2    Arrested development following protein-calorie malnutrition
263.8    Other protein-calorie malnutrition
263.9    Unspecified protein-calorie malnutrition
275.0    Disorders of iron metabolism
277.1    Disorders of porphyrin metabolism
280.0    Iron deficiency anemia, unspecified
280.1    Iron deficiency anemia, secondary to inadequate dietary iron intake
280.8    Other specified iron deficiency anemias
280.9    Iron deficiency anemia, unspecified
281.0    Pernicious anemia
281.1    Other vitamin B12 deficiency anemia
281.2    Folate-deficiency anemia
281.3    Other specified megaloblastic anemias, not elsewhere classified
281.4    Protein deficiency anemia
281.8    Anemia associated with other specified nutritional deficiency
281.9    Unspecified deficiency anemia
282.41   Sickle-cell thalassemia without crisis
282.42   Sickle-cell thalassemia with crisis
282.49   Other thalassemia
282.60   Sickle-cell disease, unspecified
282.61   Hb-SS disease without crisis
282.62   Hb-SS disease with crisis
282.63   Sickle-cell/Hb-C disease without crisis
282.64   Sickle-cell/Hgb-C disease with crisis
282.68   Other sickle-cell disease without crisis
282.69   Other Sickle-cell disease with crisis
285.0    Sideroblastic anemia
285.1    Acute posthemorrhagic anemia
285.21   Anemia in chronic kidney disease
285.9    Anemia, unspecified
286.0    Congenital factor VIII disorder
286.1    Congenital factor IX disorder
286.2    Congenital factor XI deficiency
286.3    Congenital deficiency of other clotting factors
286.4    von Willebrand's disease
286.5    Hemorrhagic disorder due to circulating anticoagulants
286.6    Defibrination syndrome
286.7    Acquired coagulation factor deficiency
286.9    Other and unspecified coagulation defects
287.0    Allergic purpura
287.1    Qualitative platelet defects
287.2    Other nonthrombocytopenic purpuras
287.30   Primary thrombocytopenia, unspecified
287.31   Immune thrombocytopenic purpura
287.32   Evans' syndrome
287.33   Congenital and hereditary thrombocytopenic purpura
287.39   Other primary thrombocytopenia
287.4    Secondary thrombocytopenia
287.5    Thrombocytopenia, unspecified
287.8    Other specified hemorrhagic conditions
287.9    Unspecified hemorrhagic conditions
289.52   Splenic sequestration



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306.4    Physiological malfunction arising from mental factors Gastrointestinal
307.1    Anorexia nervosa
307.50   Eating disorder, unspecified
307.51   Bulimia nervosa
307.52   Pica
307.53   Rumination disorder
307.54   Psychogenic vomiting
307.59   Other eating disorder
403.01   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or
         end stage renal disease
403.11   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end
         stage renal disease
403.91   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or
         end stage renal disease
404.02   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.03   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.12   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.13   Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic
         kidney disease stage V or end stage renal disease
404.92   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage V or end stage renal disease
404.93   Hypertensive heart and chronic kidney disease, unspecified, with heart failure and
         chronic kidney disease stage V or end stage renal disease
425.4    Other primary cardiomyopathies
425.5    Alcoholic cardiomyopathy
425.7    Nutritional and metabolic cardiomyopathy
425.8    Cardiomyopathy in other diseases classified elsewhere
425.9    Secondary cardiomyopathy, unspecified
426.0    Atrioventricular block, complete
426.10   Atrioventricular block, unspecified
426.11   First degree atrioventricular block
426.12   Mobitz (type) II atrioventricular block
426.13   Other second degree atrioventricular block
426.2    Left bundle branch hemiblock
426.3    Other left bundle branch block
426.4    Right bundle branch block
426.50   Bundle branch block, unspecified
426.51   Right bundle branch block and left posterior fascicular block
426.52   Right bundle branch block and left anterior fascicular block
426.53   Other bilateral bundle branch block
426.54   Trifascicular block
426.6    Other heart block
426.7    Anomalous atrioventricular excitation
426.81   Lown-Ganong-Levine syndrome
426.89   Other conductive disorders
426.9    Conduction disorder, unspecified
427.0    Paroxysmal supraventricular tachycardia
427.1    Paroxysmal ventricular tachycardia
427.2    Paroxysmal tachycardia, unspecified
427.31   Atrial fibrillation



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427.32   Atrial flutter
427.41   Ventricular fibrillation
427.42   Ventricular flutter
427.5    Cardiac arrest
427.60   Premature beats, unspecified
427.61   Supraventricular premature beats
427.69   Other Premature beats
427.81   Sinoatrial node dysfunction
427.89   Other node dysfunction
427.9    Cardiac dysrhythmia, unspecified
428.0    Congestive heart failure
428.1    Left heart failure
428.20   Systolic heart failure, unspecified
428.21   Systolic heart failure, acute
428.22   Systolic heart failure, chronic
428.23   Systolic heart failure, acute on chronic
428.30   Diastolic heart failure, unspecified
428.31   Diastolic heart failure, acute
428.32   Diastolic heart failure, chronic
428.33   Diastolic heart failure, acute on chronic
428.40   Combined systolic and diastolic heart failure, unspecified
428.41   Combined systolic and diastolic heart failure, acute
428.42   Combined systolic and diastolic heart failure, chronic
428.43   Combined systolic and diastolic heart failure, acute on chronic
428.9    Heart failure, unspecified
530.7    Gastroesophageal laceration-hemorrhage syndrome
530.82   Esophageal hemorrhage
531.00   Peptic ulcer, acute with hemorrhage without obstruction
531.01   Peptic ulcer, acute with hemorrhage with obstruction
531.10   Peptic ulcer, acute with perforation without obstruction
531.11   Peptic ulcer, acute with perforation with obstruction
531.20   Peptic ulcer, acute with hemorrhage and perforation without obstruction
531.21   Peptic ulcer, acute with hemorrhage and perforation with obstruction
531.30   Peptic ulcer, acute without hemorrhage or perforation without obstruction
531.31   Peptic ulcer, acute without hemorrhage or perforation with obstruction
531.40   Peptic ulcer, chronic or unspecified with hemorrhage without obstruction
531.41   Peptic ulcer, chronic or unspecified with hemorrhage with obstruction
531.50   Peptic ulcer, chronic or unspecified with perforation without obstruction
531.51   Peptic ulcer, chronic or unspecified with perforation with obstruction
531.60   Peptic ulcer, chronic or unspecified with hemorrhage and perforation without obstruction
531.61   Peptic ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
531.70   Peptic ulcer, chronic without hemorrhage or perforation without obstruction
531.71   Peptic ulcer, chronic without hemorrhage or perforation with obstruction
531.90   Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation without
         obstruction
531.91   Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation with
         obstruction
532.00   Peptic ulcer, acute with hemorrhage without obstruction
532.01   Peptic ulcer, acute with hemorrhage with obstruction
532.10   Peptic ulcer, acute with perforation without obstruction
532.11   Peptic ulcer, acute with perforation with obstruction
532.20   Peptic ulcer, acute with hemorrhage and perforation without obstruction
532.21   Peptic ulcer, acute with hemorrhage and perforation with obstruction



                                                                                           Page 66
NATIONAL COVERAGE DETERMINATION                                              Serum Iron Studies

532.30   Peptic ulcer, acute without hemorrhage or perforation without obstruction
532.31   Peptic ulcer, acute without hemorrhage or perforation with obstruction
532.40   Peptic ulcer, chronic or unspecified with hemorrhage without obstruction
532.41   Peptic ulcer, chronic or unspecified with hemorrhage with obstruction
532.50   Peptic ulcer, chronic or unspecified with perforation without obstruction
532.51   Peptic ulcer, chronic or unspecified with perforation with obstruction
532.60   Peptic ulcer, chronic or unspecified with hemorrhage and perforation without obstruction
532.61   Peptic ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
532.70   Peptic ulcer, chronic without hemorrhage or perforation without obstruction
532.71   Peptic ulcer, chronic without hemorrhage or perforation with obstruction
532.90   Peptic ulcer, unspecified as acute or chronic without obstruction
532.91   Peptic ulcer, unspecified as acute or chronic with obstruction hemorrhage or perforation
533.00   Peptic ulcer, acute with hemorrhage without obstruction
533.01   Peptic ulcer, acute with hemorrhage with obstruction
533.10   Peptic ulcer, acute with perforation without obstruction
533.11   Peptic ulcer, acute with perforation with obstruction
533.20   Peptic ulcer, acute with hemorrhage and perforation without obstruction
533.21   Peptic ulcer, acute with hemorrhage and perforation with obstruction
533.30   Peptic ulcer, acute without hemorrhage and perforation without obstruction
533.31   Peptic ulcer, acute without hemorrhage and perforation with obstruction
533.40   Peptic ulcer, chronic or unspecified with hemorrhage without obstruction
533.41   Peptic ulcer, chronic or unspecified with hemorrhage with obstruction
533.50   Peptic ulcer, chronic or unspecified with perforation without obstruction
533.51   Peptic ulcer, chronic or unspecified with perforation with obstruction
533.60   Peptic ulcer, chronic or unspecified with hemorrhage and perforation without obstruction
533.61   Peptic ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
533.70   Peptic ulcer, chronic without hemorrhage or perforation without obstruction
533.71   Peptic ulcer, chronic without hemorrhage or perforation with obstruction
533.90   Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation without
         obstruction
533.91   Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation with
         obstruction
534.00   Gastrojejunal ulcer, acute with hemorrhage without obstruction
534.01   Gastrojejunal ulcer, acute with hemorrhage with obstruction
534.10   Gastrojejunal ulcer, acute with perforation without obstruction
534.11   Gastrojejunal ulcer, acute with perforation with obstruction
534.20   Gastrojejunal ulcer, acute with hemorrhage and perforation without obstruction
534.21   Gastrojejunal ulcer, acute with hemorrhage and perforation with obstruction
534.30   Gastrojejunal ulcer, acute without hemorrhage or perforation without obstruction
534.31   Gastrojejunal ulcer, acute without hemorrhage or perforation with obstruction
534.40   Gastrojejunal ulcer, chronic or unspecified with hemorrhage without obstruction
534.41   Gastrojejunal ulcer, chronic or unspecified with hemorrhage with obstruction
534.50   Gastrojejunal ulcer, chronic or unspecified with perforation without obstruction
534.51   Gastrojejunal ulcer, chronic or unspecified with perforation with obstruction
534.60   Gastrojejunal ulcer, chronic or unspecified with hemorrhage and perforation without
         obstruction
534.61   Gastrojejunal ulcer, chronic or unspecified with hemorrhage and perforation with
         obstruction
534.70   Gastrojejunal ulcer, chronic without hemorrhage or perforation without mention of
         obstruction
534.71   Gastrojejunal ulcer, chronic without hemorrhage or perforation with obstruction
534.90   Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
         without obstruction



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NATIONAL COVERAGE DETERMINATION                                            Serum Iron Studies

534.91 Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
       with obstruction
535.00 Acute gastritis without hemorrhage
535.01 Acute gastritis with hemorrhage
535.10 Atrophic gastritis without hemorrhage
535.11 Atrophic gastritis with hemorrhage
535.20 Gastric mucosal hypertrophy without hemorrhage
535.21 Gastric mucosal hypertrophy with hemorrhage
535.30 Alcoholic gastritis without hemorrhage
535.31 Alcoholic gastritis with hemorrhage
535.40 Other specified gastritis without hemorrhage
535.41 Other specified gastritis with hemorrhage
535.50 Unspecified gastritis and gastroduodenitis without hemorrhage
535.51 Unspecified gastritis and gastroduodenitis with hemorrhage
535.60 Duodenitis without hemorrhage
535.61 Duodenitis with hemorrhage
536.0 Achlorhydria
536.1 Acute dilatation of stomach
536.2 Persistent vomiting
536.3 Gastroparesis
536.40 Gastrostomy complication, unspecified
536.41 Gastrostomy complication, infection
536.42 Gastrostomy complication, mechanical
536.49 Gastrostomy complication, other
536.8 Dyspepsia and other specified disorders of function of stomach
536.9 Unspecified functional disorder of stomach
537.83 Angiodysplasia of stomach and duodenum with hemorrhage
537.84 Dieulafoy lesion (hemorrhagic) of stomach and duodeum
555.0 Regional enteritis, small intestine
555.1 Regional enteritis, large intestine
555.2 Regional enteritis, small intestine with large intestine
555.9 Regional enteritis, unspecified site
556.0 Ulcerative (chronic) enterocolitis
556.1 Ulcerative (chronic) ileocolitis
556.2 Ulcerative (chronic) proctitis
556.3 Ulcerative (chronic) proctosigmoiditis
556.4 Pseudopolyposis of colon
556.5 Left-sided ulcerative (chronic) colitis
556.6 Universal ulcerative (chronic) colitis
556.8 Other ulcerative colitis
556.9 Ulcerative colitis, unspecified
557.0 Acute vascular insufficiency of intestine
557.1 Chronic vascular insufficiency of intestine
562.02 Diverticulosis of small intestine with hemorrhage
562.03 Diverticulitis of small intestine with hemorrhage
562.12 Diverticulosis of colon with hemorrhage
562.13 Diverticulitis of colon with hemorrhage
569.3 Hemorrhage of rectum and anus
569.85 Angiodysplasia of intestine with hemorrhage
569.86 Dieulafoy lesion (hemorrhagic) of intestine
570    Acute and subacute necrosis of liver
571.0 Alcoholic fatty liver
571.1 Acute alcoholic hepatitis



                                                                                         Page 68
NATIONAL COVERAGE DETERMINATION                                            Serum Iron Studies

571.2    Alcoholic cirrhosis of liver
571.3    Alcoholic liver damage, unspecified
571.40   Chronic hepatitis, unspecified
571.41   Chronic persistent hepatitis
571.49   Other chronic hepatitis
571.5    Cirrhosis of liver without mention of alcohol
571.6    Biliary cirrhosis
571.8    Other chronic nonalcoholic liver disease
571.9    Unspecified chronic liver disease without mention of
572.0    Abscess of liver
572.1    Portal pyemia
572.2    Hepatic coma
572.3    Portal hypertension
572.4    Hepatorenal syndrome
572.8    Other sequelae of chronic liver disease
573.0    Chronic passive congestion of liver
573.1    Hepatitis in viral diseases classified elsewhere
573.2    Hepatitis in other infectious diseases classified elsewhere
573.3    Hepatitis, unspecified
573.4    Hepatic infarction
573.8    Other specified disorders of liver
573.9    Unspecified disorder of liver
578.0    Hematemesis
578.1    Blood in stool
578.9    Hemorrhage of gastrointestinal tract, unspecified
579.0    Celiac disease
579.1    Tropical sprue
579.2    Blind loop syndrome
579.3    Other and unspecified postsurgical nonabsorption
579.8    Other specified intestinal malabsorption
579.9    Unspecified intestinal malabsorption
581.0    Nephrotic syndrome with lesion of proliferative glomerulonephritis
581.1    Nephrotic syndrome with lesion of membranous glomerulonephritis
581.2    Nephrotic syndrome with lesion of membranoproliferative glomerulonephritis
581.3    Nephrotic syndrome with lesion of minimal change glomerulonephritis
581.81   Nephrotic syndrome in diseases classified elsewhere
581.89   Other nephrotic syndrome
581.9    Nephrotic syndrome with unspecified pathological lesion in
585.4    Chronic kidney disease, Stage IV (severe)
585.5    Chronic kidney disease, Stage V
585.6    End stage renal disease
585.9    Chronic kidney disease, unspecified
586      Renal failure, unspecified
608.3    Atrophy of testis
626.0    Absence of menstruation
626.1    Scanty or infrequent menstruation
626.2    Excessive or frequent menstruation
626.3    Puberty bleeding
626.4    Irregular menstrual cycle
626.5    Ovulation bleeding
626.6    Metrorrhagia
626.7    Postcoital bleeding
626.8    Other disorders of menstruation



                                                                                      Page 69
NATIONAL COVERAGE DETERMINATION                                            Serum Iron Studies

626.9    Unspecified disorders of menstruation
627.0    Premenopausal menorrhagia
627.1    Postmenopausal bleeding
648.20   Other conditions of mother complicating pregnancy, anemia, unspecified episode of care
648.21   Other conditions of mother complicating pregnancy, anemia, delivered, with or without
         antepartum condition
648.22   Other conditions of mother complicating pregnancy, anemia, delivered, with postpartum
         complication
648.23   Other conditions of mother complicating pregnancy, anemia, antepartum condition or
         complication
648.24   Other conditions of mother complicating pregnancy, anemia, postpartum condition or
         complication
698.0    Pruritus ani
698.1    Pruritus of genital organs
698.2    Prurigo
698.3    Lichenification and lichen simplex chronicus
698.4    Dermatitis factitia [artefacta]
698.8    Other specified pruritic conditions
698.9    Unspecified pruritic disorder
704.00   Alopecia, unspecified
704.01   Alopecia areata
704.02   Telogen effluvium
704.09   Other alopecia
709.00   Dyschromia, unspecified
709.01   Vitiligo
709.09   Other disorders of skin and subcutaneous tissue
713.0    Arthropathy associated with other endocrine and metabolic disorders
716.40   Transient arthropathy, site unspecified
716.41   Transient arthropathy, shoulder region
716.42   Transient arthropath,y upper arm
716.43   Transient arthropathy, forearm
716.44   Transient arthropathy, hand
716.45   Transient arthropathy, pelvic region and thigh
716.46   Transient arthropathy, lower leg
716.47   Transient arthropathy, ankle and foot
716.48   Transient arthropathy, other specified sites
716.49   Transient arthropathy, multiple sites
716.50   Unspecified polyarthropathy or polyarthritis, site unspecified
716.51   Unspecified polyarthropathy or polyarthritis, shoulder region
716.52   Unspecified polyarthropathy or polyarthritis, upper arm
716.53   Unspecified polyarthropathy or polyarthritis, forearm
716.54   Unspecified polyarthropathy or polyarthritis, hand
716.55   Unspecified polyarthropathy or polyarthritis, pelvic region and thigh
716.56   Unspecified polyarthropathy or polyarthritis, lower leg
716.57   Unspecified polyarthropathy or polyarthritis, ankle and foot
716.58   Unspecified polyarthropathy or polyarthritis, other specified sites
716.59   Unspecified polyarthropathy or polyarthritis, multiple sites
716.60   Unspecified monoarthritis, site unspecified
716.61   Unspecified monoarthritis, shoulder region
716.62   Unspecified monoarthritis, upper arm
716.63   Unspecified monoarthritis, forearm
716.64   Unspecified monoarthritis, hand
716.65   Unspecified monoarthritis, pelvic region and thigh



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NATIONAL COVERAGE DETERMINATION                                           Serum Iron Studies

716.66   Unspecified monoarthritis, lower leg
716.67   Unspecified monoarthritis, ankle and foot
716.68   Unspecified monoarthritis, other specified sites
716.80   Other specified arthropathy, site unspecified
716.81   Other specified arthropathy, shoulder region
716.82   Other specified arthropathy, upper arm
716.83   Other specified arthropathy, forearm
716.84   Other specified arthropathy, hand
716.85   Other specified arthropathy, pelvic region and thigh
716.86   Other specified arthropathy, lower leg
716.87   Other specified arthropathy, ankle and foot
716.88   Other specified arthropathy, other specified sites
716.89   Other specified arthropathy, multiple sites
716.90   Arthropathy, unspecified, site unspecified
716.91   Arthropathy, unspecified, shoulder region
716.92   Arthropathy, unspecified, upper arm
716.93   Arthropathy, unspecified, forearm
716.94   Arthropathy, unspecified, hand
716.95   Arthropathy, unspecified, pelvic region and thigh
716.96   Arthropathy, unspecified, lower leg
716.97   Arthropathy, unspecified, ankle and foot
716.98   Arthropathy, unspecified, other specified sites
716.99   Arthropathy, unspecified, multiple sites
719.40   Pain in joint, site unspecified
719.41   Pain in joint, shoulder region
719.42   Pain in joint, upper arm
719.43   Pain in joint, forearm
719.44   Pain in joint, hand
719.45   Pain in joint, pelvic region and thigh
719.46   Pain in joint, lower leg
719.47   Pain in joint, ankle and foot
719.48   Pain in joint, other specified sites
719.49   Pain in joint, multiple sites
773.2    Hemolytic disease of newborn due to other and unspecified isoimmunization
773.3    Hydrops fetalis of newborn due to isoimmunization
773.4    Kernicterus of newborn due to isoimmunization
773.5    Late anemia of newborn due to isoimmunization
783.9    Other symptoms concerning nutrition, metabolism, and development
790.01   Precipitous drop in hematocrit
790.09   Other abnormality of red blood cells
790.4    Nonspecific elevation transaminase or lactic acid dehydrogenase [LDH]
790.5    Other nonspecific abnormalserum enzyme levels
790.6    Other abnormal blood chemistry
799.4    Cachexia
964.0    Poisoning by iron and its compounds
984.0    Toxic effect of inorganic lead compounds
984.1    Toxic effect of organic lead compounds
984.8    Toxic effect of other lead compounds
984.9    Toxic effect of unspecified lead compound
996.85   Complications, transplanted bone marrow
999.8    Other transfusion reaction
V08      Asymptomatic human immunodeficiency virus [HIV] infection status
V12.1    Personal history of nutritional deficiency



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NATIONAL COVERAGE DETERMINATION                                                Serum Iron Studies

V12.3    Personal history of diseases of blood and blood-forming organs
V15.1    Personal history of surgery to heart and great vessels
V15.2    Personal history of surgery to other major organs
V43.21   Organ or tissue replaced by other means, heart assist device
V43.22   Organ or tissue replaced by other means, fully implantable artificial heart
V43.3    Organ or tissue replaced by other means, heart valve
V43.4    Organ or tissue replaced by other means, blood vessel
V43.60   Organ or tissue replaced by other means, unspecified joint
V56.0    Extracorporeal dialysis
V56.8    Other dialysis




                                                                                          Page 72
NATIONAL COVERAGE DETERMINATION                                                                                          82947


NATIONAL COVERAGE DETERMINATION
82947
82947-Glucose; quantitative, blood (except reagent strip)




CPT CODE: 82947



CPT CODE DESCRIPTOR: Glucose; quantitative, blood (except reagent strip)



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                            In stable, non-hospitalized patients who are unable or unwilling to do home
                                            glucose monitoring, it may be reasonable and necessary to measure quantitative
                                            blood glucose up to 4 times annually.

                                            Depending on the age and condition of the patient, the type of diabetes, degree of
                                            control, and other co-morbid conditions, more frequent testing may be reasonable
                                            and necessary.



COVERED ICD-9 CODES:
011.00 Tuberculosis of lung, infiltrative, unspecified
011.01 Tuberculosis of lung, infiltrative, bacteriological or histological examination not done
011.02 Tuberculosis of lung, infiltrative, bacteriological or histological examination unknown (at
       present)
011.03 Tuberculosis of lung, infiltrative, tubercle bacilli found (in sputum) by microscopy
011.04 Tuberculosis of lung, infiltrative, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture
011.05 Tuberculosis of lung, infiltrative, tubercle bacilli not found by bacteriological examination,
       but tuberculosis confirmed histologically
011.06 Tuberculosis of lung, infiltrative, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.10 Tuberculosis of lung, nodular, unspecified
011.11 Tuberculosis of lung, nodular, bacteriological or histological examination not done
011.12 Tuberculosis of lung, nodular, bacteriological or histological examination unknown (at
       present)
011.13 Tuberculosis of lung, nodular, tubercle bacilli found (in sputum) by microscopy
011.14 Tuberculosis of lung, nodular, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture
011.15 Tuberculosis of lung, nodular, tubercle bacilli not found by bacteriological examination,
       but tuberculosis confirmed histologically
011.16 Tuberculosis of lung, nodular, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.20 Tuberculosis of lung with cavitation, unspecified
011.21 Tuberculosis of lung with cavitation, bacteriological or histological examination not done
011.22 Tuberculosis of lung with cavitation, bacteriological or histological examination unknown
       (at present)
011.23 Tuberculosis of lung with cavitation, tubercle bacilli found (in sputum) by microscopy
011.24 Tuberculosis of lung with cavitation, tubercle bacilli not found (in sputum) by microscopy,
       but found by bacterial culture
011.25 Tuberculosis of lung with cavitation, tubercle bacilli not found by bacteriological
       examination, but tuberculosis confirmed histologically



                                                                                                                        Page 73
NATIONAL COVERAGE DETERMINATION                                                               82947

011.26 Tuberculosis of lung with cavitation, tubercle bacilli not found by bacteriological or
       histological examination, but tuberculosis confirmed by other methods
011.30 Tuberculosis of bronchus, unspecified
011.31 Tuberculosis of bronchus, bacteriological or histological examination not done
011.32 Tuberculosis of bronchus, bacteriological or histological examination unknown (at
       present)
011.33 Tuberculosis of bronchus, tubercle bacilli found (in sputum) by microscopy
011.34 Tuberculosis of bronchus, tubercle bacilli not found (in sputum) by microscopy, but found
       by bacterial culture
011.35 Tuberculosis of bronchus, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.36 Tuberculosis of bronchus, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.40 Tuberculous fibrosis of lung, unspecified
011.41 Tuberculous fibrosis of lung, bacteriological or histological examination not done
011.42 Tuberculous fibrosis of lung, bacteriological or histological examination unknown (at
       present)
011.43 Tuberculous fibrosis of lung, tubercle bacilli found (in sputum) by microscopy
011.44 Tuberculous fibrosis of lung, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture
011.45 Tuberculous fibrosis of lung, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.46 Tuberculous fibrosis of lung, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.50 Tuberculous bronchiectasis, unspecified
011.51 Tuberculous bronchiectasis, bacteriological or histological examination not done
011.52 Tuberculous bronchiectasis, bacteriological or histological examination unknown (at
       present)
011.53 Tuberculous bronchiectasis, tubercle bacilli found (in sputum) by microscopy
011.54 Tuberculous bronchiectasis, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture
011.55 Tuberculous bronchiectasis, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.56 Tuberculous bronchiectasis, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.60 Tuberculous pneumonia [any form], unspecified
011.61 Tuberculous pneumonia [any form], bacteriological or histological examination not done
011.62 Tuberculous pneumonia [any form], bacteriological or histological examination unknown
       (at present)
011.63 Tuberculous pneumonia [any form], tubercle bacilli found (in sputum) by microscopy
011.64 Tuberculous pneumonia [any form], tubercle bacilli not found (in sputum) by microscopy,
       but found by bacterial culture
011.65 Tuberculous pneumonia [any form], tubercle bacilli not found by bacteriological
       examination, but tuberculosis confirmed histologically
011.66 Tuberculous pneumonia [any form], tubercle bacilli not found by bacteriological or
       histological examination, but tuberculosis confirmed by other methods
011.70 Tuberculous pneumothorax, unspecified
011.71 Tuberculous pneumothorax, bacteriological or histological examination not done
011.72 Tuberculous pneumothorax, bacteriological or histological examination unknown (at
       present)
011.73 Tuberculous pneumothorax, tubercle bacilli found (in sputum) by microscopy
011.74 Tuberculous pneumothorax, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture



                                                                                            Page 74
NATIONAL COVERAGE DETERMINATION                                                           82947

011.75 Tuberculous pneumothorax, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.76 Tuberculous pneumothorax, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.80 Other specified pulmonary tuberculosis, unspecified
011.81 Other specified pulmonary tuberculosis, bacteriological or histological examination not
       done
011.82 Other specified pulmonary tuberculosis, bacteriological or histological examination
       unknown (at present)
011.83 Other specified pulmonary tuberculosis, tubercle bacilli found (in sputum) by microscopy
011.84 Other specified pulmonary tuberculosis, tubercle bacilli not found (in sputum) by
       microscopy, but found by bacterial culture
011.85 Other specified pulmonary tuberculosis, tubercle bacilli not found by bacteriological
       examination, but tuberculosis confirmed histologically
011.86 Other specified pulmonary tuberculosis, tubercle bacilli not found by bacteriological or
       histological examination, but tuberculosis confirmed by other methods
011.90 Pulmonary tuberculosis, unspecified
011.91 Pulmonary tuberculosis, bacteriological or histological examination not done
011.92 Pulmonary tuberculosis, bacteriological or histological examination unknown (at present)
011.93 Pulmonary tuberculosis, tubercle bacilli found (in sputum) by microscopy
011.94 Pulmonary tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found
       by bacterial culture
011.95 Pulmonary tuberculosis, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.96 Pulmonary tuberculosis, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
038.0 Streptococcal septicemia
038.10 Staphylococcal septicemia, unspecified
038.11 Staphylococcus aureus septicemia
038.19 Other staphylococcal septicemia
038.2 Pneumococcal septicemia
038.3 Septicemia due to anaerobes
038.40 Septicemia due to Gram-negative organism, unspecified
038.41 Septicemia due to Hemophilus influenzae [H. influenzae]
038.42 Septicemia due to Escherichia coli [E. coli]
038.43 Septicemia due to Pseudomonas
038.44 Septicemia due to Serratia
038.49 Other Septicemia due to other gram-negative organisms
038.8 Other specified septicemias
038.9 Unspecified septicemia
112.1 Candidiasis of vulva and vagina
112.3 Candidiasis of skin and nails
118    Opportunistic mycoses
157.4 Malignant neoplasm, islets of Langerhans
158.0 Malignant neoplasm, retroperitoneum
211.7 Benign neoplasm of islets of Langerhans
242.00 Toxic diffuse goiter without thyrotoxic crisis or storm
242.01 Toxic diffuse goiter with thyrotoxic crisis or storm
242.10 Toxic uninodular goiter without thyrotoxic crisis or storm
242.11 Toxic uninodular goiter with thyrotoxic crisis or storm
242.20 Toxic multinodular goiter without thyrotoxic crisis or storm
242.21 Toxic multinodular goiter with thyrotoxic crisis or storm
242.30 Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm



                                                                                        Page 75
NATIONAL COVERAGE DETERMINATION                                                                82947

242.31   Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40   Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41   Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
242.80   Thyrotoxicosis of other specified origin without thyrotoxic crisis or storm
242.81   Thyrotoxicosis of other specified origin with thyrotoxic crisis or storm
242.90   Thyrotoxicosis without of goiter or other cause without thyrotoxic crisis or storm
242.91   Thyrotoxicosis without goiter or other cause with mention of thyrotoxic crisis or storm
250.00   Diabetes mellitus without complication, type II or unspecified type, not stated as
         uncontrolled
250.01   Diabetes mellitus without complication, type I, not stated as uncontrolled
250.02   Diabetes mellitus without complication, type II or unspecified type, uncontrolled
250.03   Diabetes mellitus without complication, type I, uncontrolled
250.10   Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
250.11   Diabetes with ketoacidosis, type I, not stated as uncontrolled
250.12   Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13   Diabetes with ketoacidosis, type I, uncontrolled
250.20   Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
250.21   Diabetes with hyperosmolarity, type I, not stated as uncontrolled
250.22   Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23   Diabetes with hyperosmolarity, type I, uncontrolled
250.30   Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
250.31   Diabetes with other coma, type I, not stated as uncontrolled
250.32   Diabetes with other coma, type II or unspecified type, uncontrolled
250.33   Diabetes with other coma type I, uncontrolled
250.40   Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41   Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42   Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43   Diabetes with renal manifestations, type I, uncontrolled
250.50   Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
         uncontrolled
250.51   Diabetes with ophthalmic manifestations, type I, not stated as uncontrolled
250.52   Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53   Diabetes with ophthalmic manifestations, type I, uncontrolled
250.60   Diabetes with neurological manifestations, type II or unspecified type, not stated as
         uncontrolled
250.61   Diabetes with neurological manifestations, type I, not stated as uncontrolled
250.62   Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
250.63   Diabetes with neurological manifestations, type I, uncontrolled
250.70   Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
         uncontrolled
250.71   Diabetes with peripheral circulatory disorders, type I, not stated as uncontrolled
250.72   Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
250.73   Diabetes with peripheral circulatory disorders, type I, uncontrolled
250.80   Diabetes with other specified manifestations, type II or unspecified type, not stated as
         uncontrolled
250.81   Diabetes with other specified manifestations, type I, not stated as uncontrolled
250.82   Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
250.83   Diabetes with other specified manifestations, type I uncontrolled
250.90   Diabetes with unspecified complication, type II or unspecified type, not stated as
         uncontrolled
250.91   Diabetes with unspecified complication, type I, not stated as uncontrolled
250.92   Diabetes with unspecified complication, type II or unspecified type, uncontrolled
250.93   Diabetes with unspecified complication, type I, uncontrolled



                                                                                             Page 76
NATIONAL COVERAGE DETERMINATION                                                            82947

251.0    Hypoglycemic coma
251.1    Other specified hypoglycemia
251.2    Hypoglycemia, unspecified
251.3    Postsurgical hypoinsulinemia
251.4    Abnormality of secretion of glucagon
251.5    Abnormality of secretion of gastrin
251.8    Other specified disorders of pancreatic internal secretion
251.9    Unspecified disorder of pancreatic internal secretion
253.0    Acromegaly and gigantism
253.1    Other and unspecified anterior pituitary hyperfunction
253.2    Panhypopituitarism
253.3    Pituitary dwarfism
253.4    Other anterior pituitary disorders
253.5    Diabetes insipidus
253.6    Other disorders of neurohypophysis
253.7    Iatrogenic pituitary disorders
253.8    Other disorders of the pituitary gland
253.9    Unspecified disorders of the pituitary gland
255.0    Cushing's syndrome
263.0    Malnutrition of moderate degree
263.1    Malnutrition of mild degree
263.2    Arrested development following protein-calorie malnutrition
263.8    Other protein-calorie malnutrition
263.9    Unspecified protein-calorie malnutrition
271.0    Glycogenosis
271.1    Galactosemia
271.2    Hereditary fructose intolerance
271.3    Intestinal disaccharidase deficiencies and disaccharide malabsorption
271.4    Renal glycosuria
271.8    Other specified disorders of carbohydrate transport and metabolism
271.9    Unspecified disorder of carbohydrate transport and metabolism
272.0    Pure hypercholesterolemia
272.1    Pure hyperglyceridemia
272.2    Mixed hyperlipidemia
272.3    Hyperchylomicronemia
272.4    Other and unspecified hyperlipidemia
275.0    Disorders of iron metabolism
276.0    Hyperosmolality and/or hypernatremia
276.1    Hyposmolality and/or hyponatremia
276.2    Acidosis
276.3    Alkalosis
276.4    Mixed acid-base balance disorder
276.50   Volume depletion, unspecified
276.51   Dehydration
276.52   Hypovolemia
276.6    Fluid overload
276.7    Hyperpotassemia
276.8    Hypopotassemia
276.9    Electrolyte and fluid disorders not elsewhere classified
278.3    Hypercarotinemia
293.0    Delirium due to conditions classified elsewhere
294.9    Unspecified persistent mental disorders due to conditions classified elsewhere
298.9    Unspecified psychosis



                                                                                          Page 77
NATIONAL COVERAGE DETERMINATION                                          82947

300.9    Unspecified nonpsychotic mental disorder
310.1    Personality change due to conditions classified elsewhere
331.83   Mild cognitive impairment, so stated
337.9    Unspecified disorder of autonomic nervous system
345.10   Generalized convulsive epilepsy without intractable epilepsy
345.11   Generalized convulsive epilepsy with intractable epilepsy
348.31   Metabolic encephalopathy
355.9    Mononeuritis of unspecified site
356.9    Unspecified idiopathic peripheral neuropathy
357.9    Unspecified polyneuropathy
362.10   Background retinopathy, unspecified
362.18   Retinal vasculitis
362.29   Other nondiabetic proliferative retinopathy
362.50   Macular degeneration (senile), unspecified
362.51   Nonexudative senile macular degeneration
362.52   Exudative senile macular degeneration
362.53   Cystoid macular degeneration
362.54   Macular cyst, hole, or pseudohole
362.55   Toxic maculopathy
362.56   Macular puckering
362.57   Drusen (degenerative)
362.60   Peripheral retinal degeneration, unspecified
362.61   Paving stone degeneration
362.62   Microcystoid degeneration
362.63   Lattice degeneration
362.64   Senile reticular degeneration
362.65   Secondary pigmentary degeneration
362.66   Secondary vitreoretinal degenerations
362.81   Retinal hemorrhage
362.82   Retinal exudates and deposits
362.83   Retinal edema
362.84   Retinal ischemia
362.85   Retinal nerve fiber bundle defects
362.89   Other retinal disorders
362.9    Unspecified retinal disorder
365.04   Ocular hypertension
365.32   Corticosteroid-induced glucoma, residual stage
366.00   Nonsenile cataract, unspecified
366.01   Anterior subcapsular polar cataract
366.02   Posterior subcapsular polar cataract
366.03   Cortical, lamellar, or zonular cataract
366.04   Nuclear cataract
366.09   Other and combined forms of nonsenile cataract
366.10   Senile cataract, unspecified
366.11   Pseudoexfoliation of lens capsule
366.12   Incipient cataract
366.13   Anterior subcapsular polar senile cataract
366.14   Posterior subcapsular polar senile cataract
366.15   Cortical senile cataract
366.16   Nuclear sclerosis
366.17   Total or mature cataract
366.18   Hypermature cataract
366.19   Other and combined forms of senile cataract



                                                                        Page 78
NATIONAL COVERAGE DETERMINATION                                                      82947

367.1    Myopia
368.8    Other specified visual disturbances
373.00   Blepharitis, unspecified
377.24   Pseudopapilledema
377.9    Unspecified disorder of optic nerve and visual pathways
378.50   Paralytic strabismus, unspecified
378.51   Third or oculomotor nerve palsy, partial
378.52   Third or oculomotor nerve palsy, total
378.53   Fourth or trochlear nerve palsy
378.54   Sixth or abducens nerve palsy
378.55   External ophthalmoplegia
379.45   Argyll Robertson pupil, atypical
410.00   Infarction of anterolateral wall, episode of care unspecified
410.01   Infarction of anterolateral wall, initial episode of care
410.02   Infarction of anterolateral wall, subsequent episode of care
410.10   Infarction of other anterior wall, episode of care unspecified
410.11   Infarction of other anterior wall, initial episode of care
410.12   Infarction of other anterior wall, subsequent episode of care
410.20   Infarction of inferolateral wall, episode of care unspecified
410.21   Infarction of inferolateral wall, initial episode of care
410.22   Infarction of inferolateral wall, subsequent episode of care
410.30   Infarction of inferoposterior wall, episode of care unspecified
410.31   Infarction of inferoposterior wall, initial episode of care
410.32   Infarction of inferoposterior wall,subsequent episode of care
410.40   Infarction of other inferior wall, episode of care unspecified
410.41   Infarction of other inferior wal, initial episode of care
410.42   Infarction of other inferior wall, subsequent episode of care
410.50   Infarction of other lateral wall, episode of care unspecified
410.51   Infarction of other lateral wall, initial episode of care
410.52   Infarction of other lateral wall, subsequent episode of care
410.60   True posterior wall infarction, episode of care unspecified
410.61   True posterior wall infarction, initial episode of care
410.62   True posterior wall infarction, subsequent episode of care
410.70   Subendocardial infarction, episode of care unspecified
410.71   Subendocardial infarction, initial episode of care
410.72   Subendocardial infarction, subsequent episode of care
410.80   Infarction of other specified sites, episode of care unspecified
410.81   Infarction of other specified sites, initial episode of care
410.82   Infarction of other specified sites, subsequent episode of care
410.90   Infarction, unspecified site, episode of care unspecified
410.91   Infarction, unspecified site, initial episode of care
410.92   Infarction, unspecified site, subsequent episode of care
414.00   Coronary atherosclerosis of unspecified vessel
414.01   Coronary atherosclerosis of native coronary artery
414.02   Coronary atherosclerosis of autologous biological bypass graft
414.03   Coronary atherosclerosis of nonautologous biological bypass graft
414.04   Coronary atherosclerosis of artery bypass graft
414.05   Coronary atherosclerosis of unspecified bypass graft
414.06   Coronary atherosclerosis of native coronary artery of transplanted heart
414.07   Coronary atherosclerosis, of bypass graft of transplanted heart
414.10   Aneurysm of heart (wall)
414.11   Aneurysm of coronary vessels
414.12   Dissection of coronary artery



                                                                                    Page 79
NATIONAL COVERAGE DETERMINATION                                         82947

414.19   Aneurysm, other
425.9    Secondary cardiomyopathy, unspecified
440.23   Atherosclerosis of the extremities with ulceration
440.24   Atherosclerosis of the extremities with gangrene
440.9    Generalized and unspecified atherosclerosis
458.0    Orthostatic hypotension
462      Acute pharyngitis
466.0    Acute bronchitis
480.0    Pneumonia due to adenovirus
480.1    Pneumonia due to respiratory syncytial virus
480.2    Pneumonia due to parainfluenza virus
480.3    Pneumonia due to SARS-associated coronavirus
480.8    Pneumonia due to other virus not elsewhere classified
480.9    Viral pneumonia, unspecified
481      Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]
482.0    Pneumonia due to Klebsiella pneumoniae
482.1    Pneumonia due to Pseudomonas
482.2    Pneumonia due to Hemophilus influenzae [H. influenzae]
482.30   Pneumonia due to Streptococcus, unspecified
482.31   Pneumonia due to Streptococcus, group A
482.32   Pneumonia due to Streptococcus, group B
482.39   Pneumonia due to other Streptococcus
482.40   Pneumonia due to Staphylococcus, unspecified
482.41   Pneumonia due to Staphylococcus aureus
482.49   Other Staphylococcal pneumonia
482.81   Pneumonia due to anaerobes
482.82   Pneumonia due to Escherichia coli [E. coli]
482.83   Pneumonia due to other gram-negative bacteria
482.84   Legionnaires' disease
482.89   Pneumonia due to other specified bacteria
482.9    Bacterial pneumonia unspecified
483.0    Pneumonia due to Mycoplasma pneumoniae
483.1    Legionnaires disease
483.8    Pneumonia due to other specified organism
484.1    Pneumonia in cytomegalic inclusion disease
484.3    Pneumonia in whooping cough
484.5    Pneumonia in anthrax
484.6    Pneumonia in aspergillosis
484.7    Pneumonia in other systemic mycoses
484.8    Pneumonia in other infectious diseases classified elsewhere
485      Bronchopneumonia, organism unspecified
486      Pneumonia, organism unspecified
490      Bronchitis, not specified as acute or chronic
491.0    Simple chronic bronchitis
491.1    Mucopurulent chronic bronchitis
491.20   Obstructive chronic bronchitis without exacerbation
491.21   Obstructive chronic bronchitis with (acute) exacerbation
491.22   Obstructive chronic bronchitis with acute bronchitis
491.8    Other chronic bronchitis
491.9    Unspecified chronic bronchitis
527.7    Disturbance of salivary secretion
528.00   Stomatitis and mucositis, unspecified
528.09   Other stomatitis and mucositis (ulcerative)



                                                                       Page 80
NATIONAL COVERAGE DETERMINATION                                                               82947

535.50   Unspecified gastritis and gastroduodenitis without hemorrhage
535.51   Unspecified gastritis and gastroduodenitis with hemorrhage
536.8    Dyspepsia and other specified disorders of function of stomach
571.8    Other chronic nonalcoholic liver disease
572.0    Abscess of liver
572.1    Portal pyemia
572.2    Hepatic coma
572.3    Portal hypertension
572.4    Hepatorenal syndrome
572.8    Other sequelae of chronic liver disease
574.50   Calculus of bile duct without cholecystitis without obstruction
574.51   Calculus of bile duct without cholecystitis with obstruction
575.0    Acute cholecystitis
575.10   Cholecystitis, unspecified
575.11   Cholecystitis, chronic
575.12   Cholecystitis, acute and chronic
576.1    Cholangitis
577.0    Acute pancreatitis
577.1    Chronic pancreatitis
577.8    Other specified diseases of pancreas
590.00   Chronic pyelonephritis without lesion of renal medullary necrosis
590.01   Chronic pyelonephritis with lesion of renal medullary
590.10   Acute pyonephrosis without lesion of renal medullary necrosis
590.11   Acute pyonephrosis with lesion of renal medullary necrosis
590.2    Renal and perinephric abscess
590.3    Pyeloureteritis cystica
590.80   Pyelonephritis, unspecified
590.81   Pyelitis or pyelonephritis in diseases classified elsewhere
590.9    Infection of kidney, unspecified
595.9    Cystitis, unspecified
596.4    Atony of bladder
596.53   Paralysis of bladder
599.0    Urinary tract infection, site not specified
607.84   Impotence of organic origin
608.89   Other Vascular disorders of male genital orga
616.10   Vaginitis and vulvovaginitis, unspecified
626.0    Absence of menstruation
626.4    Irregular menstrual cycle
628.9    Infertility, female, of unspecified origin
648.00   Other conditions of mother complicating pregnancy, diabetes mellitus, unspecified
         episode of care
648.03   Other conditions of mother complicating pregnancy, diabetes mellitus, antepartum
         condition or complication
648.04   Other conditions of mother complicating pregnancy, diabetes mellitus, postpartum
         condition or complication
648.80   Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
         unspecified episode of care
648.83   Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
         antepartum condition or complication
648.84   Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
         postpartum condition or complication
649.20   Bariatric surgery status complicating pregnancy, childbirth, or the puerperium,
         unspecified as to episode of care or not applicable



                                                                                             Page 81
NATIONAL COVERAGE DETERMINATION                                                            82947

649.21 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, delivered,
       with or without mention of antepartum condition
649.22 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, delivered,
       with mention of postpartum complication
649.23 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium,
       antepartum condition or complication
649.24 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, postpartum
       condition or complication
656.60 Excessive fetal growth, unspecified episode of care
656.61 Excessive fetal growth, delivered, with or without antepartum condition
656.63 Excessive fetal growth, antepartum condition or complication
657.00 Polyhydramnios, unspecified episode of care
657.01 Polyhydramnios, delivered, with or without antepartum condition
657.03 Polyhydramnios, antepartum condition or complication
680.0 Carbuncle and furuncle of face
680.1 Carbuncle and furuncle of neck
680.2 Carbuncle and furuncle of trunk
680.3 Carbuncle and furuncle of upper arm and forearm
680.4 Carbuncle and furuncle og hand
680.5 Carbuncle and furuncle oh buttock
680.6 Carbuncle and furuncle of leg
680.7 Carbuncle and furuncle of foot
680.8 Carbuncle and furuncle, other specified sites
680.9 Carbuncle and furuncle, unspecified site
686.00 Pyoderma, unspecified
686.01 Pyoderma, gangrenosum
686.09 Pyoderma, other
686.1 Pyogenic granuloma
686.8 Other specified local infections of skin and subcutaneous tissue
686.9 Unspecified local infection of skin and subcutaneous tissue
698.0 Pruritus ani
698.1 Pruritus of genital organs
704.1 Hirsutism
705.0 Anhidrosis
707.00 Decubitus ulcer, unspecified site
707.01 Decubitus ulcer, elbow
707.02 Decubitus ulcer, upper back
707.03 Decubitus ulcer, lower back
707.04 Decubitus ulcer, hip
707.05 Decubitus ulcer, buttock
707.06 Decubitus ulcer, ankle
707.07 Decubitus ulcer, heel
707.09 Decubitus ulcer, other site
707.10 Ulcer of lower limbs, unspecified
707.11 Ulcer of thigh
707.12 Ulcer of calf
707.13 Ulcer of ankle
707.14 Ulcer of heel and midfoot
707.15 Ulcer of other aprt of foot
707.19 Ulcer of other part of lower limb
707.8 Chronic ulcer of other specified sites
707.9 Chronic ulcer of unspecified site
709.3 Degenerative skin disorders



                                                                                         Page 82
NATIONAL COVERAGE DETERMINATION                             82947

729.1    Mylagia and myositis, unspecified
730.07   Acute osteomyelitis, ankle and foot
730.17   Chronic osteomyelitis, ankle and foot
730.27   Unspecified osteomyelitis, ankle and foot
780.01   Coma
780.02   Transient alteration of awareness
780.09   Other alteration of awareness
780.2    Syncope and collapse
780.31   Febrile convulsions (simple), unspecified
780.32   Complex febrile convulsions
780.39   Other convulsions
780.4    Dizziness and giddiness
780.71   Chronic fatigue syndrome
780.79   Other malaise and fatigue
780.8    Generalized hyperhidrosis
781.0    Abnormal involuntary movements
782.0    Disturbance of skin sensation
783.1    Abnormal weight gain
783.21   Abnormal loss of weight
783.5    Polydipsia
783.6    Polyphagia
785.0    Tachycardia, unspecified
785.4    Gangrene
786.01   Hyperventilation
786.09   Other respiratory abnormality
786.50   Chest pain, unspecified
787.6    Incontinence of feces
787.91   Diarrhea
788.41   Urinary frequency
788.42   Polyuria
788.43   Nocturia
789.1    Hepatomegaly
790.21   Impaired fasting glucose
790.22   Impaired glucose tolerance test
790.29   Other abnormal glucose
790.6    Other abnormal blood chemistry
791.0    Proteinuria
791.5    Glycosuria
796.1    Abnormal reflex
799.4    Cachexia
V23.0    Pregnancy with history of infertility
V23.1    Pregnancy with history of trophoblastic disease
V23.2    Pregnancy with history of abortion
V23.3    Grand multiparity
V23.41   Pregnancy with history of pre-term labor
V23.49   Pregnancy with other poor obstetric history
V23.5    Pregnancy with other poor reproductive history
V23.7    Insufficient prenatal care
V23.81   Elderly primigravida
V23.82   Elderly multigravida
V23.83   Young primigravida
V23.84   Young multigravida
V23.89   Other high risk pregnancy



                                                           Page 83
NATIONAL COVERAGE DETERMINATION                                                               82947

V23.9    Unspecified high-risk pregnancy
V58.63   Long-term (current) use of antiplatelet/antithrombotic
V58.64   Long-term (current) use of non-steroidal anti-inflammatories
V58.65   Long-term (current) use of steroids
V58.67   Long-term (current) use of insulin
V58.69   Long-term (current) use of other medications
V67.2    Follow-up examination following chemotherapy
V67.51   Follow-up examination following completed treatment with high-risk medication, not
         elsewhere classified
V77.1    Special screening for diabetes mellitus




                                                                                          Page 84
NATIONAL COVERAGE DETERMINATION                                                                                    82948


NATIONAL COVERAGE DETERMINATION
82948
82948-Glucose; blood, reagent strip




CPT CODE: 82948



CPT CODE DESCRIPTOR: Glucose; blood, reagent strip



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                      In stable, non-hospitalized patients who are unable or unwilling to do home
                                      glucose monitoring, it may be reasonable and necessary to measure quantitative
                                      blood glucose up to 4 times annually.

                                      Depending on the age and condition of the patient, the type of diabetes, degree of
                                      control, and other co-morbid conditions, more frequent testing may be reasonable
                                      and necessary.



COVERED ICD-9 CODES:
011.00 Tuberculosis of lung, infiltrative, unspecified
011.01 Tuberculosis of lung, infiltrative, bacteriological or histological examination not done
011.02 Tuberculosis of lung, infiltrative, bacteriological or histological examination unknown (at
       present)
011.03 Tuberculosis of lung, infiltrative, tubercle bacilli found (in sputum) by microscopy
011.04 Tuberculosis of lung, infiltrative, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture
011.05 Tuberculosis of lung, infiltrative, tubercle bacilli not found by bacteriological examination,
       but tuberculosis confirmed histologically
011.06 Tuberculosis of lung, infiltrative, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.10 Tuberculosis of lung, nodular, unspecified
011.11 Tuberculosis of lung, nodular, bacteriological or histological examination not done
011.12 Tuberculosis of lung, nodular, bacteriological or histological examination unknown (at
       present)
011.13 Tuberculosis of lung, nodular, tubercle bacilli found (in sputum) by microscopy
011.14 Tuberculosis of lung, nodular, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture
011.15 Tuberculosis of lung, nodular, tubercle bacilli not found by bacteriological examination,
       but tuberculosis confirmed histologically
011.16 Tuberculosis of lung, nodular, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.20 Tuberculosis of lung with cavitation, unspecified
011.21 Tuberculosis of lung with cavitation, bacteriological or histological examination not done
011.22 Tuberculosis of lung with cavitation, bacteriological or histological examination unknown
       (at present)
011.23 Tuberculosis of lung with cavitation, tubercle bacilli found (in sputum) by microscopy
011.24 Tuberculosis of lung with cavitation, tubercle bacilli not found (in sputum) by microscopy,
       but found by bacterial culture
011.25 Tuberculosis of lung with cavitation, tubercle bacilli not found by bacteriological
       examination, but tuberculosis confirmed histologically



                                                                                                                  Page 85
NATIONAL COVERAGE DETERMINATION                                                               82948

011.26 Tuberculosis of lung with cavitation, tubercle bacilli not found by bacteriological or
       histological examination, but tuberculosis confirmed by other methods
011.30 Tuberculosis of bronchus, unspecified
011.31 Tuberculosis of bronchus, bacteriological or histological examination not done
011.32 Tuberculosis of bronchus, bacteriological or histological examination unknown (at
       present)
011.33 Tuberculosis of bronchus, tubercle bacilli found (in sputum) by microscopy
011.34 Tuberculosis of bronchus, tubercle bacilli not found (in sputum) by microscopy, but found
       by bacterial culture
011.35 Tuberculosis of bronchus, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.36 Tuberculosis of bronchus, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.40 Tuberculous fibrosis of lung, unspecified
011.41 Tuberculous fibrosis of lung, bacteriological or histological examination not done
011.42 Tuberculous fibrosis of lung, bacteriological or histological examination unknown (at
       present)
011.43 Tuberculous fibrosis of lung, tubercle bacilli found (in sputum) by microscopy
011.44 Tuberculous fibrosis of lung, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture
011.45 Tuberculous fibrosis of lung, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.46 Tuberculous fibrosis of lung, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.50 Tuberculous bronchiectasis, unspecified
011.51 Tuberculous bronchiectasis, bacteriological or histological examination not done
011.52 Tuberculous bronchiectasis, bacteriological or histological examination unknown (at
       present)
011.53 Tuberculous bronchiectasis, tubercle bacilli found (in sputum) by microscopy
011.54 Tuberculous bronchiectasis, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture
011.55 Tuberculous bronchiectasis, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.56 Tuberculous bronchiectasis, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.60 Tuberculous pneumonia [any form], unspecified
011.61 Tuberculous pneumonia [any form], bacteriological or histological examination not done
011.62 Tuberculous pneumonia [any form], bacteriological or histological examination unknown
       (at present)
011.63 Tuberculous pneumonia [any form], tubercle bacilli found (in sputum) by microscopy
011.64 Tuberculous pneumonia [any form], tubercle bacilli not found (in sputum) by microscopy,
       but found by bacterial culture
011.65 Tuberculous pneumonia [any form], tubercle bacilli not found by bacteriological
       examination, but tuberculosis confirmed histologically
011.66 Tuberculous pneumonia [any form], tubercle bacilli not found by bacteriological or
       histological examination, but tuberculosis confirmed by other methods
011.70 Tuberculous pneumothorax, unspecified
011.71 Tuberculous pneumothorax, bacteriological or histological examination not done
011.72 Tuberculous pneumothorax, bacteriological or histological examination unknown (at
       present)
011.73 Tuberculous pneumothorax, tubercle bacilli found (in sputum) by microscopy
011.74 Tuberculous pneumothorax, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture



                                                                                            Page 86
NATIONAL COVERAGE DETERMINATION                                                           82948

011.75 Tuberculous pneumothorax, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.76 Tuberculous pneumothorax, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.80 Other specified pulmonary tuberculosis, unspecified
011.81 Other specified pulmonary tuberculosis, bacteriological or histological examination not
       done
011.82 Other specified pulmonary tuberculosis, bacteriological or histological examination
       unknown (at present)
011.83 Other specified pulmonary tuberculosis, tubercle bacilli found (in sputum) by microscopy
011.84 Other specified pulmonary tuberculosis, tubercle bacilli not found (in sputum) by
       microscopy, but found by bacterial culture
011.85 Other specified pulmonary tuberculosis, tubercle bacilli not found by bacteriological
       examination, but tuberculosis confirmed histologically
011.86 Other specified pulmonary tuberculosis, tubercle bacilli not found by bacteriological or
       histological examination, but tuberculosis confirmed by other methods
011.90 Pulmonary tuberculosis, unspecified
011.91 Pulmonary tuberculosis, bacteriological or histological examination not done
011.92 Pulmonary tuberculosis, bacteriological or histological examination unknown (at present)
011.93 Pulmonary tuberculosis, tubercle bacilli found (in sputum) by microscopy
011.94 Pulmonary tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found
       by bacterial culture
011.95 Pulmonary tuberculosis, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.96 Pulmonary tuberculosis, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
038.0 Streptococcal septicemia
038.10 Staphylococcal septicemia, unspecified
038.11 Staphylococcus aureus septicemia
038.19 Other staphylococcal septicemia
038.2 Pneumococcal septicemia
038.3 Septicemia due to anaerobes
038.40 Septicemia due to Gram-negative organism, unspecified
038.41 Septicemia due to Hemophilus influenzae [H. influenzae]
038.42 Septicemia due to Escherichia coli [E. coli]
038.43 Septicemia due to Pseudomonas
038.44 Septicemia due to Serratia
038.49 Other Septicemia due to other gram-negative organisms
038.8 Other specified septicemias
038.9 Unspecified septicemia
112.1 Candidiasis of vulva and vagina
112.3 Candidiasis of skin and nails
118    Opportunistic mycoses
157.4 Malignant neoplasm, islets of Langerhans
158.0 Malignant neoplasm, retroperitoneum
211.7 Benign neoplasm of islets of Langerhans
242.00 Toxic diffuse goiter without thyrotoxic crisis or storm
242.01 Toxic diffuse goiter with thyrotoxic crisis or storm
242.10 Toxic uninodular goiter without thyrotoxic crisis or storm
242.11 Toxic uninodular goiter with thyrotoxic crisis or storm
242.20 Toxic multinodular goiter without thyrotoxic crisis or storm
242.21 Toxic multinodular goiter with thyrotoxic crisis or storm
242.30 Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm



                                                                                        Page 87
NATIONAL COVERAGE DETERMINATION                                                                82948

242.31   Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40   Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41   Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
242.80   Thyrotoxicosis of other specified origin without thyrotoxic crisis or storm
242.81   Thyrotoxicosis of other specified origin with thyrotoxic crisis or storm
242.90   Thyrotoxicosis without of goiter or other cause without thyrotoxic crisis or storm
242.91   Thyrotoxicosis without goiter or other cause with mention of thyrotoxic crisis or storm
250.00   Diabetes mellitus without complication, type II or unspecified type, not stated as
         uncontrolled
250.01   Diabetes mellitus without complication, type I, not stated as uncontrolled
250.02   Diabetes mellitus without complication, type II or unspecified type, uncontrolled
250.03   Diabetes mellitus without complication, type I, uncontrolled
250.10   Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
250.11   Diabetes with ketoacidosis, type I, not stated as uncontrolled
250.12   Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13   Diabetes with ketoacidosis, type I, uncontrolled
250.20   Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
250.21   Diabetes with hyperosmolarity, type I, not stated as uncontrolled
250.22   Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23   Diabetes with hyperosmolarity, type I, uncontrolled
250.30   Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
250.31   Diabetes with other coma, type I, not stated as uncontrolled
250.32   Diabetes with other coma, type II or unspecified type, uncontrolled
250.33   Diabetes with other coma type I, uncontrolled
250.40   Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41   Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42   Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43   Diabetes with renal manifestations, type I, uncontrolled
250.50   Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
         uncontrolled
250.51   Diabetes with ophthalmic manifestations, type I, not stated as uncontrolled
250.52   Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53   Diabetes with ophthalmic manifestations, type I, uncontrolled
250.60   Diabetes with neurological manifestations, type II or unspecified type, not stated as
         uncontrolled
250.61   Diabetes with neurological manifestations, type I, not stated as uncontrolled
250.62   Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
250.63   Diabetes with neurological manifestations, type I, uncontrolled
250.70   Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
         uncontrolled
250.71   Diabetes with peripheral circulatory disorders, type I, not stated as uncontrolled
250.72   Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
250.73   Diabetes with peripheral circulatory disorders, type I, uncontrolled
250.80   Diabetes with other specified manifestations, type II or unspecified type, not stated as
         uncontrolled
250.81   Diabetes with other specified manifestations, type I, not stated as uncontrolled
250.82   Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
250.83   Diabetes with other specified manifestations, type I uncontrolled
250.90   Diabetes with unspecified complication, type II or unspecified type, not stated as
         uncontrolled
250.91   Diabetes with unspecified complication, type I, not stated as uncontrolled
250.92   Diabetes with unspecified complication, type II or unspecified type, uncontrolled
250.93   Diabetes with unspecified complication, type I, uncontrolled



                                                                                             Page 88
NATIONAL COVERAGE DETERMINATION                                                            82948

251.0    Hypoglycemic coma
251.1    Other specified hypoglycemia
251.2    Hypoglycemia, unspecified
251.3    Postsurgical hypoinsulinemia
251.4    Abnormality of secretion of glucagon
251.5    Abnormality of secretion of gastrin
251.8    Other specified disorders of pancreatic internal secretion
251.9    Unspecified disorder of pancreatic internal secretion
253.0    Acromegaly and gigantism
253.1    Other and unspecified anterior pituitary hyperfunction
253.2    Panhypopituitarism
253.3    Pituitary dwarfism
253.4    Other anterior pituitary disorders
253.5    Diabetes insipidus
253.6    Other disorders of neurohypophysis
253.7    Iatrogenic pituitary disorders
253.8    Other disorders of the pituitary gland
253.9    Unspecified disorders of the pituitary gland
255.0    Cushing's syndrome
263.0    Malnutrition of moderate degree
263.1    Malnutrition of mild degree
263.2    Arrested development following protein-calorie malnutrition
263.8    Other protein-calorie malnutrition
263.9    Unspecified protein-calorie malnutrition
271.0    Glycogenosis
271.1    Galactosemia
271.2    Hereditary fructose intolerance
271.3    Intestinal disaccharidase deficiencies and disaccharide malabsorption
271.4    Renal glycosuria
271.8    Other specified disorders of carbohydrate transport and metabolism
271.9    Unspecified disorder of carbohydrate transport and metabolism
272.0    Pure hypercholesterolemia
272.1    Pure hyperglyceridemia
272.2    Mixed hyperlipidemia
272.3    Hyperchylomicronemia
272.4    Other and unspecified hyperlipidemia
275.0    Disorders of iron metabolism
276.0    Hyperosmolality and/or hypernatremia
276.1    Hyposmolality and/or hyponatremia
276.2    Acidosis
276.3    Alkalosis
276.4    Mixed acid-base balance disorder
276.50   Volume depletion, unspecified
276.51   Dehydration
276.52   Hypovolemia
276.6    Fluid overload
276.7    Hyperpotassemia
276.8    Hypopotassemia
276.9    Electrolyte and fluid disorders not elsewhere classified
278.3    Hypercarotinemia
293.0    Delirium due to conditions classified elsewhere
294.9    Unspecified persistent mental disorders due to conditions classified elsewhere
298.9    Unspecified psychosis



                                                                                          Page 89
NATIONAL COVERAGE DETERMINATION                                          82948

300.9    Unspecified nonpsychotic mental disorder
310.1    Personality change due to conditions classified elsewhere
331.83   Mild cognitive impairment, so stated
337.9    Unspecified disorder of autonomic nervous system
345.10   Generalized convulsive epilepsy without intractable epilepsy
345.11   Generalized convulsive epilepsy with intractable epilepsy
348.31   Metabolic encephalopathy
355.9    Mononeuritis of unspecified site
356.9    Unspecified idiopathic peripheral neuropathy
357.9    Unspecified polyneuropathy
362.10   Background retinopathy, unspecified
362.18   Retinal vasculitis
362.29   Other nondiabetic proliferative retinopathy
362.50   Macular degeneration (senile), unspecified
362.51   Nonexudative senile macular degeneration
362.52   Exudative senile macular degeneration
362.53   Cystoid macular degeneration
362.54   Macular cyst, hole, or pseudohole
362.55   Toxic maculopathy
362.56   Macular puckering
362.57   Drusen (degenerative)
362.60   Peripheral retinal degeneration, unspecified
362.61   Paving stone degeneration
362.62   Microcystoid degeneration
362.63   Lattice degeneration
362.64   Senile reticular degeneration
362.65   Secondary pigmentary degeneration
362.66   Secondary vitreoretinal degenerations
362.81   Retinal hemorrhage
362.82   Retinal exudates and deposits
362.83   Retinal edema
362.84   Retinal ischemia
362.85   Retinal nerve fiber bundle defects
362.89   Other retinal disorders
362.9    Unspecified retinal disorder
365.04   Ocular hypertension
365.32   Corticosteroid-induced glucoma, residual stage
366.00   Nonsenile cataract, unspecified
366.01   Anterior subcapsular polar cataract
366.02   Posterior subcapsular polar cataract
366.03   Cortical, lamellar, or zonular cataract
366.04   Nuclear cataract
366.09   Other and combined forms of nonsenile cataract
366.10   Senile cataract, unspecified
366.11   Pseudoexfoliation of lens capsule
366.12   Incipient cataract
366.13   Anterior subcapsular polar senile cataract
366.14   Posterior subcapsular polar senile cataract
366.15   Cortical senile cataract
366.16   Nuclear sclerosis
366.17   Total or mature cataract
366.18   Hypermature cataract
366.19   Other and combined forms of senile cataract



                                                                        Page 90
NATIONAL COVERAGE DETERMINATION                                                      82948

367.1    Myopia
368.8    Other specified visual disturbances
373.00   Blepharitis, unspecified
377.24   Pseudopapilledema
377.9    Unspecified disorder of optic nerve and visual pathways
378.50   Paralytic strabismus, unspecified
378.51   Third or oculomotor nerve palsy, partial
378.52   Third or oculomotor nerve palsy, total
378.53   Fourth or trochlear nerve palsy
378.54   Sixth or abducens nerve palsy
378.55   External ophthalmoplegia
379.45   Argyll Robertson pupil, atypical
410.00   Infarction of anterolateral wall, episode of care unspecified
410.01   Infarction of anterolateral wall, initial episode of care
410.02   Infarction of anterolateral wall, subsequent episode of care
410.10   Infarction of other anterior wall, episode of care unspecified
410.11   Infarction of other anterior wall, initial episode of care
410.12   Infarction of other anterior wall, subsequent episode of care
410.20   Infarction of inferolateral wall, episode of care unspecified
410.21   Infarction of inferolateral wall, initial episode of care
410.22   Infarction of inferolateral wall, subsequent episode of care
410.30   Infarction of inferoposterior wall, episode of care unspecified
410.31   Infarction of inferoposterior wall, initial episode of care
410.32   Infarction of inferoposterior wall,subsequent episode of care
410.40   Infarction of other inferior wall, episode of care unspecified
410.41   Infarction of other inferior wal, initial episode of care
410.42   Infarction of other inferior wall, subsequent episode of care
410.50   Infarction of other lateral wall, episode of care unspecified
410.51   Infarction of other lateral wall, initial episode of care
410.52   Infarction of other lateral wall, subsequent episode of care
410.60   True posterior wall infarction, episode of care unspecified
410.61   True posterior wall infarction, initial episode of care
410.62   True posterior wall infarction, subsequent episode of care
410.70   Subendocardial infarction, episode of care unspecified
410.71   Subendocardial infarction, initial episode of care
410.72   Subendocardial infarction, subsequent episode of care
410.80   Infarction of other specified sites, episode of care unspecified
410.81   Infarction of other specified sites, initial episode of care
410.82   Infarction of other specified sites, subsequent episode of care
410.90   Infarction, unspecified site, episode of care unspecified
410.91   Infarction, unspecified site, initial episode of care
410.92   Infarction, unspecified site, subsequent episode of care
414.00   Coronary atherosclerosis of unspecified vessel
414.01   Coronary atherosclerosis of native coronary artery
414.02   Coronary atherosclerosis of autologous biological bypass graft
414.03   Coronary atherosclerosis of nonautologous biological bypass graft
414.04   Coronary atherosclerosis of artery bypass graft
414.05   Coronary atherosclerosis of unspecified bypass graft
414.06   Coronary atherosclerosis of native coronary artery of transplanted heart
414.07   Coronary atherosclerosis, of bypass graft of transplanted heart
414.10   Aneurysm of heart (wall)
414.11   Aneurysm of coronary vessels
414.12   Dissection of coronary artery



                                                                                    Page 91
NATIONAL COVERAGE DETERMINATION                                         82948

414.19   Aneurysm, other
425.9    Secondary cardiomyopathy, unspecified
440.23   Atherosclerosis of the extremities with ulceration
440.24   Atherosclerosis of the extremities with gangrene
440.9    Generalized and unspecified atherosclerosis
458.0    Orthostatic hypotension
462      Acute pharyngitis
466.0    Acute bronchitis
480.0    Pneumonia due to adenovirus
480.1    Pneumonia due to respiratory syncytial virus
480.2    Pneumonia due to parainfluenza virus
480.3    Pneumonia due to SARS-associated coronavirus
480.8    Pneumonia due to other virus not elsewhere classified
480.9    Viral pneumonia, unspecified
481      Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]
482.0    Pneumonia due to Klebsiella pneumoniae
482.1    Pneumonia due to Pseudomonas
482.2    Pneumonia due to Hemophilus influenzae [H. influenzae]
482.30   Pneumonia due to Streptococcus, unspecified
482.31   Pneumonia due to Streptococcus, group A
482.32   Pneumonia due to Streptococcus, group B
482.39   Pneumonia due to other Streptococcus
482.40   Pneumonia due to Staphylococcus, unspecified
482.41   Pneumonia due to Staphylococcus aureus
482.49   Other Staphylococcal pneumonia
482.81   Pneumonia due to anaerobes
482.82   Pneumonia due to Escherichia coli [E. coli]
482.83   Pneumonia due to other gram-negative bacteria
482.84   Legionnaires' disease
482.89   Pneumonia due to other specified bacteria
482.9    Bacterial pneumonia unspecified
483.0    Pneumonia due to Mycoplasma pneumoniae
483.1    Legionnaires disease
483.8    Pneumonia due to other specified organism
484.1    Pneumonia in cytomegalic inclusion disease
484.3    Pneumonia in whooping cough
484.5    Pneumonia in anthrax
484.6    Pneumonia in aspergillosis
484.7    Pneumonia in other systemic mycoses
484.8    Pneumonia in other infectious diseases classified elsewhere
485      Bronchopneumonia, organism unspecified
486      Pneumonia, organism unspecified
490      Bronchitis, not specified as acute or chronic
491.0    Simple chronic bronchitis
491.1    Mucopurulent chronic bronchitis
491.20   Obstructive chronic bronchitis without exacerbation
491.21   Obstructive chronic bronchitis with (acute) exacerbation
491.22   Obstructive chronic bronchitis with acute bronchitis
491.8    Other chronic bronchitis
491.9    Unspecified chronic bronchitis
527.7    Disturbance of salivary secretion
528.00   Stomatitis and mucositis, unspecified
528.09   Other stomatitis and mucositis (ulcerative)



                                                                       Page 92
NATIONAL COVERAGE DETERMINATION                                                               82948

535.50   Unspecified gastritis and gastroduodenitis without hemorrhage
535.51   Unspecified gastritis and gastroduodenitis with hemorrhage
536.8    Dyspepsia and other specified disorders of function of stomach
571.8    Other chronic nonalcoholic liver disease
572.0    Abscess of liver
572.1    Portal pyemia
572.2    Hepatic coma
572.3    Portal hypertension
572.4    Hepatorenal syndrome
572.8    Other sequelae of chronic liver disease
574.50   Calculus of bile duct without cholecystitis without obstruction
574.51   Calculus of bile duct without cholecystitis with obstruction
575.0    Acute cholecystitis
575.10   Cholecystitis, unspecified
575.11   Cholecystitis, chronic
575.12   Cholecystitis, acute and chronic
576.1    Cholangitis
577.0    Acute pancreatitis
577.1    Chronic pancreatitis
577.8    Other specified diseases of pancreas
590.00   Chronic pyelonephritis without lesion of renal medullary necrosis
590.01   Chronic pyelonephritis with lesion of renal medullary
590.10   Acute pyonephrosis without lesion of renal medullary necrosis
590.11   Acute pyonephrosis with lesion of renal medullary necrosis
590.2    Renal and perinephric abscess
590.3    Pyeloureteritis cystica
590.80   Pyelonephritis, unspecified
590.81   Pyelitis or pyelonephritis in diseases classified elsewhere
590.9    Infection of kidney, unspecified
595.9    Cystitis, unspecified
596.4    Atony of bladder
596.53   Paralysis of bladder
599.0    Urinary tract infection, site not specified
607.84   Impotence of organic origin
608.89   Other Vascular disorders of male genital orga
616.10   Vaginitis and vulvovaginitis, unspecified
626.0    Absence of menstruation
626.4    Irregular menstrual cycle
628.9    Infertility, female, of unspecified origin
648.00   Other conditions of mother complicating pregnancy, diabetes mellitus, unspecified
         episode of care
648.03   Other conditions of mother complicating pregnancy, diabetes mellitus, antepartum
         condition or complication
648.04   Other conditions of mother complicating pregnancy, diabetes mellitus, postpartum
         condition or complication
648.80   Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
         unspecified episode of care
648.83   Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
         antepartum condition or complication
648.84   Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
         postpartum condition or complication
649.20   Bariatric surgery status complicating pregnancy, childbirth, or the puerperium,
         unspecified as to episode of care or not applicable



                                                                                             Page 93
NATIONAL COVERAGE DETERMINATION                                                            82948

649.21 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, delivered,
       with or without mention of antepartum condition
649.22 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, delivered,
       with mention of postpartum complication
649.23 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium,
       antepartum condition or complication
649.24 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, postpartum
       condition or complication
656.60 Excessive fetal growth, unspecified episode of care
656.61 Excessive fetal growth, delivered, with or without antepartum condition
656.63 Excessive fetal growth, antepartum condition or complication
657.00 Polyhydramnios, unspecified episode of care
657.01 Polyhydramnios, delivered, with or without antepartum condition
657.03 Polyhydramnios, antepartum condition or complication
680.0 Carbuncle and furuncle of face
680.1 Carbuncle and furuncle of neck
680.2 Carbuncle and furuncle of trunk
680.3 Carbuncle and furuncle of upper arm and forearm
680.4 Carbuncle and furuncle og hand
680.5 Carbuncle and furuncle oh buttock
680.6 Carbuncle and furuncle of leg
680.7 Carbuncle and furuncle of foot
680.8 Carbuncle and furuncle, other specified sites
680.9 Carbuncle and furuncle, unspecified site
686.00 Pyoderma, unspecified
686.01 Pyoderma, gangrenosum
686.09 Pyoderma, other
686.1 Pyogenic granuloma
686.8 Other specified local infections of skin and subcutaneous tissue
686.9 Unspecified local infection of skin and subcutaneous tissue
698.0 Pruritus ani
698.1 Pruritus of genital organs
704.1 Hirsutism
705.0 Anhidrosis
707.00 Decubitus ulcer, unspecified site
707.01 Decubitus ulcer, elbow
707.02 Decubitus ulcer, upper back
707.03 Decubitus ulcer, lower back
707.04 Decubitus ulcer, hip
707.05 Decubitus ulcer, buttock
707.06 Decubitus ulcer, ankle
707.07 Decubitus ulcer, heel
707.09 Decubitus ulcer, other site
707.10 Ulcer of lower limbs, unspecified
707.11 Ulcer of thigh
707.12 Ulcer of calf
707.13 Ulcer of ankle
707.14 Ulcer of heel and midfoot
707.15 Ulcer of other aprt of foot
707.19 Ulcer of other part of lower limb
707.8 Chronic ulcer of other specified sites
707.9 Chronic ulcer of unspecified site
709.3 Degenerative skin disorders



                                                                                         Page 94
NATIONAL COVERAGE DETERMINATION                             82948

729.1    Mylagia and myositis, unspecified
730.07   Acute osteomyelitis, ankle and foot
730.17   Chronic osteomyelitis, ankle and foot
730.27   Unspecified osteomyelitis, ankle and foot
780.01   Coma
780.02   Transient alteration of awareness
780.09   Other alteration of awareness
780.2    Syncope and collapse
780.31   Febrile convulsions (simple), unspecified
780.32   Complex febrile convulsions
780.39   Other convulsions
780.4    Dizziness and giddiness
780.71   Chronic fatigue syndrome
780.79   Other malaise and fatigue
780.8    Generalized hyperhidrosis
781.0    Abnormal involuntary movements
782.0    Disturbance of skin sensation
783.1    Abnormal weight gain
783.21   Abnormal loss of weight
783.5    Polydipsia
783.6    Polyphagia
785.0    Tachycardia, unspecified
785.4    Gangrene
786.01   Hyperventilation
786.09   Other respiratory abnormality
786.50   Chest pain, unspecified
787.6    Incontinence of feces
787.91   Diarrhea
788.41   Urinary frequency
788.42   Polyuria
788.43   Nocturia
789.1    Hepatomegaly
790.21   Impaired fasting glucose
790.22   Impaired glucose tolerance test
790.29   Other abnormal glucose
790.6    Other abnormal blood chemistry
791.0    Proteinuria
791.5    Glycosuria
796.1    Abnormal reflex
799.4    Cachexia
V23.0    Pregnancy with history of infertility
V23.1    Pregnancy with history of trophoblastic disease
V23.2    Pregnancy with history of abortion
V23.3    Grand multiparity
V23.41   Pregnancy with history of pre-term labor
V23.49   Pregnancy with other poor obstetric history
V23.5    Pregnancy with other poor reproductive history
V23.7    Insufficient prenatal care
V23.81   Elderly primigravida
V23.82   Elderly multigravida
V23.83   Young primigravida
V23.84   Young multigravida
V23.89   Other high risk pregnancy



                                                           Page 95
NATIONAL COVERAGE DETERMINATION                                                               82948

V23.9    Unspecified high-risk pregnancy
V58.63   Long-term (current) use of antiplatelet/antithrombotic
V58.64   Long-term (current) use of non-steroidal anti-inflammatories
V58.65   Long-term (current) use of steroids
V58.67   Long-term (current) use of insulin
V58.69   Long-term (current) use of other medications
V67.2    Follow-up examination following chemotherapy
V67.51   Follow-up examination following completed treatment with high-risk medication, not
         elsewhere classified




                                                                                          Page 96
NATIONAL COVERAGE DETERMINATION                                                                                         82962


NATIONAL COVERAGE DETERMINATION
82962
82962-Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use




CPT CODE: 82962



CPT CODE DESCRIPTOR: Glucose, blood by glucose monitoring device(s) cleared by the
      FDA specifically for home use



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                           In stable, non-hospitalized patients who are unable or unwilling to do home
                                           glucose monitoring, it may be reasonable and necessary to measure quantitative
                                           blood glucose up to 4 times annually.

                                           Depending on the age and condition of the patient, the type of diabetes, degree of
                                           control, and other co-morbid conditions, more frequent testing may be reasonable
                                           and necessary.



COVERED ICD-9 CODES:
011.00 Tuberculosis of lung, infiltrative, unspecified
011.01 Tuberculosis of lung, infiltrative, bacteriological or histological examination not done
011.02 Tuberculosis of lung, infiltrative, bacteriological or histological examination unknown (at
       present)
011.03 Tuberculosis of lung, infiltrative, tubercle bacilli found (in sputum) by microscopy
011.04 Tuberculosis of lung, infiltrative, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture
011.05 Tuberculosis of lung, infiltrative, tubercle bacilli not found by bacteriological examination,
       but tuberculosis confirmed histologically
011.06 Tuberculosis of lung, infiltrative, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.10 Tuberculosis of lung, nodular, unspecified
011.11 Tuberculosis of lung, nodular, bacteriological or histological examination not done
011.12 Tuberculosis of lung, nodular, bacteriological or histological examination unknown (at
       present)
011.13 Tuberculosis of lung, nodular, tubercle bacilli found (in sputum) by microscopy
011.14 Tuberculosis of lung, nodular, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture
011.15 Tuberculosis of lung, nodular, tubercle bacilli not found by bacteriological examination,
       but tuberculosis confirmed histologically
011.16 Tuberculosis of lung, nodular, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.20 Tuberculosis of lung with cavitation, unspecified
011.21 Tuberculosis of lung with cavitation, bacteriological or histological examination not done
011.22 Tuberculosis of lung with cavitation, bacteriological or histological examination unknown
       (at present)
011.23 Tuberculosis of lung with cavitation, tubercle bacilli found (in sputum) by microscopy
011.24 Tuberculosis of lung with cavitation, tubercle bacilli not found (in sputum) by microscopy,
       but found by bacterial culture
011.25 Tuberculosis of lung with cavitation, tubercle bacilli not found by bacteriological
       examination, but tuberculosis confirmed histologically


                                                                                                                       Page 97
NATIONAL COVERAGE DETERMINATION                                                               82962

011.26 Tuberculosis of lung with cavitation, tubercle bacilli not found by bacteriological or
       histological examination, but tuberculosis confirmed by other methods
011.30 Tuberculosis of bronchus, unspecified
011.31 Tuberculosis of bronchus, bacteriological or histological examination not done
011.32 Tuberculosis of bronchus, bacteriological or histological examination unknown (at
       present)
011.33 Tuberculosis of bronchus, tubercle bacilli found (in sputum) by microscopy
011.34 Tuberculosis of bronchus, tubercle bacilli not found (in sputum) by microscopy, but found
       by bacterial culture
011.35 Tuberculosis of bronchus, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.36 Tuberculosis of bronchus, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.40 Tuberculous fibrosis of lung, unspecified
011.41 Tuberculous fibrosis of lung, bacteriological or histological examination not done
011.42 Tuberculous fibrosis of lung, bacteriological or histological examination unknown (at
       present)
011.43 Tuberculous fibrosis of lung, tubercle bacilli found (in sputum) by microscopy
011.44 Tuberculous fibrosis of lung, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture
011.45 Tuberculous fibrosis of lung, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.46 Tuberculous fibrosis of lung, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.50 Tuberculous bronchiectasis, unspecified
011.51 Tuberculous bronchiectasis, bacteriological or histological examination not done
011.52 Tuberculous bronchiectasis, bacteriological or histological examination unknown (at
       present)
011.53 Tuberculous bronchiectasis, tubercle bacilli found (in sputum) by microscopy
011.54 Tuberculous bronchiectasis, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture
011.55 Tuberculous bronchiectasis, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.56 Tuberculous bronchiectasis, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.60 Tuberculous pneumonia [any form], unspecified
011.61 Tuberculous pneumonia [any form], bacteriological or histological examination not done
011.62 Tuberculous pneumonia [any form], bacteriological or histological examination unknown
       (at present)
011.63 Tuberculous pneumonia [any form], tubercle bacilli found (in sputum) by microscopy
011.64 Tuberculous pneumonia [any form], tubercle bacilli not found (in sputum) by microscopy,
       but found by bacterial culture
011.65 Tuberculous pneumonia [any form], tubercle bacilli not found by bacteriological
       examination, but tuberculosis confirmed histologically
011.66 Tuberculous pneumonia [any form], tubercle bacilli not found by bacteriological or
       histological examination, but tuberculosis confirmed by other methods
011.70 Tuberculous pneumothorax, unspecified
011.71 Tuberculous pneumothorax, bacteriological or histological examination not done
011.72 Tuberculous pneumothorax, bacteriological or histological examination unknown (at
       present)
011.73 Tuberculous pneumothorax, tubercle bacilli found (in sputum) by microscopy
011.74 Tuberculous pneumothorax, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture



                                                                                            Page 98
NATIONAL COVERAGE DETERMINATION                                                           82962

011.75 Tuberculous pneumothorax, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.76 Tuberculous pneumothorax, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
011.80 Other specified pulmonary tuberculosis, unspecified
011.81 Other specified pulmonary tuberculosis, bacteriological or histological examination not
       done
011.82 Other specified pulmonary tuberculosis, bacteriological or histological examination
       unknown (at present)
011.83 Other specified pulmonary tuberculosis, tubercle bacilli found (in sputum) by microscopy
011.84 Other specified pulmonary tuberculosis, tubercle bacilli not found (in sputum) by
       microscopy, but found by bacterial culture
011.85 Other specified pulmonary tuberculosis, tubercle bacilli not found by bacteriological
       examination, but tuberculosis confirmed histologically
011.86 Other specified pulmonary tuberculosis, tubercle bacilli not found by bacteriological or
       histological examination, but tuberculosis confirmed by other methods
011.90 Pulmonary tuberculosis, unspecified
011.91 Pulmonary tuberculosis, bacteriological or histological examination not done
011.92 Pulmonary tuberculosis, bacteriological or histological examination unknown (at present)
011.93 Pulmonary tuberculosis, tubercle bacilli found (in sputum) by microscopy
011.94 Pulmonary tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found
       by bacterial culture
011.95 Pulmonary tuberculosis, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
011.96 Pulmonary tuberculosis, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
038.0 Streptococcal septicemia
038.10 Staphylococcal septicemia, unspecified
038.11 Staphylococcus aureus septicemia
038.19 Other staphylococcal septicemia
038.2 Pneumococcal septicemia
038.3 Septicemia due to anaerobes
038.40 Septicemia due to Gram-negative organism, unspecified
038.41 Septicemia due to Hemophilus influenzae [H. influenzae]
038.42 Septicemia due to Escherichia coli [E. coli]
038.43 Septicemia due to Pseudomonas
038.44 Septicemia due to Serratia
038.49 Other Septicemia due to other gram-negative organisms
038.8 Other specified septicemias
038.9 Unspecified septicemia
112.1 Candidiasis of vulva and vagina
112.3 Candidiasis of skin and nails
118    Opportunistic mycoses
157.4 Malignant neoplasm, islets of Langerhans
158.0 Malignant neoplasm, retroperitoneum
211.7 Benign neoplasm of islets of Langerhans
242.00 Toxic diffuse goiter without thyrotoxic crisis or storm
242.01 Toxic diffuse goiter with thyrotoxic crisis or storm
242.10 Toxic uninodular goiter without thyrotoxic crisis or storm
242.11 Toxic uninodular goiter with thyrotoxic crisis or storm
242.20 Toxic multinodular goiter without thyrotoxic crisis or storm
242.21 Toxic multinodular goiter with thyrotoxic crisis or storm
242.30 Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm



                                                                                        Page 99
NATIONAL COVERAGE DETERMINATION                                                                82962

242.31   Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40   Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41   Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
242.80   Thyrotoxicosis of other specified origin without thyrotoxic crisis or storm
242.81   Thyrotoxicosis of other specified origin with thyrotoxic crisis or storm
242.90   Thyrotoxicosis without of goiter or other cause without thyrotoxic crisis or storm
242.91   Thyrotoxicosis without goiter or other cause with mention of thyrotoxic crisis or storm
250.00   Diabetes mellitus without complication, type II or unspecified type, not stated as
         uncontrolled
250.01   Diabetes mellitus without complication, type I, not stated as uncontrolled
250.02   Diabetes mellitus without complication, type II or unspecified type, uncontrolled
250.03   Diabetes mellitus without complication, type I, uncontrolled
250.10   Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
250.11   Diabetes with ketoacidosis, type I, not stated as uncontrolled
250.12   Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13   Diabetes with ketoacidosis, type I, uncontrolled
250.20   Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
250.21   Diabetes with hyperosmolarity, type I, not stated as uncontrolled
250.22   Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23   Diabetes with hyperosmolarity, type I, uncontrolled
250.30   Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
250.31   Diabetes with other coma, type I, not stated as uncontrolled
250.32   Diabetes with other coma, type II or unspecified type, uncontrolled
250.33   Diabetes with other coma type I, uncontrolled
250.40   Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41   Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42   Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43   Diabetes with renal manifestations, type I, uncontrolled
250.50   Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
         uncontrolled
250.51   Diabetes with ophthalmic manifestations, type I, not stated as uncontrolled
250.52   Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53   Diabetes with ophthalmic manifestations, type I, uncontrolled
250.60   Diabetes with neurological manifestations, type II or unspecified type, not stated as
         uncontrolled
250.61   Diabetes with neurological manifestations, type I, not stated as uncontrolled
250.62   Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
250.63   Diabetes with neurological manifestations, type I, uncontrolled
250.70   Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
         uncontrolled
250.71   Diabetes with peripheral circulatory disorders, type I, not stated as uncontrolled
250.72   Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
250.73   Diabetes with peripheral circulatory disorders, type I, uncontrolled
250.80   Diabetes with other specified manifestations, type II or unspecified type, not stated as
         uncontrolled
250.81   Diabetes with other specified manifestations, type I, not stated as uncontrolled
250.82   Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
250.83   Diabetes with other specified manifestations, type I uncontrolled
250.90   Diabetes with unspecified complication, type II or unspecified type, not stated as
         uncontrolled
250.91   Diabetes with unspecified complication, type I, not stated as uncontrolled
250.92   Diabetes with unspecified complication, type II or unspecified type, uncontrolled
250.93   Diabetes with unspecified complication, type I, uncontrolled



                                                                                           Page 100
NATIONAL COVERAGE DETERMINATION                                                             82962

251.0    Hypoglycemic coma
251.1    Other specified hypoglycemia
251.2    Hypoglycemia, unspecified
251.3    Postsurgical hypoinsulinemia
251.4    Abnormality of secretion of glucagon
251.5    Abnormality of secretion of gastrin
251.8    Other specified disorders of pancreatic internal secretion
251.9    Unspecified disorder of pancreatic internal secretion
253.0    Acromegaly and gigantism
253.1    Other and unspecified anterior pituitary hyperfunction
253.2    Panhypopituitarism
253.3    Pituitary dwarfism
253.4    Other anterior pituitary disorders
253.5    Diabetes insipidus
253.6    Other disorders of neurohypophysis
253.7    Iatrogenic pituitary disorders
253.8    Other disorders of the pituitary gland
253.9    Unspecified disorders of the pituitary gland
255.0    Cushing's syndrome
263.0    Malnutrition of moderate degree
263.1    Malnutrition of mild degree
263.2    Arrested development following protein-calorie malnutrition
263.8    Other protein-calorie malnutrition
263.9    Unspecified protein-calorie malnutrition
271.0    Glycogenosis
271.1    Galactosemia
271.2    Hereditary fructose intolerance
271.3    Intestinal disaccharidase deficiencies and disaccharide malabsorption
271.4    Renal glycosuria
271.8    Other specified disorders of carbohydrate transport and metabolism
271.9    Unspecified disorder of carbohydrate transport and metabolism
272.0    Pure hypercholesterolemia
272.1    Pure hyperglyceridemia
272.2    Mixed hyperlipidemia
272.3    Hyperchylomicronemia
272.4    Other and unspecified hyperlipidemia
275.0    Disorders of iron metabolism
276.0    Hyperosmolality and/or hypernatremia
276.1    Hyposmolality and/or hyponatremia
276.2    Acidosis
276.3    Alkalosis
276.4    Mixed acid-base balance disorder
276.50   Volume depletion, unspecified
276.51   Dehydration
276.52   Hypovolemia
276.6    Fluid overload
276.7    Hyperpotassemia
276.8    Hypopotassemia
276.9    Electrolyte and fluid disorders not elsewhere classified
278.3    Hypercarotinemia
293.0    Delirium due to conditions classified elsewhere
294.9    Unspecified persistent mental disorders due to conditions classified elsewhere
298.9    Unspecified psychosis



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NATIONAL COVERAGE DETERMINATION                                           82962

300.9    Unspecified nonpsychotic mental disorder
310.1    Personality change due to conditions classified elsewhere
331.83   Mild cognitive impairment, so stated
337.9    Unspecified disorder of autonomic nervous system
345.10   Generalized convulsive epilepsy without intractable epilepsy
345.11   Generalized convulsive epilepsy with intractable epilepsy
348.31   Metabolic encephalopathy
355.9    Mononeuritis of unspecified site
356.9    Unspecified idiopathic peripheral neuropathy
357.9    Unspecified polyneuropathy
362.10   Background retinopathy, unspecified
362.18   Retinal vasculitis
362.29   Other nondiabetic proliferative retinopathy
362.50   Macular degeneration (senile), unspecified
362.51   Nonexudative senile macular degeneration
362.52   Exudative senile macular degeneration
362.53   Cystoid macular degeneration
362.54   Macular cyst, hole, or pseudohole
362.55   Toxic maculopathy
362.56   Macular puckering
362.57   Drusen (degenerative)
362.60   Peripheral retinal degeneration, unspecified
362.61   Paving stone degeneration
362.62   Microcystoid degeneration
362.63   Lattice degeneration
362.64   Senile reticular degeneration
362.65   Secondary pigmentary degeneration
362.66   Secondary vitreoretinal degenerations
362.81   Retinal hemorrhage
362.82   Retinal exudates and deposits
362.83   Retinal edema
362.84   Retinal ischemia
362.85   Retinal nerve fiber bundle defects
362.89   Other retinal disorders
362.9    Unspecified retinal disorder
365.04   Ocular hypertension
365.32   Corticosteroid-induced glucoma, residual stage
366.00   Nonsenile cataract, unspecified
366.01   Anterior subcapsular polar cataract
366.02   Posterior subcapsular polar cataract
366.03   Cortical, lamellar, or zonular cataract
366.04   Nuclear cataract
366.09   Other and combined forms of nonsenile cataract
366.10   Senile cataract, unspecified
366.11   Pseudoexfoliation of lens capsule
366.12   Incipient cataract
366.13   Anterior subcapsular polar senile cataract
366.14   Posterior subcapsular polar senile cataract
366.15   Cortical senile cataract
366.16   Nuclear sclerosis
366.17   Total or mature cataract
366.18   Hypermature cataract
366.19   Other and combined forms of senile cataract



                                                                        Page 102
NATIONAL COVERAGE DETERMINATION                                                       82962

367.1    Myopia
368.8    Other specified visual disturbances
373.00   Blepharitis, unspecified
377.24   Pseudopapilledema
377.9    Unspecified disorder of optic nerve and visual pathways
378.50   Paralytic strabismus, unspecified
378.51   Third or oculomotor nerve palsy, partial
378.52   Third or oculomotor nerve palsy, total
378.53   Fourth or trochlear nerve palsy
378.54   Sixth or abducens nerve palsy
378.55   External ophthalmoplegia
379.45   Argyll Robertson pupil, atypical
410.00   Infarction of anterolateral wall, episode of care unspecified
410.01   Infarction of anterolateral wall, initial episode of care
410.02   Infarction of anterolateral wall, subsequent episode of care
410.10   Infarction of other anterior wall, episode of care unspecified
410.11   Infarction of other anterior wall, initial episode of care
410.12   Infarction of other anterior wall, subsequent episode of care
410.20   Infarction of inferolateral wall, episode of care unspecified
410.21   Infarction of inferolateral wall, initial episode of care
410.22   Infarction of inferolateral wall, subsequent episode of care
410.30   Infarction of inferoposterior wall, episode of care unspecified
410.31   Infarction of inferoposterior wall, initial episode of care
410.32   Infarction of inferoposterior wall,subsequent episode of care
410.40   Infarction of other inferior wall, episode of care unspecified
410.41   Infarction of other inferior wal, initial episode of care
410.42   Infarction of other inferior wall, subsequent episode of care
410.50   Infarction of other lateral wall, episode of care unspecified
410.51   Infarction of other lateral wall, initial episode of care
410.52   Infarction of other lateral wall, subsequent episode of care
410.60   True posterior wall infarction, episode of care unspecified
410.61   True posterior wall infarction, initial episode of care
410.62   True posterior wall infarction, subsequent episode of care
410.70   Subendocardial infarction, episode of care unspecified
410.71   Subendocardial infarction, initial episode of care
410.72   Subendocardial infarction, subsequent episode of care
410.80   Infarction of other specified sites, episode of care unspecified
410.81   Infarction of other specified sites, initial episode of care
410.82   Infarction of other specified sites, subsequent episode of care
410.90   Infarction, unspecified site, episode of care unspecified
410.91   Infarction, unspecified site, initial episode of care
410.92   Infarction, unspecified site, subsequent episode of care
414.00   Coronary atherosclerosis of unspecified vessel
414.01   Coronary atherosclerosis of native coronary artery
414.02   Coronary atherosclerosis of autologous biological bypass graft
414.03   Coronary atherosclerosis of nonautologous biological bypass graft
414.04   Coronary atherosclerosis of artery bypass graft
414.05   Coronary atherosclerosis of unspecified bypass graft
414.06   Coronary atherosclerosis of native coronary artery of transplanted heart
414.07   Coronary atherosclerosis, of bypass graft of transplanted heart
414.10   Aneurysm of heart (wall)
414.11   Aneurysm of coronary vessels
414.12   Dissection of coronary artery



                                                                                    Page 103
NATIONAL COVERAGE DETERMINATION                                          82962

414.19   Aneurysm, other
425.9    Secondary cardiomyopathy, unspecified
440.23   Atherosclerosis of the extremities with ulceration
440.24   Atherosclerosis of the extremities with gangrene
440.9    Generalized and unspecified atherosclerosis
458.0    Orthostatic hypotension
462      Acute pharyngitis
466.0    Acute bronchitis
480.0    Pneumonia due to adenovirus
480.1    Pneumonia due to respiratory syncytial virus
480.2    Pneumonia due to parainfluenza virus
480.3    Pneumonia due to SARS-associated coronavirus
480.8    Pneumonia due to other virus not elsewhere classified
480.9    Viral pneumonia, unspecified
481      Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]
482.0    Pneumonia due to Klebsiella pneumoniae
482.1    Pneumonia due to Pseudomonas
482.2    Pneumonia due to Hemophilus influenzae [H. influenzae]
482.30   Pneumonia due to Streptococcus, unspecified
482.31   Pneumonia due to Streptococcus, group A
482.32   Pneumonia due to Streptococcus, group B
482.39   Pneumonia due to other Streptococcus
482.40   Pneumonia due to Staphylococcus, unspecified
482.41   Pneumonia due to Staphylococcus aureus
482.49   Other Staphylococcal pneumonia
482.81   Pneumonia due to anaerobes
482.82   Pneumonia due to Escherichia coli [E. coli]
482.83   Pneumonia due to other gram-negative bacteria
482.84   Legionnaires' disease
482.89   Pneumonia due to other specified bacteria
482.9    Bacterial pneumonia unspecified
483.0    Pneumonia due to Mycoplasma pneumoniae
483.1    Legionnaires disease
483.8    Pneumonia due to other specified organism
484.1    Pneumonia in cytomegalic inclusion disease
484.3    Pneumonia in whooping cough
484.5    Pneumonia in anthrax
484.6    Pneumonia in aspergillosis
484.7    Pneumonia in other systemic mycoses
484.8    Pneumonia in other infectious diseases classified elsewhere
485      Bronchopneumonia, organism unspecified
486      Pneumonia, organism unspecified
490      Bronchitis, not specified as acute or chronic
491.0    Simple chronic bronchitis
491.1    Mucopurulent chronic bronchitis
491.20   Obstructive chronic bronchitis without exacerbation
491.21   Obstructive chronic bronchitis with (acute) exacerbation
491.22   Obstructive chronic bronchitis with acute bronchitis
491.8    Other chronic bronchitis
491.9    Unspecified chronic bronchitis
527.7    Disturbance of salivary secretion
528.00   Stomatitis and mucositis, unspecified
528.09   Other stomatitis and mucositis (ulcerative)



                                                                       Page 104
NATIONAL COVERAGE DETERMINATION                                                              82962

535.50   Unspecified gastritis and gastroduodenitis without hemorrhage
535.51   Unspecified gastritis and gastroduodenitis with hemorrhage
536.8    Dyspepsia and other specified disorders of function of stomach
571.8    Other chronic nonalcoholic liver disease
572.0    Abscess of liver
572.1    Portal pyemia
572.2    Hepatic coma
572.3    Portal hypertension
572.4    Hepatorenal syndrome
572.8    Other sequelae of chronic liver disease
574.50   Calculus of bile duct without cholecystitis without obstruction
574.51   Calculus of bile duct without cholecystitis with obstruction
575.0    Acute cholecystitis
575.10   Cholecystitis, unspecified
575.11   Cholecystitis, chronic
575.12   Cholecystitis, acute and chronic
576.1    Cholangitis
577.0    Acute pancreatitis
577.1    Chronic pancreatitis
577.8    Other specified diseases of pancreas
590.00   Chronic pyelonephritis without lesion of renal medullary necrosis
590.01   Chronic pyelonephritis with lesion of renal medullary
590.10   Acute pyonephrosis without lesion of renal medullary necrosis
590.11   Acute pyonephrosis with lesion of renal medullary necrosis
590.2    Renal and perinephric abscess
590.3    Pyeloureteritis cystica
590.80   Pyelonephritis, unspecified
590.81   Pyelitis or pyelonephritis in diseases classified elsewhere
590.9    Infection of kidney, unspecified
595.9    Cystitis, unspecified
596.4    Atony of bladder
596.53   Paralysis of bladder
599.0    Urinary tract infection, site not specified
607.84   Impotence of organic origin
608.89   Other Vascular disorders of male genital orga
616.10   Vaginitis and vulvovaginitis, unspecified
626.0    Absence of menstruation
626.4    Irregular menstrual cycle
628.9    Infertility, female, of unspecified origin
648.00   Other conditions of mother complicating pregnancy, diabetes mellitus, unspecified
         episode of care
648.03   Other conditions of mother complicating pregnancy, diabetes mellitus, antepartum
         condition or complication
648.04   Other conditions of mother complicating pregnancy, diabetes mellitus, postpartum
         condition or complication
648.80   Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
         unspecified episode of care
648.83   Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
         antepartum condition or complication
648.84   Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
         postpartum condition or complication
649.20   Bariatric surgery status complicating pregnancy, childbirth, or the puerperium,
         unspecified as to episode of care or not applicable



                                                                                        Page 105
NATIONAL COVERAGE DETERMINATION                                                            82962

649.21 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, delivered,
       with or without mention of antepartum condition
649.22 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, delivered,
       with mention of postpartum complication
649.23 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium,
       antepartum condition or complication
649.24 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, postpartum
       condition or complication
656.60 Excessive fetal growth, unspecified episode of care
656.61 Excessive fetal growth, delivered, with or without antepartum condition
656.63 Excessive fetal growth, antepartum condition or complication
657.00 Polyhydramnios, unspecified episode of care
657.01 Polyhydramnios, delivered, with or without antepartum condition
657.03 Polyhydramnios, antepartum condition or complication
680.0 Carbuncle and furuncle of face
680.1 Carbuncle and furuncle of neck
680.2 Carbuncle and furuncle of trunk
680.3 Carbuncle and furuncle of upper arm and forearm
680.4 Carbuncle and furuncle og hand
680.5 Carbuncle and furuncle oh buttock
680.6 Carbuncle and furuncle of leg
680.7 Carbuncle and furuncle of foot
680.8 Carbuncle and furuncle, other specified sites
680.9 Carbuncle and furuncle, unspecified site
686.00 Pyoderma, unspecified
686.01 Pyoderma, gangrenosum
686.09 Pyoderma, other
686.1 Pyogenic granuloma
686.8 Other specified local infections of skin and subcutaneous tissue
686.9 Unspecified local infection of skin and subcutaneous tissue
698.0 Pruritus ani
698.1 Pruritus of genital organs
704.1 Hirsutism
705.0 Anhidrosis
707.00 Decubitus ulcer, unspecified site
707.01 Decubitus ulcer, elbow
707.02 Decubitus ulcer, upper back
707.03 Decubitus ulcer, lower back
707.04 Decubitus ulcer, hip
707.05 Decubitus ulcer, buttock
707.06 Decubitus ulcer, ankle
707.07 Decubitus ulcer, heel
707.09 Decubitus ulcer, other site
707.10 Ulcer of lower limbs, unspecified
707.11 Ulcer of thigh
707.12 Ulcer of calf
707.13 Ulcer of ankle
707.14 Ulcer of heel and midfoot
707.15 Ulcer of other aprt of foot
707.19 Ulcer of other part of lower limb
707.8 Chronic ulcer of other specified sites
707.9 Chronic ulcer of unspecified site
709.3 Degenerative skin disorders



                                                                                        Page 106
NATIONAL COVERAGE DETERMINATION                              82962

729.1    Mylagia and myositis, unspecified
730.07   Acute osteomyelitis, ankle and foot
730.17   Chronic osteomyelitis, ankle and foot
730.27   Unspecified osteomyelitis, ankle and foot
780.01   Coma
780.02   Transient alteration of awareness
780.09   Other alteration of awareness
780.2    Syncope and collapse
780.31   Febrile convulsions (simple), unspecified
780.32   Complex febrile convulsions
780.39   Other convulsions
780.4    Dizziness and giddiness
780.71   Chronic fatigue syndrome
780.79   Other malaise and fatigue
780.8    Generalized hyperhidrosis
781.0    Abnormal involuntary movements
782.0    Disturbance of skin sensation
783.1    Abnormal weight gain
783.21   Abnormal loss of weight
783.5    Polydipsia
783.6    Polyphagia
785.0    Tachycardia, unspecified
785.4    Gangrene
786.01   Hyperventilation
786.09   Other respiratory abnormality
786.50   Chest pain, unspecified
787.6    Incontinence of feces
787.91   Diarrhea
788.41   Urinary frequency
788.42   Polyuria
788.43   Nocturia
789.1    Hepatomegaly
790.21   Impaired fasting glucose
790.22   Impaired glucose tolerance test
790.29   Other abnormal glucose
790.6    Other abnormal blood chemistry
791.0    Proteinuria
791.5    Glycosuria
796.1    Abnormal reflex
799.4    Cachexia
V23.0    Pregnancy with history of infertility
V23.1    Pregnancy with history of trophoblastic disease
V23.2    Pregnancy with history of abortion
V23.3    Grand multiparity
V23.41   Pregnancy with history of pre-term labor
V23.49   Pregnancy with other poor obstetric history
V23.5    Pregnancy with other poor reproductive history
V23.7    Insufficient prenatal care
V23.81   Elderly primigravida
V23.82   Elderly multigravida
V23.83   Young primigravida
V23.84   Young multigravida
V23.89   Other high risk pregnancy



                                                           Page 107
NATIONAL COVERAGE DETERMINATION                                                               82962

V23.9    Unspecified high-risk pregnancy
V58.63   Long-term (current) use of antiplatelet/antithrombotic
V58.64   Long-term (current) use of non-steroidal anti-inflammatories
V58.65   Long-term (current) use of steroids
V58.67   Long-term (current) use of insulin
V58.69   Long-term (current) use of other medications
V67.2    Follow-up examination following chemotherapy
V67.51   Follow-up examination following completed treatment with high-risk medication, not
         elsewhere classified




                                                                                        Page 108
NATIONAL COVERAGE DETERMINATION                                                                                        82977


NATIONAL COVERAGE DETERMINATION
82977
82977-Glutamyltransferase, gamma (GGT)




CPT CODE: 82977



CPT CODE DESCRIPTOR: Glutamyltransferase, gamma (GGT)



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                         When used to determine if other abnormal enzyme tests reflect liver abnormality
                                         rather than other tissue, it generally is not necessary to repeat a GGT more than
                                         one time per week.



COVERED ICD-9 CODES:
003.1 Salmonella septicemia
006.0 Acute amebic dysentery without abscess
006.1 Chronic intestinal amebiasis without abscess
006.2 Amebic nondysenteric colitis
006.3 Amebic liver abscess
006.4 Amebic lung abscess
006.5 Amebic brain abscess
006.6 Amebic skin ulceration
006.8 Amebic infection of other sites
006.9 Amebiasis, unspecified
014.00 Tuberculous peritonitis, unspecified
014.01 Tuberculous peritonitis, bacteriological or histological examination not done
014.02 Tuberculous peritonitis, bacteriological or histological examination unknown (at present)
014.03 Tuberculous peritonitis, tubercle bacilli found (in sputum) by microscopy
014.04 Tuberculous peritonitis, tubercle bacilli not found (in sputum) by microscopy, but found by
       bacterial culture
014.05 Tuberculous peritonitis, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
014.06 Tuberculous peritonitis, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
014.80 Other tuberculosis, unspecified
014.81 Other tuberculosis, bacteriological or histological examination not done
014.82 Other tuberculosis, bacteriological or histological examination unknown (at present)
014.83 Other tuberculosis, tubercle bacilli found (in sputum) by microscopy
014.84 Other tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found by
       bacterial culture
014.85 Other tuberculosis, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
014.86 Other tuberculosis, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
017.90 Tuberculosis of other specified organs, unspecified
017.91 Tuberculosis of other specified organs, bacteriological or histological examination not
       done
017.92 Tuberculosis of other specified organs, bacteriological or histological examination
       unknown (at present)
017.93 Tuberculosis of other specified organs, tubercle bacilli found (in sputum) by microscopy


                                                                                                                    Page 109
NATIONAL COVERAGE DETERMINATION                                                              82977

017.94 Tuberculosis of other specified organs, tubercle bacilli not found (in sputum) by
       microscopy, but found by bacterial culture
017.95 Tuberculosis of other specified organs, tubercle bacilli not found by bacteriological
       examination, but tuberculosis confirmed histologically
017.96 Tuberculosis of other specified organs, tubercle bacilli not found by bacteriological or
       histological examination, but tuberculosis confirmed by other methods
018.90 Military tuberculosis, unspecified
018.91 Military tuberculosis, bacteriological or histological examination not done
018.92 Military tuberculosis, bacteriological or histological examination unknown (at present)
018.93 Military tuberculosis, tubercle bacilli found (in sputum) by microscopy
018.94 Military tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found by
       bacterial culture
018.95 Military tuberculosis, tubercle bacilli not found by bacteriological examination, but
       tuberculosis confirmed histologically
018.96 Military tuberculosis, tubercle bacilli not found by bacteriological or histological
       examination, but tuberculosis confirmed by other methods
020.0 Bubonic plague
020.1 Cellulocutaneous plague
020.2 Septicemic plague
020.3 Primary pneumonic plague
020.4 Secondary pneumonic plague
020.5 Pneumonic plague, unspecified
020.8 Other specified types of plague
020.9 Plague, unspecified
022.3 Anthrax septicemia
027.0 Listeriosis
027.1 Erysipelothrix infection
030.1 Tuberculoid [type T]
032.83 Diphtheritic peritonitis
036.1 Meningococcal encephalitis
036.2 Meningococcemia
038.0 Streptococcal septicemia
038.10 Staphylococcal septicemia, unspecified
038.11 Staphylococcus aureus septicemia
038.19 Other staphylococcal septicemia
038.2 Pneumococcal septicemia
038.3 Septicemia due to anaerobes
038.40 Septicemia due to Gram-negative organism, unspecified
038.41 Septicemia due to Hemophilus influenzae [H. influenzae]
038.42 Septicemia due to Escherichia coli [E. coli]
038.43 Septicemia due to Pseudomonas
038.44 Septicemia due to Serratia
038.49 Other Septicemia due to other gram-negative organisms
038.8 Other specified septicemias
038.9 Unspecified septicemia
039.2 Abdominal Actinomycotic infections
040.0 Gas gangrene
042    Human immunodeficiency virus [HIV] disease
054.0 Eczema herpeticum
054.5 Herpetic septicemia
060.0 Sylvatic yellow fever
060.1 Urban yellow fever
070.0 Viral hepatitis A with hepatic coma



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NATIONAL COVERAGE DETERMINATION                                                                  82977

070.1    Viral hepatitis A without hepatic coma
070.20   Viral hepatitis B with hepatic coma, acute or unspecified, without hepatitis delta
070.21   Viral hepatitis B with hepatic coma, acute or unspecified, with hepatitis delta
070.22   Viral hepatitis B with hepatic coma, chronic, without hepatitis delta
070.23   Viral hepatitis B with hepatic coma, chronic, with hepatitis delta
070.30   Viral hepatitis B without hepatic coma, acute or unspecified, without hepatitis delta
070.31   Viral hepatitis B without hepatic coma, acute or unspecified, with hepatitis delta
070.32   Viral hepatitis B without hepatic coma, chronic, without hepatitis delta
070.33   Viral hepatitis B without hepatic coma, chronic, with hepatitis delta
070.41   Acute hepatitis C with hepatic coma
070.42   Hepatitis delta without active hepatitis B disease with hepatic coma
070.43   Hepatitis E with hepatic coma
070.44   Chronic hepatitis C with hepatic coma
070.49   Other specified viral hepatitis with hepatic coma
070.51   Acute hepatitis C without mention of hepatic coma
070.52   Hepatitis delta without active hepatitis B disease or hepatic coma
070.53   Hepatitis E without hepatic coma
070.54   Chronic hepatitis C without hepatic coma
070.59   Other specified viral hepatitis without hepatic coma
070.6    Unspecified viral hepatitis with hepatic coma
070.70   Unspecified viral hepatitis C without hepatic coma
070.71   Unspecified viral hepatitis C with hepatic coma
070.9    Unspecified viral hepatitis without hepatic coma
072.71   Mumps hepatitis
073.0    Ornithosis with pneumonia
074.8    Other specified diseases due to Coxsackie virus
075      Infectious mononucleosis
078.5    Cytomegaloviral disease
079.99   Unspecified viral infection in conditions classified elsewhere
082.0    Spotted fevers
082.1    Boutonneuse fever
082.2    North Asian tick fever
082.3    Queensland tick typhus
082.40   Ehrlichiosis, unspecified
082.41   Ehrlichiosis chafeensis
082.49   Other ehrlichiosis
082.8    Other specified tick-borne rickettsioses
082.9    Tick-borne rickettsiosis, unspecified
084.9    Other pernicious complications of malaria
086.1    Chagas' disease with other organ involvement
088.81   Lyme disease
091.62   Secondary syphilitic hepatitis
095.3    Syphilis of liver
100.0    Leptospirosis icterohemorrhagica
112.5    Candidiasis, disseminated
115.00   Infection by Histoplasma capsulatum, unspecified manifestation
120.9    Schistosomiasis, unspecified
121.1    Clonorchiasis
121.3    Fascioliasis
122.0    Echinococcus granulosus infection of liver
122.5    Echinococcus multilocularis infection of liver
122.8    Echinococcosis, unspecified, of liver
122.9    Echinococcosis, other and unspecified



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NATIONAL COVERAGE DETERMINATION                                             82977

130.5   Hepatitis due to toxoplasmosis
135     Sarcoidosis
150.0   Malignant neoplasm of cervical esophagus
150.1   Malignant neoplasm of thoracic esophagus
150.2   Malignant neoplasm of abdominal esophagus
150.3   Malignant neoplasm of uUpper third of esophagus
150.4   Malignant neoplasm of middle third of esophagus
150.5   Malignant neoplasm of lower third of esophagus
150.8   Malignant neoplasm of other specified part of esophagus
150.9   Malignant neoplasm of esophagus, unspecified
151.0   Malignant neoplasm of cardia
151.1   Malignant neoplasm of pylorus
151.2   Malignant neoplasm of pyloric antrum
151.3   Malignant neoplasm of fundus of stomach
151.4   Malignant neoplasm of body of stomach
151.5   Malignant neoplasm of lesser curvature, unspecified
151.6   Malignant neoplasm of greater curvature of stomach, unspecified
151.8   Malignant neoplasm of other specified sites of stomach
151.9   Malignant neoplasm of stomach, unspecified
152.0   Malignant neoplasm of duodenum
152.1   Malignant neoplasm of jejunum
152.2   Malignant neoplasm of ileum
152.3   Malignant neoplasm of meckel's diverticulum
152.8   Malignant neoplasm of other specified sites of small intestine
152.9   Malignant neoplasm of small intestine, unspecified
153.0   Malignant neoplasm of hepatic flexure of colon
153.1   Malignant neoplasm, transverse colon
153.2   Malignant neoplasm, descending colon
153.3   Malignant neoplasm, sigmoid colon
153.4   Malignant neoplasm, cecum
153.5   Malignant neoplasm, appendix
153.6   Malignant neoplasm, ascending colon
153.7   Malignant neoplasm, splenic flexure
153.8   Malignant neoplasm, other specified sites of large intestine
153.9   Malignant neoplasm, colon, unspecified
154.0   Malignant neoplasm, rectosigmoid junction
154.1   Malignant neoplasm, rectum
154.2   Malignant neoplasm, anal canal
154.3   Malignant neoplasm, anus, unspecified
154.8   Malignant neoplasm, other
155.0   Malignant neoplasm, liver, primary
155.1   Malignant neoplasm, intrahepatic bile ducts
155.2   Malignant neoplasm, liver, not specified as primary or
156.0   Malignant neoplasm, gallbladder
156.1   Malignant neoplasm, extrahepatic bile ducts
156.2   Malignant neoplasm, ampulla of Vater
156.8   Malignant neoplasm, other specified sites of gallbladder
156.9   Malignant neoplasm, biliary tract, part unspecified
157.0   Malignant neoplasm, head of pancreas
157.1   Malignant neoplasm, body of pancreas
157.2   Malignant neoplasm, tail of pancreas
157.3   Malignant neoplasm, pancreatic duct
157.4   Malignant neoplasm, islets of Langerhans



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NATIONAL COVERAGE DETERMINATION                                                    82977

157.8   Malignant neoplasm, other specified sites of pancreas
157.9   Malignant neoplasm, pancreas, part unspecified
158.0   Malignant neoplasm, retroperitoneum
158.8   Malignant neoplasm, specified parts of peritoneum
158.9   Malignant neoplasm, peritoneum, unspecified
159.0   Malignant neoplasm, intestinal tract, part unspecified
159.1   Malignant neoplasm, spleen, not elsewhere classified
159.8   Malignant neoplasm, other sites of digestive system
159.9   Malignant neoplasm, ill-defined sites of digestive system
160.0   Malignant neoplasm of nasal cavities
160.1   Malignant neoplasm of auditory tube, middle ear, and mastoid air cells
160.2   Malignant neoplasm of maxillary sinus
160.3   Malignant neoplasm of ethmoidal sinus
160.4   Malignant neoplasm of frontal sinus
160.5   Malignant neoplasm of sphenoidal sinus
160.8   Malignant neoplasm of other
160.9   Malignant neoplasm of accessory sinus, unspecified
161.0   Malignant neoplasm of glottis
161.1   Malignant neoplasm of supraglottis
161.2   Malignant neoplasm of subglottis
161.3   Malignant neoplasm of laryngeal cartilages
161.8   Malignant neoplasm of other specified sites of larynx
161.9   Malignant neoplasm of larynx, unspecified
162.0   Malignant neoplasm of trachea
162.2   Malignant neoplasm of main bronchus
162.3   Malignant neoplasm of upper lobe, bronchus or lung
162.4   Malignant neoplasm of middle lobe, bronchus or lung
162.5   Malignant neoplasm of lower lobe, bronchus or lung
162.8   Malignant neoplasm of other parts of bronchus or lung
162.9   Malignant neoplasm of bronchus and lung, unspecified
163.0   Malignant neoplasm of parietal pleura
163.1   Malignant neoplasm of visceral pleura
163.8   Malignant neoplasm of other specified sites of pleura
163.9   Malignant neoplasm of pleura, unspecified
164.0   Malignant neoplasm of thymus
164.1   Malignant neoplasm of heart
164.2   Malignant neoplasm of anterior mediastinum
164.3   Malignant neoplasm of posterior mediastinum
164.8   Other malignant neoplasm of thymus, heart, and mediastinum
164.9   Malignant neoplasm of mediastinum, part unspecified
165.0   Malignant neoplasm of upper respiratory tract, part unspecified
165.8   Malignant neoplasm of other part of thymus, heart, and mediastinum
165.9   Malignant neoplasm of ill-defined sites within the respiratory system
170.0   Malignant neoplasm of bones of skull and face, except
170.1   Malignant neoplasm of mandible
170.2   Malignant neoplasm of vertebral column, excluding sacrum
170.3   Malignant neoplasm of ribs, sternum, and clavicle
170.4   Malignant neoplasm of scapula and long bones of upper
170.5   Malignant neoplasm of short bones of upper limb
170.6   Malignant neoplasm of pelvic bones, sacrum, and coccyx
170.7   Malignant neoplasm of long bones of lower limb
170.8   Malignant neoplasm of short bones of lower limb
170.9   Malignant neoplasm of bone and articular cartilage, site



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171.0   Malignant neoplasm of head, face, and neck
171.2   Malignant neoplasm of upper limb, including shoulder
171.3   Malignant neoplasm of lower limb, including hip
171.4   Malignant neoplasm of thorax
171.5   Malignant neoplasm of abdomen
171.6   Malignant neoplasm of pelvis
171.7   Malignant neoplasm of trunk, unspecified
171.8   Malignant neoplasm of connective/soft tissue, other sites
171.9   Malignant neoplasm of connective and other soft tissue,
172.0   Malignant neoplasm of lip
172.1   Malignant neoplasm of eyelid, including canthus
172.2   Malignant neoplasm of ear and external auditory canal
172.3   Malignant neoplasm of other and unspecified parts of face
172.4   Malignant melanoma of skin, scalp and neck
172.5   Malignant melanoma of skin, trunk, except scrotum
172.6   Malignant neoplasm of upper limb, including shoulder
172.7   Malignant neoplasm of lower limb, including hip
172.8   Malignant neoplasm of other specified sites of skin
172.9   Malignant neoplasm of melanoma of skin, site unspecified
173.0   Malignant neoplasm of skin of lip
173.1   Malignant neoplasm of eyelid, including canthus
173.2   Malignant neoplasm of skin of ear and external auditory
173.3   Malignant neoplasm of skin of other and unspecified parts
173.4   Malignant neoplasm of scalp and skin of neck
173.5   Malignant neoplasm of skin of trunk, except scrotum
173.6   Malignant neoplasm of skin of upper limb, including
173.7   Skin of lower limb, including hip
173.8   Malignant neoplasm of other specified sites of skin
173.9   Malignant neoplasm of skin, site unspecified
174.0   Malignant neoplasm of nipple and areola of female breast
174.1   Malignant neoplasm of central portion of breast
174.2   Upper-inner quadrant of female breast
174.3   Lower-inner quadrant of female breast
174.4   Upper-outer quadrant of female breast
174.5   Lower-outer quadrant of female breast
174.6   Axillary tail of female breast
174.8   Other specified sites of female breast
174.9   Malignant neoplasm of breast (female), unspecified
175.0   Malignant neoplasm of nipple and areola of male breast
175.9   Malignant neoplasm, other and unspecified sites of male breast
176.0   Kaposi's sarcoma skin
176.1   Kaposi's sarcoma soft tissue
176.2   Kaposi's sarcoma, palate
176.3   Kaposi's sarcoma, gastrointestinal sites
176.4   Kaposi's sarcoma, lung
176.5   Kaposi's sarcoma, lymph nodes
176.8   Kaposi's sarcoma, other specified sites
176.9   Kaposi's sarcoma, unspecified
179     Malignant neoplasm of uterus, part unspecified
180.0   Malignant neoplasm of endocervix
180.1   Malignant neoplasm of exocervix
180.8   Malignant neoplasm of other specified sites of cervix
180.9   Malignant neoplasm of cervix uteri, unspecified



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NATIONAL COVERAGE DETERMINATION                                                   82977

181      Malignant neoplasm of placenta
182.0    Malignant neoplasm of corpus uteri, except isthmus
182.1    Malignant neoplasm of uterus, isthmus
182.8    Malignant neoplasm, other specified sites, body of uterus
183.0    Malignant neoplasm of ovary
183.2    Malignant neoplasm of fallopian tube
183.3    Malignant neoplasm of broad ligament
183.4    Malignant neoplasm of parametrium
183.5    Malignant neoplasm of round ligament
183.8    Malignant neoplasm of other specified sites of uterine adnexa
183.9    Malignant neoplasm of uterine adnexa, unspecified
184.0    Malignant neoplasm of vagina
184.1    Malignant neoplasm of labia majora
184.2    Malignant neoplasm of labia minora
184.3    Malignant neoplasm of clitoris
184.4    Malignant neoplasm of vulva, unspecified
184.8    Malignant neoplasm of other specified sites of female genital organs
184.9    Malignant neoplasm of female genital organ, site unspecified
185      Malignant neoplasm of prostate
186.0    Malignant neoplasm of undescended testis
186.9    Malignant neoplasm of other and unspecified testis
187.1    Malignant neoplasm of prepuce
187.2    Malignant neoplasm of glans penis
187.3    Malignant neoplasm of body of penis
187.4    Malignant neoplasm of penis, part unspecified
187.5    Malignant neoplasm of epididymis
187.6    Malignant neoplasm of spermatic cord
187.7    Malignant neoplasm of scrotum
187.8    Malignant neoplasm of other specified sites of male genital organs
187.9    Malignant neoplasm of male genital organ, site unspecified
188.0    Malignant neoplasm of trigone of urinary bladder
188.1    Malignant neoplasm of dome of urinary bladder
188.2    Malignant neoplasm of lateral wall of urinary bladder
188.3    Malignant neoplasm, anterior wall of urinary bladder
188.4    Malignant neoplasm, posterior wall of urinary bladder
188.5    Malignant neoplasm of bladder neck
188.6    Malignant neoplasm of ureteric orifice
188.7    Malignant neoplasm of urachus
188.8    Malignant neoplasm of other specified sites of bladder
188.9    Malignant neoplasm of bladder, part unspecified
189.0    Malignant neoplasm of kidney, except pelvis
189.1    Malignant neoplasm of renal pelvis
189.2    Malignant neoplasm of ureter
189.3    Malignant neoplasm of urethra
189.4    Malignant neoplasm of paraurethral glands
189.8    Malignant neoplasm of other specified sites of urinary organs
189.9    Malignant neoplasm of urinary organ, site unspecified
200.00   Reticulosarcoma, unspecified site, extranodal and solid organ sites
200.01   Reticulosarcoma of lymph nodes of head, face, and neck
200.02   Reticulosarcoma of intrathoracic lymph nodes
200.03   Reticulosarcoma of intra-abdominal lymph nodes
200.04   Reticulosarcoma of lymph nodes of axilla and upper limb
200.05   Reticulosarcoma of lymph nodes of inguinal region and lower limb



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NATIONAL COVERAGE DETERMINATION                                                           82977

200.06   Reticulosarcoma of intrapelvic lymph nodes
200.07   Reticulosarcoma of spleen
200.08   Reticulosarcoma, lymph nodes of multiple sites
200.10   Lymphosarcoma, unspecified site, extranodal and solid organ sites
200.11   Lymphosarcoma of lymph nodes of head, face, and neck
200.12   Lymphosarcoma of intrathoracic lymph nodes
200.13   Lymphosarcoma of intra-abdominal lymph nodes
200.14   Lymphosarcoma of lymph nodes of axilla and upper limb
200.15   Lymphosarcoma of lymph nodes of inguinal region and lower limb
200.16   Lymphosarcoma of intrapelvic lymph nodes
200.17   Lymphosarcoma of spleen
200.18   Lymphosarcoma, lymph nodes of multiple sites
200.20   Burkitt's tumor or lymphoma, unspecified site, extranodal and solid organ sites
200.21   Burkitt's tumor or lymphoma of lymph nodes of head, face, and neck
200.22   Burkitt's tumor or lymphoma of intrathoracic lymph nodes
200.23   Burkitt's tumor or lymphoma of intra-abdominal lymph nodes
200.24   Burkitt's tumor or lymphoma of lymph nodes of axilla and upper limb
200.25   Burkitt's tumor or lymphoma of lymph nodes of inguinal region and lower limb
200.26   Burkitt's tumor or lymphoma of intrapelvic lymph nodes
200.27   Burkitt's tumor or lymphoma of spleen
200.28   Burkitt's tumor or lymphoma, lymph nodes of multiple sites
200.30   Marginal zone lymphoma, unspecified site, extranodal and solid organ sites
200.31   Marginal zone lymphoma, lymph nodes of head, face, and neck
200.32   Marginal zone lymphoma, intrathoracic lymph nodes
200.33   Marginal zone lymphoma, intraabdominal lymph nodes
200.34   Marginal zone lymphoma, lymph nodes of axilla and upper limb
200.35   Marginal zone lymphoma, lymph nodes of inguinal region and lower limb
200.36   Marginal zone lymphoma, intrapelvic lymph nodes
200.37   Marginal zone lymphoma, spleen
200.38   Marginal zone lymphoma, lymph nodes of multiple sites
200.40   Mantle cell lymphoma, unspecified site, extranodal and solid organ sites
200.41   Mantle cell lymphoma, lymph nodes of head, face, and neck
200.42   Mantle cell lymphoma, intrathoracic lymph nodes
200.43   Mantle cell lymphoma, intra-abdominal lymph nodes
200.44   Mantle cell lymphoma, lymph nodes of axilla and upper limb
200.45   Mantle cell lymphoma, lymph nodes of inguinal region and lower limb
200.46   Mantle cell lymphoma, intrapelvic lymph nodes
200.47   Mantle cell lymphoma, spleen
200.48   Mantle cell lymphoma, lymph nodes of multiple sites
200.50   Primary central nervous system lymphoma, unspecified site, extranodal and solid organ
         sites
200.51   Primary central nervous system lymphoma, lymph nodes of head, face, and neck
200.52   Primary central nervous system lymphoma, intrathoracic lymph nodes
200.53   Primary central nervous system lymphoma, intra-abdominal lymph nodes
200.54   Primary central nervous system lymphoma, lymph nodes of axilla and upper limb
200.55   Primary central nervous system lymphoma, lymph nodes of inguinal region and lower
         limb
200.56   Primary central nervous system lymphoma, intrapelvic lymph nodes
200.57   Primary central nervous system lymphoma, spleen
200.58   Primary central nervous system lymphoma, lymph nodes of multiple sites
200.60   Anaplastic large cell lymphoma, unspecified site, extranodal and solid organ sites
200.61   Anaplastic large cell lymphoma, lymph nodes of head, face, and neck
200.62   Anaplastic large cell lymphoma, intrathoracic lymph nodes



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NATIONAL COVERAGE DETERMINATION                                                         82977

200.63   Anaplastic large cell lymphoma, intra-abdominal lymph nodes
200.64   Anaplastic large cell lymphoma, lymph nodes of axilla and upper limb
200.65   Anaplastic large cell lymphoma, lymph nodes of inguinal region and lower limb
200.66   Anaplastic large cell lymphoma, intrapelvic lymph nodes
200.67   Anaplastic large cell lymphoma, spleen
200.68   Anaplastic large cell lymphoma, lymph nodes of multiple sites
200.70   Large cell lymphoma, unspecified site, extranodal and solid organ sites
200.71   Large cell lymphoma, lymph nodes of head, face, and neck
200.72   Large cell lymphoma, intrathoracic lymph nodes
200.73   Large cell lymphoma, intra-abdominal lymph nodes
200.74   Large cell lymphoma, lymph nodes of axilla and upper limb
200.75   Large cell lymphoma, lymph nodes of inguinal region and lower limb
200.76   Large cell lymphoma, intrapelvic lymph nodes
200.77   Large cell lymphoma, spleen
200.78   Large cell lymphoma, lymph nodes of multiple sites
200.80   Other named variants of lymphosarcoma and reticulosarcoma, unspecified site,
         extranodal and solid organ sites
200.81   Other named variants of lymphosarcoma and reticulosarcoma of lymph nodes of head,
         face, and neck
200.82   Other named variants of lymphosarcoma and reticulosarcoma of intrathoracic lymph
         nodes
200.83   Other named variants of lymphosarcoma and reticulosarcoma of intra-abdominal lymph
         nodes
200.84   Other named variants of lymphosarcoma and reticulosarcoma of lymph nodes of axilla
         and upper limb
200.85   Other named variants of lymphosarcoma and reticulosarcoma of lymph nodes of inguinal
         region and lower limb
200.86   Other named variants of lymphosarcoma and reticulosarcoma of intrapelvic lymph nodes
200.87   Other named variants of lymphosarcoma and reticulosarcoma of spleen
200.88   Other named variants of lymphosarcoma and reticulosarcoma of lymph nodes, multiple
         sites
201.00   Hodgkin's paragranuloma, unspecified site, extranodal and solid organ sites
201.01   Hodgkin's paragranuloma of lymph nodes of head, face, and neck
201.02   Hodgkin's paragranuloma of intrathoracic lymph nodes
201.03   Hodgkin's paragranuloma of intra-abdominal lymph nodes
201.04   Hodgkin's paragranuloma of lymph nodes of axilla and upper limb
201.05   Hodgkin's paragranuloma of lymph nodes of inguinal region and lower limb
201.06   Hodgkin's paragranuloma of intrapelvic lymph nodes
201.07   Hodgkin's paragranuloma of spleen
201.08   Hodgkin's paragranuloma, lymph nodes at multiple sites
201.10   Hodgkin's granuloma, unspecified site, extranodal and solid organ sites
201.11   Hodgkin's granuloma of lymph nodes of head, face, and neck
201.12   Hodgkin's granuloma of intrathoracic lymph nodes
201.13   Hodgkin's granuloma of intra-abdominal lymph nodes
201.14   Hodgkin's granuloma of lymph nodes of axilla and upper limb
201.15   Hodgkin's granuloma of lymph nodes of inguinal region and lower limb
201.16   Hodgkin's granuloma of intrapelvic lymph nodes
201.17   Hodgkin's granuloma of spleen
201.18   Hodgkin's granuloma of lymph nodes at multiple sites
201.20   Hodgkin's sarcoma, unspecified site, extranodal and solid organ sites
201.21   Hodgkin's sarcoma of lymph nodes of head, face, and neck
201.22   Hodgkin's sarcoma of intrathoracic lymph nodes
201.23   Hodgkin's sarcoma of intra-abdominal lymph nodes



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201.24   Hodgkin's sarcoma of lymph nodes of axilla and upper limb
201.25   Hodgkin's sarcoma of lymph nodes of inguinal region and lower limb
201.26   Hodgkin's sarcoma of intrapelvic lymph nodes
201.27   Hodgkin's sarcoma of spleen
201.28   Hodgkin's sarcoma of lymph nodes, multiple sites
201.40   Hodgkin's disease, lymphocytic-histiocytic predominance, unspecified site, extranodal
         and solid organ sites
201.41   Hodgkin's disease, lymphocytic-histiocytic predominance, lymph nodes of head, face,
         and neck
201.42   Hodgkin's disease, lymphocytic-histiocytic predominance, intrathoracic lymph nodes
201.43   Hodgkin's disease, lymphocytic-histiocytic predominance, intra-abdominal lymph nodes
201.44   Hodgkin's disease, lymphocytic-histiocytic predominance, lymph nodes of axilla and
         upper limb
201.45   Hodgkin's disease, lymphocytic-histiocytic predominance, lymph nodes of inguinal region
         and lower limb
201.46   Hodgkin's disease, lymphocytic-histiocytic predominance, intrapelvic lymph nodes
201.47   Hodgkin's disease, lymphocytic-histiocytic predominance, spleen
201.48   Hodgkin's disease, lymphocytic-histiocytic predominance, lymph nodes of multiple sites
201.50   Hodgkin's disease, nodular sclerosis, unspecified site, extranodal and solid organ sites
201.51   Hodgkin's disease, nodular sclerosis lymph nodes of head, face, and neck
201.52   Hodgkin's disease, nodular sclerosis of intrathoracic lymph nodes
201.53   Hodgkin's disease, nodular sclerosis of intra-abdominal lymph nodes
201.54   Hodgkin's disease, nodular sclerosis of lymph nodes of axilla and upper limb
201.55   Hodgkin's disease, nodular sclerosis of lymph nodes of inguinal region and lower limb
201.56   Hodgkin's disease, nodular sclerosis of intrapelvic lymph nodes
201.57   Hodgkin's disease, nodular sclerosis of spleen
201.58   Hodgkin's disease, nodular sclerosis of lymph nodes of multiple sites
201.60   Hodgkin's disease, mixed cellularity, unspecified site, extranodal and solid organ sites
201.61   Hodgkin's disease, mixed cellularity of lymph nodes of head, face, and neck
201.62   Hodgkin's disease, mixed cellularity of intrathoracic lymph nodes
201.63   Hodgkin's disease, mixed cellularity of intra-abdominal lymph nodes
201.64   Hodgkin's disease, mixed cellularity of lymph nodes of axilla and upper limb
201.65   Hodgkin's disease, mixed cellularity of lymph nodes of inguinal region and lower limb
201.66   Hodgkin's disease, mixed cellularity of intrapelvic lymph nodes
201.67   Hodgkin's disease, mixed cellularity of spleen
201.68   Hodgkin's disease, mixed cellularity, lymph nodes of multiple sites
201.70   Hodgkin's disease, lymphocytic depletion, unspecified site, extranodal and solid organ
         sites
201.71   Hodgkin's disease, lymphocytic depletion, lymph nodes of head, face, and neck
201.72   Hodgkin's disease, lymphocytic depletion, intrathoracic lymph nodes
201.73   Hodgkin's disease, lymphocytic depletion, intra-abdominal lymph nodes
201.74   Hodgkin's disease, lymphocytic depletion, lymph nodes of axilla and upper limb
201.75   Hodgkin's disease, lymphocytic depletion, lymph nodes of inguinal region and lower limb
201.76   Hodgkin's disease, lymphocytic depletion, intrapelvic lymph nodes
201.77   Hodgkin's disease, lymphocytic depletion, spleen
201.78   Hodgkin's disease, lymphocytic depletion, lymph nodes of multiple sites
201.90   Unspecified Hodgkin's disease, unspecified site, extranodal and solid organ sites
201.91   Hodgkin's disease, unspecified lymph nodes of head, face, and neck
201.92   Hodgkin's disease, unspecified intrathoracic lymph nodes
201.93   Hodgkin's disease, unspecified intra-abdominal lymph nodes
201.94   Hodgkin's disease, unspecified lymph nodes of axilla and upper limb
201.95   Hodgkin's disease, unspecified lymph nodes of inguinal region and lower limb
201.96   Hodgkin's disease, unspecified intrapelvic lymph nodes



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201.97   Hodgkin's disease, unspecified spleen
201.98   Hodgkin's disease, unspecified lymph nodes of multiple sites
202.00   Nodular lymphoma, unspecified site, extranodal and solid organ sites
202.01   Nodular lymphoma, lymph nodes of head, face, and neck
202.02   Nodular lymphoma, intrathoracic lymph nodes
202.03   Nodular lymphoma, intra-abdominal lymph nodes
202.04   Nodular lymphoma, lymph nodes of axilla and upper limb
202.05   Nodular lymphoma, lymph nodes of inguinal region and lower limb
202.06   Nodular lymphoma, intrapelvic lymph nodes
202.07   Nodular lymphoma, spleen
202.08   Nodular lymphoma, lymph nodes of multiple sites
202.10   Mycosis fungoides, unspecified site, extranodal and solid organ sites
202.11   Mycosis fungoides, lymph nodes of head, face, and neck
202.12   Mycosis fungoides, intrathoracic lymph nodes
202.13   Mycosis fungoides, intra-abdominal lymph nodes
202.14   Mycosis fungoides, lymph nodes of axilla and upper limb
202.15   Mycosis fungoides, lymph nodes of inguinal region and lower limb
202.16   Mycosis fungoides, intrapelvic lymph nodes
202.17   Mycosis fungoides, spleen
202.18   Mycosis fungoides, lymph nodes of multiple sites
202.20   Sézary's disease, unspecified site, extranodal and solid organ sites
202.21   Sézary's disease, lymph nodes of head, face, and neck
202.22   Sézary's disease, intrathoracic lymph nodes
202.23   Sézary's disease, intra-abdominal lymph nodes
202.24   Sézary's disease, lymph nodes of axilla and upper limb
202.25   Sézary's disease, lymph nodes of inguinal region and lower limb
202.26   Sézary's disease, intrapelvic lymph nodes
202.27   Sézary's disease, spleen
202.28   Sézary's disease, lymph nodes of multiple sites
202.30   Malignant histiocytosis, unspecified site, extranodal and solid organ sites
202.31   Malignant histiocytosis, lymph nodes of head, face, and neck
202.32   Malignant histiocytosis, intrathoracic lymph nodes
202.33   Malignant histiocytosis, intra-abdominal lymph nodes
202.34   Malignant histiocytosis, lymph nodes of axilla and upper limb
202.35   Malignant histiocytosis, lymph nodes of inguinal region and lower limb
202.36   Malignant histiocytosis, intrapelvic lymph nodes
202.37   Malignant histiocytosis, spleen
202.38   Malignant histiocytosis, lymph nodes of multiple sites
202.40   Leukemic reticuloendotheliosis, unspecified site, extranodal and solid organ sites
202.41   Leukemic reticuloendotheliosis, lymph nodes of head, face, and neck
202.42   Leukemic reticuloendotheliosis, intrathoracic lymph nodes
202.43   Leukemic reticuloendotheliosis, intra-abdominal lymph nodes
202.44   Leukemic reticuloendotheliosis, lymph nodes of axilla and upper limb
202.45   Leukemic reticuloendotheliosis, lymph nodes of inguinal region and lower limb
202.46   Leukemic reticuloendotheliosis, intrapelvic lymph nodes
202.47   Leukemic reticuloendotheliosis, spleen
202.48   Leukemic reticuloendotheliosis, lymph nodes of multiple sites
202.50   Letterer-Siwe disease, unspecified site, extranodal and solid organ sites
202.51   Letterer-Siwe disease, lymph nodes of head, face, and neck
202.52   Letterer-Siwe disease, intrathoracic lymph nodes
202.53   Letterer-Siwe disease, intra-abdominal lymph nodes
202.54   Letterer-Siwe disease, lymph nodes of axilla and upper limb
202.55   Letterer-Siwe disease, lymph nodes of inguinal region and lower limb



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NATIONAL COVERAGE DETERMINATION                                                          82977

202.56   Letterer-Siwe disease, intrapelvic lymph nodes
202.57   Letterer-Siwe disease, spleen
202.58   Letterer-Siwe disease, lymph nodes of multiple sites
202.60   Malignant mast cell tumors, unspecified site, extranodal and solid organ sites
202.61   Malignant mast cell tumors, lymph nodes of head, face, and neck
202.62   Malignant mast cell tumors, intrathoracic lymph nodes
202.63   Malignant mast cell tumors, intra-abdominal lymph nodes
202.64   Malignant mast cell tumors, lymph nodes of axilla and upper limb
202.65   Malignant mast cell tumors, lymph nodes of inguinal region and lower limb
202.66   Malignant mast cell tumors, intrapelvic lymph nodes
202.67   Malignant mast cell tumors, spleen
202.68   Malignant mast cell tumors, lymph nodes of multiple sites
202.70   Peripheral T cell lymphoma, unspecified site, extranodal and solid organ sites
202.71   Peripheral T cell lymphoma, lymph nodes of head, face, and neck
202.72   Peripheral T cell lymphoma, intrathoracic lymph nodes
202.73   Peripheral T cell lymphoma, intra-abdominal lymph nodes
202.74   Peripheral T cell lymphoma, lymph nodes of axilla and upper limb
202.75   Peripheral T cell lymphoma, lymph nodes of inguinal region and lower limb
202.76   Peripheral T cell lymphoma, intrapelvic lymph nodes
202.77   Peripheral T cell lymphoma, spleen
202.78   Peripheral T cell lymphoma, lymph nodes of multiple sites
202.80   Other lymphomas, unspecified site, extranodal and solid organ sites
202.81   Other lymphomas, lymph nodes of head, face, and neck
202.82   Other lymphomas, intrathoracic lymph nodes
202.83   Other lymphomas, intra-abdominal lymph nodes
202.84   Other lymphomas, lymph nodes of axilla and upper limb
202.85   Other lymphomas, lymph nodes of inguinal region and lower limb
202.86   Other lymphomas, intrapelvic lymph nodes
202.87   Other lymphomas, spleen
202.88   Other lymphomas, lymph nodes of multiple sites
202.90   Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue,
         unspecified site, extranodal and solid organ sites
202.91   Other and unspecified malignant neoplasms, lymph nodes of head, face, and neck
202.92   Other and unspecified malignant neoplasms, intrathoracic lymph nodes
202.93   Other and unspecified malignant neoplasms, intra-abdominal lymph nodes
202.94   Other and unspecified malignant neoplasms, lymph nodes of axilla and upper limb
202.95   Other and unspecified malignant neoplasms, lymph nodes of inguinal region and lower
         limb
202.96   Other and unspecified malignant neoplasms, intrapelvic lymph nodes
202.97   Other and unspecified malignant neoplasms, spleen
202.98   Other and unspecified malignant neoplasms, lymph nodes of multiple sites
203.00   Multiple myeloma without remission
203.01   Multiple myeloma in remission
203.10   Plasma cell leukemia without remission
203.11   Plasma cell leukemia in remission
203.80   Other immunoproliferative neoplasms without remission
203.81   Other immunoproliferative neoplasms in remission
204.00   Acute lymphoid leukemia without remission
204.01   Acute lymphoid leukemia in remission
204.10   Chronic lymphoid leukemia without remission
204.11   Chronic lymphoid leukemia in remission
204.20   Subacute lymphoid leukemia without remission
204.21   Subacute lymphoid leukemia in remission



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NATIONAL COVERAGE DETERMINATION                                              82977

204.80   Other lymphoid leukemia without remission
204.81   Other lymphoid leukemia in remission
204.90   Unspecified lymphoid leukemia without remission
204.91   Unspecified lymphoid leukemia in remission
205.00   Acute myeloid leukemia without remission
205.01   Acute myeloid leukemia in remission
205.10   Chronic myeloid leukemia without remission
205.11   Chronic myeloid leukemia in remission
205.20   Subacute myeloid sarcoma, without remission
205.21   Subacute myeloid sarcoma in remission
205.30   Myeloid sarcoma without remission
205.31   Myeloid sarcoma in remission
205.80   Other myeloid leukemia without remission
205.81   Other myeloid leukemia in remission
205.90   Unspecified myeloid leukemia without remission
205.91   Unspecified myeloid leukemia in remission
206.00   Acute monocytic leukemia without remission
206.01   Acute monocytic leukemia in remission
206.10   Chronic monocytic leukemia without remission
206.11   Chronic monocytic leukemia in remission
206.20   Subacute monocytic leukemia without remission
206.21   Subacute monocytic leukemia in remission
206.80   Other monocytic leukemia without remission
206.81   Other monocytic leukemia in remission
206.90   Unspecified monocytic leukemia without remission
206.91   Unspecified monocytic leukemia in remission
207.00   Acute erythremia and erythroleukemia without remission
207.01   Acute erythremia and erythroleukemia in remission
207.10   Chronic erythremia without remission
207.11   Chronic erythremia in remission
207.20   Megakaryocytic leukemia without remission
207.21   Megakaryocytic leukemia in remission
207.80   Other specified leukemia without remission
207.81   Other specified leukemia in remission
208.00   Acute leukemia of unspecified cell type without remission
208.01   Acute leukemia of unspecified cell type in remission
208.10   Chronic leukemia of unspecified cell type without remission
208.11   Chronic leukemia of unspecified cell type in remission
208.20   Subacute leukemia of unspecified cell type without remission
208.21   Subacute leukemia of unspecified cell type in remission
208.80   Other leukemia of unspecified cell type without remission
208.81   Other leukemia of unspecified cell type in remission
208.90   Unspecified leukemia without remission
208.91   Unspecified leukemia in remission
211.5    Benign neoplasm of liver and biliary passages
211.6    Benign neoplasm of pancreas, except islets of Langerhans
211.7    Benign neoplasm of islets of Langerhans
228.04   Hemangioma, of intra-abdominal structures
230.7    Carcinoma in situ of other and unspecified parts of intestine
230.8    Carcinoma in situ of liver and biliary system
230.9    Carcinoma in situ of other and unspecified digestive organs
235.0    Neoplasm of uncertain behavior of major salivary glands
235.1    Neoplasm of uncertain behavior of lip, oral cavity, and pharynx



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235.2    Neoplasm of uncertain behavior of stomach, intestines, and rectum
235.3    Neoplasm of uncertain behavior of liver and biliary passages
235.4    Neoplasm of uncertain behavior of retroperitoneum and peritoneum
235.5    Neoplasm of uncertain behavior of other and unspecified digestive organs
235.6    Neoplasm of uncertain behavior of larynx
235.7    Neoplasm of uncertain behavior of trachea, bronchus, and lung
235.8    Neoplasm of uncertain behavior of pleura, thymus, and mediastinum
235.9    Neoplasm of uncertain behavior of other and unspecified respiratory organs
236.0    Neoplasm of uncertain behavior of uterus
236.1    Neoplasm of uncertain behavior of placenta
236.2    Neoplasm of uncertain behavior of ovary
236.3    Neoplasm of uncertain behavior of other and unspecified female genital organs
236.4    Neoplasm of uncertain behavior of testis
236.5    Neoplasm of uncertain behavior of prostate
236.6    Neoplasm of uncertain behavior of other and unspecified male genital organs
236.7    Neoplasm of uncertain behavior of bladder
236.90   Neoplasm of uncertain behavior of urinary organs unspecified
236.91   Neoplasm of uncertain behavior of kidney and ureter
236.99   Neoplasm of uncertain behavior of other urinary organs
237.0    Neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct
237.1    Neoplasm of uncertain behavior of pineal gland
237.2    Neoplasm of uncertain behavior of adrenal gland
237.3    Paraganglia
237.4    Neoplasm of uncertain behavior of other and unspecified endocrine glands
237.5    Neoplasm of uncertain behavior of brain and spinal cord
237.6    Neoplasm of uncertain behavior of meninges
237.70   Neurofibromatosis, unspecified
237.71   Neurofibromatosis, type 1 [von Recklinghausen's disease]
237.72   Neurofibromatosis, type 2 [acoustic neurofibromatosis]
237.9    Other and unspecified parts of nervous system
238.0    Neoplasm of uncertain behavior of bone and articular cartilage
238.1    Neoplasm of uncertain behavior of connective and other soft tissue
238.2    Neoplasm of uncertain behavior of skin
238.3    Neoplasm of uncertain behavior of breast
238.4    Polycythemia vera
238.5    Histiocytic and mast cells
238.6    Plasma cells
238.71   Essential thrombocythemia
238.72   Low grade myelodysplastic syndrome lesions
238.73   High grade myelodysplastic syndrome lesions
238.74   Myelodysplastic syndrome with 5q deletion
238.75   Myelodysplastic syndrome, unspecified
238.76   Myelofibrosis with myeloid metaplasia
238.79   Other lymphatic and hematopoietic tissues
238.8    Neoplasm of uncertain behavior of other specified sites
238.9    Neoplasm of uncertain behavior, site unspecified
239.0    Neoplasms of unspecified nature of digestive system
250.00   Diabetes mellitus without complication, type II or unspecified type, not stated as
         uncontrolled
250.01   Diabetes mellitus without complication, type I, not stated as uncontrolled
250.02   Diabetes mellitus without complication, type II or unspecified type, uncontrolled
250.03   Diabetes mellitus without complication, type I, uncontrolled
250.10   Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled



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NATIONAL COVERAGE DETERMINATION                                                                82977

250.11   Diabetes with ketoacidosis, type I, not stated as uncontrolled
250.12   Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13   Diabetes with ketoacidosis, type I, uncontrolled
250.20   Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
250.21   Diabetes with hyperosmolarity, type I, not stated as uncontrolled
250.22   Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23   Diabetes with hyperosmolarity, type I, uncontrolled
250.30   Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
250.31   Diabetes with other coma, type I, not stated as uncontrolled
250.32   Diabetes with other coma, type II or unspecified type, uncontrolled
250.33   Diabetes with other coma type I, uncontrolled
250.40   Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41   Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42   Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43   Diabetes with renal manifestations, type I, uncontrolled
250.50   Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
         uncontrolled
250.51   Diabetes with ophthalmic manifestations, type I, not stated as uncontrolled
250.52   Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53   Diabetes with ophthalmic manifestations, type I, uncontrolled
250.60   Diabetes with neurological manifestations, type II or unspecified type, not stated as
         uncontrolled
250.61   Diabetes with neurological manifestations, type I, not stated as uncontrolled
250.62   Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
250.63   Diabetes with neurological manifestations, type I, uncontrolled
250.70   Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
         uncontrolled
250.71   Diabetes with peripheral circulatory disorders, type I, not stated as uncontrolled
250.72   Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
250.73   Diabetes with peripheral circulatory disorders, type I, uncontrolled
250.80   Diabetes with other specified manifestations, type II or unspecified type, not stated as
         uncontrolled
250.81   Diabetes with other specified manifestations, type I, not stated as uncontrolled
250.82   Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
250.83   Diabetes with other specified manifestations, type I uncontrolled
250.90   Diabetes with unspecified complication, type II or unspecified type, not stated as
         uncontrolled
250.91   Diabetes with unspecified complication, type I, not stated as uncontrolled
250.92   Diabetes with unspecified complication, type II or unspecified type, uncontrolled
250.93   Diabetes with unspecified complication, type I, uncontrolled
252.00   Hyperparathyroidism, unspecified
252.01   Primary hyperparathyroidism
252.02   Secondary hyperparathyroidism, non-renal
252.08   Other hyperparathyroidism
263.1    Malnutrition of mild degree
263.9    Unspecified protein-calorie malnutrition
268.0    Rickets, active
268.2    Osteomalacia, unspecified
269.0    Vitamin K deficiency
270.2    Other disturbances of aromatic amino-acid metabolism
270.9    Unspecified disorder of amino-acid metabolism
271.0    Glycogenosis
272.0    Pure hypercholesterolemia



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272.1    Pure hyperglyceridemia
272.2    Mixed hyperlipidemia
272.4    Other and unspecified hyperlipidemia
272.7    Lipidoses
272.9    Unspecified disorder of lipoid metabolism
273.4    Alpha-1-antitrypsin deficiency
275.0    Disorders of iron metabolism
275.1    Disorders of copper metabolism
275.3    Disorders of phosphorus metabolism
275.40   Disorders of calcium metabolism, unspecified
275.41   Hypocalcemia
275.42   Hypercalcemia
275.49   Other disorders of calcium metabolism
277.1    Disorders of porphyrin metabolism
277.30   Amyloidosis, unspecified
277.31   Familial Mediterranean fever
277.39   Other amyloidosis
277.4    Disorders of bilirubin excretion
277.6    Other deficiencies of circulating enzymes
282.60   Sickle-cell disease, unspecified
282.61   Hb-SS disease without crisis
282.62   Hb-SS disease with crisis
282.63   Sickle-cell/Hb-C disease without crisis
282.64   Sickle-cell/Hgb-C disease with crisis
282.68   Other sickle-cell disease without crisis
282.69   Other Sickle-cell disease with crisis
286.6    Defibrination syndrome
286.7    Acquired coagulation factor deficiency
289.4    Hypersplenism
289.52   Splenic sequestration
291.0    Alcohol withdrawal delirium
291.1    Alcohol-induced persisting amnestic syndrome
291.2    Alcohol-induced persisting dementia
291.3    Alcohol-induced psychotic disorder with hallucinations
291.4    Idiosyncratic alcohol intoxication
291.5    Alcohol-induced psychotic disorder with delusions
291.81   Alcohol withdrawal
291.82   Alcohol induced sleep disorders
291.89   Other alcohol-induced mental disorders
291.9    Unspecified alcohol-induced mental disorders
303.00   Acute alcoholic intoxication, unspecified
303.01   Acute alcoholic intoxication, continuous
303.02   Acute alcoholic intoxication, episodic
303.03   Acute alcoholic intoxication in remission
303.90   Other and unspecified alcohol dependence, unspecified
303.91   Other and unspecified alcohol dependence, continuous
303.92   Other and unspecified alcohol dependence, episodic
303.93   Other and unspecified alcohol dependence in remission
304.00   Opioid type dependence, unspecified
304.01   Opioid type dependence, continuous
304.02   Opioid type dependence, episodic
304.03   Opioid type dependence in remission
304.10   Sedative, hypnotic or anxiolytic dependence, unspecified



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304.11   Sedative, hypnotic or anxiolytic dependence, continuous
304.12   Sedative, hypnotic or anxiolytic dependence, episodic
304.13   Sedative, hypnotic or anxiolytic dependence, in remission
304.20   Cocaine dependence, unspecified
304.21   Cocaine dependence, continuous
304.22   Cocaine dependence, episodic
304.23   Cocaine dependence in remission
304.30   Cannabis dependence, unspecified
304.31   Cannabis dependence, continuous
304.32   Cannabis dependence, episodic
304.33   Cannabis dependence in remission
304.40   Amphetamine and other psychostimulant dependence, unspecified
304.41   Amphetamine and other psychostimulant dependence, continuous
304.42   Amphetamine and other psychostimulant dependence, episodic
304.43   Amphetamine and other psychostimulant dependence in remission
304.50   Hallucinogen dependence, unspecified
304.51   Hallucinogen dependence, continuous
304.52   Hallucinogen dependence, episodic
304.53   Hallucinogen dependence in remission
304.60   Other specified drug dependence, unspecified
304.61   Other specified drug dependence, continuous
304.62   Other specified drug dependence, episodic
304.63   Other specified drug dependence in remission
304.70   Combinations of opioid type drug dependence with any other drug, unspecified
304.71   Combinations of opioid type drug dependence with any other drug, continuous
304.72   Combinations of opioid type drug dependence with any other drug, episodic
304.73   Combinations of opioid type drug dependence with any other drug, in remission
304.80   Combinations of drug dependence excluding opioid type, unspecified
304.81   Combinations of drug dependence excluding opioid type, continuous
304.82   Combinations of drug dependence excluding opioid type, episodic
304.83   Combinations of drug dependence excluding opioid type in remission drug
304.90   Unspecified drug dependence, unspecified
304.91   Unspecified drug dependence, continuous
304.92   Unspecified drug dependence, episodic
304.93   Unspecified drug dependence in remission
305.00   Alcohol abuse, unspecified
305.01   Alcohol abuse, continuous
305.02   Alcohol abuse, episodic
305.03   Alcohol abuse, in remission
305.1    Tobacco use disorder
305.20   Cannabis abuse, unspecified
305.21   Cannabis abuse, continuous
305.22   Cannabis abuse, episodic
305.23   Cannabis abuse, in remission
305.30   Hallucinogen abuse, unspecified
305.31   Hallucinogen abuse, continuous
305.32   Hallucinogen abuse, episodic
305.33   Hallucinogen abuse, in remission
305.40   Sedative, hypnotic or anxiolytic abuse, unspecified
305.41   Sedative, hypnotic or anxiolytic abuse, continuous
305.42   Sedative, hypnotic or anxiolytic abuse, episodic
305.43   Sedative, hypnotic or anxiolytic abuse, in remission
305.50   Opioid abuse, unspecified



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305.51   Opioid abuse, continuous
305.52   Opioid abuse, episodic
305.53   Opioid abuse, in remission
305.60   Cocaine abuse, unspecified
305.61   Cocaine abuse, continuous
305.62   Cocaine abuse, episodic
305.63   Cocaine abuse, in remission
305.70   Amphetamine or related acting sympathomimetic abuse, unspecified
305.71   Amphetamine or related acting sympathomimetic abuse, continuous
305.72   Amphetamine or related acting sympathomimetic abuse, episodic
305.73   Amphetamine or related acting sympathomimetic abuse, in remission
305.80   Antidepressant type abuse, unspecified
305.81   Antidepressant type abuse, continuous
305.82   Antidepressant type abuse, episodic
305.83   Antidepressant type abuse, in remission
305.90   Other, mixed, or unspecified drug abuse, unspecified
305.91   Other, mixed, or unspecified drug abuse, continuous
305.92   Other, mixed, or unspecified drug abuse, episodic
305.93   Other, mixed, or unspecified drug abuse, in remission
357.5    Alcoholic polyneuropathy
359.21   Myotonic muscular dystrophy
359.22   Myotonia congenital
359.23   Myotonic chondrodystrophy
359.24   Drug induced myotonia
359.29   Other specified myotonic disorder
452      Portal vein thrombosis
453.0    Budd-Chiari syndrome
453.1    Thrombophlebitis migrans
453.2    Embolism and thrombosis of vena cava
453.3    Embolism and thrombosis of renal vein
453.40   Venous embolism and thrombosis of unspecified deep vessels of lower extremity
453.41   Venous embolism and thrombosis of deep vessels of proximal lower extremity
453.42   Venous embolism and thrombosis of deep vessels of distal lower extremity
453.8    Embolism and thrombosis of other specified veins
453.9    Embolism and thrombosis of unspecified site
456.0    Esophageal varices with bleeding
456.1    Esophageal varices without bleeding
456.20   Esophageal varices in diseases classified elsewhere with bleeding
456.21   Esophageal varices in diseases classified elsewhere without bleeding
555.0    Regional enteritis, small intestine
555.1    Regional enteritis, large intestine
555.2    Regional enteritis, small intestine with large intestine
555.9    Regional enteritis, unspecified site
556.0    Ulcerative (chronic) enterocolitis
556.1    Ulcerative (chronic) ileocolitis
556.2    Ulcerative (chronic) proctitis
556.3    Ulcerative (chronic) proctosigmoiditis
556.4    Pseudopolyposis of colon
556.5    Left-sided ulcerative (chronic) colitis
556.6    Universal ulcerative (chronic) colitis
556.8    Other ulcerative colitis
556.9    Ulcerative colitis, unspecified
557.0    Acute vascular insufficiency of intestine



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558.1    Gastroenteritis and colitis due to radiation
558.2    Toxic gastroenteritis and colitis
558.3    Allergic gastroenteritis and colitis
558.9    Other and unspecified noninfectious gastroenteritis and colitis
560.0    Intussusception
560.1    Paralytic ileus
560.2    Volvulus
560.30   Impaction of intestine, unspecified
560.31   Gallstone ileus
560.39   Other intestinal obstruction
560.81   Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfective)
560.89   Other Intestinal or peritoneal adhesions
560.9    Unspecified intestinal obstruction
562.01   Diverticulitis of small intestine without hemorrhage
562.03   Diverticulitis of small intestine with hemorrhage
562.11   Diverticulitis of colon without hemorrhage
562.13   Diverticulitis of colon with hemorrhage
567.0    Peritonitis in infectious diseases classified elsewhere
567.1    Pneumococcal peritonitis
567.21   Peritonitis (acute) generalized
567.22   Peritoneal abscess
567.23   Spontaneous bacterial peritonitis
567.29   Other suppurative peritonitis
567.38   Other retroperitoneal abscess
567.39   Other retroperitoneal infections
567.81   Choleperitonitis
567.82   Sclerosing mesenteritis
567.89   Other specified peritonitis
567.9    Unspecified peritonitis
569.83   Perforation of intestine
570      Acute and subacute necrosis of liver
571.0    Alcoholic fatty liver
571.1    Acute alcoholic hepatitis
571.2    Alcoholic cirrhosis of liver
571.3    Alcoholic liver damage, unspecified
571.40   Chronic hepatitis, unspecified
571.41   Chronic persistent hepatitis
571.49   Other chronic hepatitis
571.5    Cirrhosis of liver without mention of alcohol
571.6    Biliary cirrhosis
571.8    Other chronic nonalcoholic liver disease
571.9    Unspecified chronic liver disease without mention of
572.0    Abscess of liver
572.1    Portal pyemia
572.2    Hepatic coma
572.3    Portal hypertension
572.4    Hepatorenal syndrome
572.8    Other sequelae of chronic liver disease
573.0    Chronic passive congestion of liver
573.1    Hepatitis in viral diseases classified elsewhere
573.2    Hepatitis in other infectious diseases classified elsewhere
573.3    Hepatitis, unspecified
573.4    Hepatic infarction



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573.8    Other specified disorders of liver
573.9    Unspecified disorder of liver
574.00   Calculus of gallbladder with acute cholecystitis without obstruction
574.01   Calculus of gallbladder with acute cholecystitis with obstruction
574.10   Calculus of gallbladder with other cholecystitis without obstruction
574.11   Calculus of gallbladder with other cholecystitis with obstruction
574.20   Calculus of gallbladder without cholecystitis without mention of obstruction
574.21   Calculus of gallbladder without cholecystitis with obstruction
574.30   Calculus of bile duct with acute cholecystitis without obstruction
574.31   Calculus of bile duct with acute cholecystitis with obstruction
574.40   Calculus of bile duct with other cholecystitis without obstruction
574.41   Calculus of bile duct with other cholecystitis with obstruction
574.50   Calculus of bile duct without cholecystitis without obstruction
574.51   Calculus of bile duct without cholecystitis with obstruction
574.60   Calculus of gallbladder and bile duct with acute cholecystitis without obstruction
574.61   Calculus of gallbladder and bile duct with acute cholecystitis with obstruction
574.70   Calculus of gallbladder and bile duct with other cholecystitis without obstruction
574.71   Calculus of gallbladder and bile duct with other cholecystitis with obstruction
574.80   Calculus of gallbladder and bile duct with acute and chronic cholecystitis without
         obstruction
574.81   Calculus of gallbladder and bile duct with acute and chronic cholecystitis with obstruction
574.90   Calculus of gallbladder and bile duct without cholecystitis without obstruction
574.91   Calculus of gallbladder and bile duct without cholecystitis with obstruction
575.0    Acute cholecystitis
575.10   Cholecystitis, unspecified
575.11   Cholecystitis, chronic
575.12   Cholecystitis, acute and chronic
575.2    Obstruction of gallbladder
575.3    Hydrops of gallbladder
575.4    Perforation of gallbladder
575.5    Fistula of gallbladder
575.6    Cholesterolosis of gallbladder
575.8    Other specified disorders of gallbladder
575.9    Unspecified disorder of gallbladder
576.0    Postcholecystectomy syndrome
576.1    Cholangitis
576.2    Obstruction of bile duct
576.3    Perforation of bile duct
576.4    Fistula of bile duct
576.5    Spasm of sphincter of Oddi
576.8    Other specified disorders of biliary tract
576.9    Unspecified disorder of biliary tract
581.0    Nephrotic syndrome with lesion of proliferative glomerulonephritis
581.1    Nephrotic syndrome with lesion of membranous glomerulonephritis
581.2    Nephrotic syndrome with lesion of membranoproliferative glomerulonephritis
581.3    Nephrotic syndrome with lesion of minimal change glomerulonephritis
581.81   Nephrotic syndrome in diseases classified elsewhere
581.89   Other nephrotic syndrome
581.9    Nephrotic syndrome with unspecified pathological lesion in
582.0    Chronic glomerulonephritis with lesion of proliferative glomerulonephritis
582.1    Chronic glomerulonephritis with lesion of membranous
582.2    Chronic glomerulonephritis with lesion of membranoproliferative glomerulonephritis
582.4    Chronic glomerulonephritis with lesion of rapidly progressive glomerulonephritis



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582.81   Chronic glomerulonephritis in diseases classified elsewhere
582.89   Chronic glomerulonephritis Other
582.9    Chronic glomerulonephritis with unspecified pathological lesion in kidney
583.0    Nephritis and nephropathy, with lesion of proliferative glomerulonephritis
583.1    Nephritis and nephropathy, with lesion of membranous glomerulonephritis
583.2    Nephritis and nephropathy, with lesion of membranoproliferative glomerulonephritis
583.4    Nephritis and nephropathy, with lesion of rapidly progressive glomerulonephritis
583.6    Nephritis and nephropathy, with lesion of renal cortical necrosis
583.7    Nephritis and nephropathy, with lesion of renal medullary necrosis
583.81   Nephritis and nephropathy, not specified as acute or chronic, in diseases classified
         elsewhere
583.89   Other nephritis and nephropathy
583.9    Nephritis and nephropathy with unspecified pathological lesion in kidney
584.5    Acute renal failure with lesion of tubular necrosis
584.6    Acute renal failure with lesion of renal cortical necrosis
584.7    Acute renal failure with lesion of renal medullary [papillary] necrosis
584.8    Acute renal failure with other specified pathological lesion in kidney
584.9    Acute renal failure, unspecified
585.6    End stage renal disease
586      Renal failure, unspecified
587      Renal sclerosis, unspecified
588.0    Renal osteodystrophy
588.1    Nephrogenic diabetes insipidus
588.81   Secondary hyperparathyroidism (of renal origin)
588.89   Other specified disorders resulting from impaired renal function
588.9    Unspecified disorder resulting from impaired renal function
590.00   Chronic pyelonephritis without lesion of renal medullary necrosis
590.01   Chronic pyelonephritis with lesion of renal medullary
590.10   Acute pyonephrosis without lesion of renal medullary necrosis
590.11   Acute pyonephrosis with lesion of renal medullary necrosis
590.2    Renal and perinephric abscess
590.3    Pyeloureteritis cystica
590.80   Pyelonephritis, unspecified
590.81   Pyelitis or pyelonephritis in diseases classified elsewhere
590.9    Infection of kidney, unspecified
642.50   Severe pre-eclampsia, unspecified as to episode of care or not applicable
642.51   Severe pre-eclampsia, delivered, with or without antepartum condition
642.52   Severe pre-eclampsia, delivered, with postpartum complication
642.53   Severe pre-eclampsia, antepartum condition or complication
642.54   Severe pre-eclampsia, postpartum condition or complication
646.70   Liver disorders in pregnancy, unspecified episode of care
646.71   Liver disorders in pregnancy, delivered, with or without antepartum condition
646.73   Liver disorders in pregnancy, antepartum condition or complication defects
782.4    Jaundice, unspecified, not of newborn
789.1    Hepatomegaly
790.4    Nonspecific elevation transaminase or lactic acid dehydrogenase [LDH]
790.5    Other nonspecific abnormalserum enzyme levels
960.0    Poisoning by penicillins
960.1    Poisoning by antifungal antibiotics
960.2    Poisoning by chloramphenicol group drugs
960.3    Poisoning by erythromycin and other macrolides
960.4    Poisoning by tetracycline group drugs
960.5    Poisoning by cephalosporin group drugs



                                                                                          Page 129
NATIONAL COVERAGE DETERMINATION                                                    82977

960.6    Poisoning by antimycobacterial antibiotics
960.7    Poisoning by antineoplastic antibiotics
960.8    Poisoning by other specified antibiotics
960.9    Poisoning by unspecified antibiotic
961.0    Poisoning by sulfonamides
961.1    Poisoning by arsenical anti-infectives
961.2    Poisoning by heavy metal anti-infectives
961.3    Poisoning by quinoline and hydroxyquinoline derivatives
961.4    Poisoning by antimalarials and drugs acting on other blood protozoa
961.5    Poisoning by other antiprotozoal drugs
961.6    Poisoning by anthelmintics
961.7    Poisoning by antiviral drugs
961.8    Poisoning by other antimycobacterial drugs
961.9    Poisoning by other and unspecified anti-infectives
962.0    Poisoning by adrenal cortical steroids
962.1    Poisoning by androgens and anabolic congeners
962.2    Poisoning by ovarian hormones and synthetic substitutes
962.3    Poisoning by insulins and antidiabetic agents
962.4    Anterior pituitary hormones
962.5    Posterior pituitary hormones
962.6    Parathyroid and parathyroid derivatives
962.7    Poisoning by thyroid and thyroid derivatives
962.8    Poisoning by antithyroid agents
962.9    Poisoning by other and unspecified hormones and synthetic substitutes
963.0    Poisoning by antiallergic and antiemetic drugs
963.1    Poisoning by antineoplastic and immunosuppressive drugs
963.2    Poisoning by acidifying agents
963.3    Poisoning by alkalizing agents
963.4    Poisoning by enzymes, not elsewhere classified
963.5    Poisoning by vitamins, not elsewhere classified
963.8    Poisoning by other specified systemic agents
963.9    Poisoning by unspecified systemic agent
964.0    Poisoning by iron and its compounds
964.1    Poisoning by liver preparations and other antianemic agents
964.2    Poisoning by anticoagulants
964.3    Poisoning by vitamin K [phytonadione]
964.4    Poisoning by fibrinolysis-affecting drugs
964.5    Poisoning by anticoagulant antagonists and other coagulants
964.6    Poisoning by gamma globulin
964.7    Poisoning by natural blood and blood products
964.8    Poisoning by other specified agents affecting blood constituents
964.9    Poisoning by unspecified agents affecting blood constituents
965.00   Poisoning by opium (alkaloids), unspecified
965.01   Poisoning by heroin
965.02   Poisoning by methadone
965.09   Poisoning by other opiates and related narcotics
965.1    Poisoning by salicylates
965.4    Poisoning by aromatic analgesics, not elsewhere classified
965.5    Poisoning by pyrazole derivatives
965.61   Poisoning by propionoic acid derivatives
965.69   Poisoning by other antirheumatics
965.7    Poisoning by other non-narcotic analgesics
965.8    Poisoning by other specified analgesics and antipyretics



                                                                                 Page 130
NATIONAL COVERAGE DETERMINATION                                                           82977

965.9   Poisoning by unspecified analgesic and antipyretic
966.0   Poisoning by oxazolidine derivatives
966.1   Poisoning by hydantoin derivatives
966.2   Poisoning by succinimides
966.3   Poisoning by other and unspecified anticonvulsants
966.4   Poisoning by anti-Parkinsonism drugs
967.0   Poisoning by barbiturates
967.1   Poisoning by chloral hydrate group drugs
967.2   Poisoning by paraldehyde
967.3   Poisoning by bromine compounds
967.4   Poisoning by methaqualone compounds
967.5   Poisoning by glutethimide group drugs
967.6   Poisoning by mixed sedatives, not elsewhere classified
967.8   Poisoning by other sedatives and hypnotics
967.9   Poisoning by unspecified sedative or hypnotic
968.0   Poisoning by central nervous system muscle-tone depressants
968.1   Poisoning by halothane
968.2   Poisoning by other gaseous anesthetics
968.3   Poisoning by intravenous anesthetics
968.4   Poisoning by other and unspecified general anesthetics
968.5   Poisoning by topical and infiltration anesthetics
968.6   Poisoning by peripheral nerve- and plexus-blocking anesthetics
968.7   Poisoning by spinal anesthetics
968.9   Poisoning by other and unspecified local anesthetics
969.0   Poisoning by antidepressants
969.1   Poisoning by phenothiazine-based tranquilizers
969.2   Poisoning by butyrophenone-based tranquilizers
969.3   Poisoning by other antipsychotics, neuroleptics, and major tranquilizers
969.4   Poisoning by benzodiazepine-based tranquilizers
969.5   Poisoning by other tranquilizers
969.6   Poisoning by psychodysleptics [hallucinogens]
969.7   Poisoning by psychostimulants
969.8   Poisoning by other specified psychotropic agents
969.9   Poisoning by unspecified psychotropic agent
970.0   Poisoning by analeptics
970.1   Poisoning by opiate antagonists
970.8   Poisoning by other specified central nervous system stimulants
970.9   Poisoning by unspecified central nervous system stimulant
971.0   Poisoning by parasympathomimetics [cholinergics]
971.1   Poisoning by parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics
971.2   Poisoning by sympathomimetics [adrenergics]
971.3   Poisoning by sympatholytics [antiadrenergics]
971.9   Poisoning by unspecified drug primarily affecting autonomic nervous system
972.0   Poisoning by cardiac rhythm regulators
972.1   Poisoning by cardiotonic glycosides and drugs of similar action
972.2   Poisoning by antilipemic and antiarteriosclerotic drugs
972.3   Poisoning by ganglion-blocking agents
972.4   Poisoning by coronary vasodilators
972.5   Poisoning by other vasodilators
972.6   Poisoning by other antihypertensive agents
972.7   Poisoning by antivaricose drugs, including sclerosing agents
972.8   Poisoning by capillary-active drugs
972.9   Poisoning by other and unspecified agents primarily affecting the cardiovascular system



                                                                                       Page 131
NATIONAL COVERAGE DETERMINATION                                                            82977

973.0   Poisoning by antacids and antigastric secretion drugs
973.1   Poisoning by irritant cathartics
973.2   Poisoning by emollient cathartics
973.3   Poisoning by other cathartics, including intestinal atonia drugs
973.4   Poisoning by digestants
973.5   Poisoning by antidiarrheal drugs
973.6   Poisoning by emetics
973.8   Poisoning by other specified agents primarily affecting the gastrointestinal system
973.9   Poisoning by Unspecified agent primarily affecting the gastrointestinal system
974.0   Poisoning by mercurial diuretics
974.1   Poisoning by purine derivative diuretics
974.2   Poisoning by carbonic acid anhydrase inhibitors
974.3   Poisoning by saluretics
974.4   Poisoning by other diuretics
974.5   Poisoning by electrolytic, caloric, and water-balance agents
974.6   Poisoning by other mineral salts, not elsewhere classified
974.7   Poisoning by uric acid metabolism drugs
975.0   Poisoning by oxytocic agents
975.1   Poisoning by smooth muscle relaxants
975.2   Poisoning by skeletal muscle relaxants
975.3   Poisoning by other and unspecified drugs acting on muscles
975.4   Poisoning by antitussives
975.5   Poisoning by expectorants
975.6   Poisoning by anti-common cold drugs
975.7   Poisoning by antiasthmatics
975.8   Poisoning by other and unspecified respiratory drugs
976.0   Poisoning by local anti-infectives and anti-inflammatory drugs
976.1   Poisoning by antipruritics
976.2   Poisoning by local astringents and local detergents
976.3   Poisoning by emollients, demulcents, and protectants
976.4   Poisoning by keratolytics, keratoplastics, other hair treatment drugs and preparations
976.5   Poisoning by eye anti-infectives and other eye drugs
976.6   Poisoning by anti-infectives and other drugs and preparations for ear, nose, and throat
976.7   Poisoning by dental drugs topically applied
976.8   Poisoning by other agents primarily affecting skin and mucous membrane
976.9   Poisoning by unspecified agent primarily affecting skin and mucous membrane
977.0   Poisoning by dietetics
977.1   Poisoning by lipotropic drugs
977.2   Poisoning by antidotes and chelating agents, not elsewhere classified
977.3   Poisoning by alcohol deterrents
977.4   Poisoning by pharmaceutical excipients
977.8   Poisoning by other specified drugs and medicinal substances
977.9   Poisoning by unspecified drug or medicinal substance
978.0   Poisoning by BCG
978.1   Poisoning by typhoid and paratyphoid vaccine
978.2   Poisoning by cholera vaccine
978.3   Poisoning by plague vaccine
978.4   Poisoning by tetanus vaccine
978.5   Poisoning by diphtheria vaccine
978.6   Poisoning by pertussis vaccine, including combinations with a pertussis component
978.8   Poisoning by other and unspecified bacterial vaccines
978.9   Poisoning by Mixed bacterial vaccines, except combinations with a pertussis component
979.0   Poisoning by smallpox vaccine



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NATIONAL COVERAGE DETERMINATION                                                              82977

979.1   Poisoning by rabies vaccine
979.2   Poisoning by typhus vaccine
979.3   Poisoning by yellow fever vaccine
979.4   Poisoning by measles vaccine
979.5   Poisoning by poliomyelitis vaccine
979.6   Poisoning by other and unspecified viral and rickettsial vaccines
979.7   Poisoning by mixed viral-rickettsial and bacterial vaccines, except combinations with a
        pertussis component
979.9   Poisoning by other and unspecified vaccines and biological substances
980.0   Toxic effect of ethyl alcohol
980.1   Toxic effect of methyl alcohol
980.2   Toxic effect of isopropyl alcohol
980.3   Toxic effect of fusel oil
980.8   Toxic effect of other specified alcohols
980.9   Toxic effect of unspecified alcohol
981     Toxic effect of petroleum products
982.0   Toxic effect of benzene and homologues
982.1   Toxic effect of carbon tetrachloride
982.2   Toxic effect of carbon disulfide
982.3   Toxic effect of other chlorinated hydrocarbon solvents
982.4   Toxic effect of nitroglycol
982.8   Toxic effect of other nonpetroleum-based solvents
983.0   Toxic effect of corrosive aromatics
983.1   Toxic effect of acids
983.2   Toxic effect of caustic alkalis
983.9   Toxic effect of caustic, unspecified
984.0   Toxic effect of inorganic lead compounds
984.1   Toxic effect of organic lead compounds
984.8   Toxic effect of other lead compounds
984.9   Toxic effect of unspecified lead compound
985.0   Toxic effect of mercury and its compounds
985.1   Toxic effect of arsenic and its compounds
985.2   Toxic effect of manganese and its compounds
985.3   Toxic effect of beryllium and its compounds
985.4   Toxic effect of antimony and its compounds
985.5   Toxic effect of cadmium and its compounds
985.6   Toxic effect of chromium
985.8   Toxic effect of other specified metals
985.9   Toxic effect of unspecified metal
986     Toxic effect of carbon monoxide
987.0   Toxic effect of liquefied petroleum gases
987.1   Toxic effect of other hydrocarbon gas
987.2   Toxic effect of nitrogen oxides
987.3   Toxic effect of sulfur dioxide
987.4   Toxic effect of freon
987.5   Toxic effect of lacrimogenic gas
987.6   Toxic effect of chlorine gas
987.7   Toxic effect of hydrocyanic acid gas
987.8   Toxic effect of other specified gases, fumes, or vapors
987.9   Toxic effect of unspecified gas, fume, or vapor
988.0   Toxic effect of fish and shellfish
988.1   Toxic effect of mushrooms
988.2   Toxic effect of berries and other plants



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NATIONAL COVERAGE DETERMINATION                                                               82977

988.8    Toxic effect of other specified noxious food substances
988.9    Toxic effect of unspecified noxious food substance
989.0    Toxic effect of hydrocyanic acid and cyanides
989.1    Toxic effect of strychnine and salts
989.2    Toxic effect of chlorinated hydrocarbons
989.3    Toxic effect of organophosphate and carbamate
989.4    Toxic effect of other pesticides, not elsewhere classified
989.5    Toxic effect of venom
989.6    Toxic effect of soaps and detergents
989.7    Toxic effect of aflatoxin and other mycotoxin [food contaminants]
989.81   Toxic effect of asbestos
989.82   Toxic effect of latex
989.83   Toxic effect of silicone
989.84   Toxic effect of tobacco
989.89   Toxic effect of other substances, chiefly nonmedicinal as to source
V42.7    Organ or tissue replaced by transplant, liver
V58.61   Long-term (current) use of anticoagulants
V58.62   Long-term (current) use of antibiotics
V58.63   Long-term (current) use of antiplatelet/antithrombotic
V58.64   Long-term (current) use of non-steroidal anti-inflammatories
V58.69   Long-term (current) use of other medications
V67.1    Follow-up examination following radiotherapy
V67.2    Follow-up examination following chemotherapy
V67.51   Follow-up examination following completed treatment with high-risk medication, not
         elsewhere classified




                                                                                        Page 134
NATIONAL COVERAGE DETERMINATION                                                              82985


NATIONAL COVERAGE DETERMINATION
82985
82985-Glycated protein




CPT CODE: 82985



CPT CODE DESCRIPTOR: Glycated protein



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS: None



COVERED ICD-9 CODES:
211.7 Benign neoplasm of islets of Langerhans
250.00 Diabetes mellitus without complication, type II or unspecified type, not stated as
       uncontrolled
250.01 Diabetes mellitus without complication, type I, not stated as uncontrolled
250.02 Diabetes mellitus without complication, type II or unspecified type, uncontrolled
250.03 Diabetes mellitus without complication, type I, uncontrolled
250.10 Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
250.11 Diabetes with ketoacidosis, type I, not stated as uncontrolled
250.12 Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13 Diabetes with ketoacidosis, type I, uncontrolled
250.20 Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
250.21 Diabetes with hyperosmolarity, type I, not stated as uncontrolled
250.22 Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23 Diabetes with hyperosmolarity, type I, uncontrolled
250.30 Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
250.31 Diabetes with other coma, type I, not stated as uncontrolled
250.32 Diabetes with other coma, type II or unspecified type, uncontrolled
250.33 Diabetes with other coma type I, uncontrolled
250.40 Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41 Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42 Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43 Diabetes with renal manifestations, type I, uncontrolled
250.50 Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
       uncontrolled
250.51 Diabetes with ophthalmic manifestations, type I, not stated as uncontrolled
250.52 Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53 Diabetes with ophthalmic manifestations, type I, uncontrolled
250.60 Diabetes with neurological manifestations, type II or unspecified type, not stated as
       uncontrolled
250.61 Diabetes with neurological manifestations, type I, not stated as uncontrolled
250.62 Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
250.63 Diabetes with neurological manifestations, type I, uncontrolled
250.70 Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
       uncontrolled
250.71 Diabetes with peripheral circulatory disorders, type I, not stated as uncontrolled
250.72 Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
250.73 Diabetes with peripheral circulatory disorders, type I, uncontrolled
250.80 Diabetes with other specified manifestations, type II or unspecified type, not stated as
       uncontrolled
250.81 Diabetes with other specified manifestations, type I, not stated as uncontrolled


                                                                                          Page 135
NATIONAL COVERAGE DETERMINATION                                                              82985

250.82 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
250.83 Diabetes with other specified manifestations, type I uncontrolled
250.90 Diabetes with unspecified complication, type II or unspecified type, not stated as
       uncontrolled
250.91 Diabetes with unspecified complication, type I, not stated as uncontrolled
250.92 Diabetes with unspecified complication, type II or unspecified type, uncontrolled
250.93 Diabetes with unspecified complication, type I, uncontrolled
251.0 Hypoglycemic coma
251.1 Other specified hypoglycemia
251.2 Hypoglycemia, unspecified
251.3 Postsurgical hypoinsulinemia
251.4 Abnormality of secretion of glucagon
251.8 Other specified disorders of pancreatic internal secretion
251.9 Unspecified disorder of pancreatic internal secretion
258.01 Multiple endocrine neoplasia [MEN] type I
258.02 Multiple endocrine neoplasia [MEN] type IIA
258.03 Multiple endocrine neoplasia [MEN] type IIB
258.1 Other combinations of endocrine dysfunction
258.8 Other specified polyglandular dysfunction
258.9 Polyglandular dysfunction, unspecified
271.4 Renal glycosuria
275.0 Disorders of iron metabolism
577.1 Chronic pancreatitis
579.3 Other and unspecified postsurgical nonabsorption
648.00 Other conditions of mother complicating pregnancy, diabetes mellitus, unspecified
       episode of care
648.03 Other conditions of mother complicating pregnancy, diabetes mellitus, antepartum
       condition or complication
648.04 Other conditions of mother complicating pregnancy, diabetes mellitus, postpartum
       condition or complication
648.80 Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
       unspecified episode of care
648.83 Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
       antepartum condition or complication
648.84 Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
       postpartum condition or complication
790.21 Impaired fasting glucose
790.22 Impaired glucose tolerance test
790.29 Other abnormal glucose
790.6 Other abnormal blood chemistry
962.3 Poisoning by insulins and antidiabetic agents
V12.2 Personal history of endocrine, metabolic, and immunity disorders
V58.67 Long-term (current) use of insulin
V58.69 Long-term (current) use of other medications




                                                                                          Page 136
NATIONAL COVERAGE DETERMINATION                                                                                     83036


NATIONAL COVERAGE DETERMINATION
83036
83036-Hemoglobin; glycosylated (A1C)




CPT CODE: 83036



CPT CODE DESCRIPTOR: Hemoglobin; glycosylated (A1C)



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                       It is not considered reasonable and necessary to perform glycated hemoglobin
                                       tests more often than every three months on a controlled diabetic patient to
                                       determine whether the patient's metabolic control has been on average within the
                                       target range. It is not considered reasonable and necessary for these tests to be
                                       performed more frequently than once a month for diabetic pregnant women.

                                       Testing for uncontrolled type one or two diabetes mellitus may require testing
                                       more than four times a year. Medical necessity documentation must support such
                                       testing in excess of the above guidelines.



COVERED ICD-9 CODES:
211.7 Benign neoplasm of islets of Langerhans
250.00 Diabetes mellitus without complication, type II or unspecified type, not stated as
       uncontrolled
250.01 Diabetes mellitus without complication, type I, not stated as uncontrolled
250.02 Diabetes mellitus without complication, type II or unspecified type, uncontrolled
250.03 Diabetes mellitus without complication, type I, uncontrolled
250.10 Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
250.11 Diabetes with ketoacidosis, type I, not stated as uncontrolled
250.12 Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13 Diabetes with ketoacidosis, type I, uncontrolled
250.20 Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
250.21 Diabetes with hyperosmolarity, type I, not stated as uncontrolled
250.22 Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23 Diabetes with hyperosmolarity, type I, uncontrolled
250.30 Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
250.31 Diabetes with other coma, type I, not stated as uncontrolled
250.32 Diabetes with other coma, type II or unspecified type, uncontrolled
250.33 Diabetes with other coma type I, uncontrolled
250.40 Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41 Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42 Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43 Diabetes with renal manifestations, type I, uncontrolled
250.50 Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
       uncontrolled
250.51 Diabetes with ophthalmic manifestations, type I, not stated as uncontrolled
250.52 Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53 Diabetes with ophthalmic manifestations, type I, uncontrolled
250.60 Diabetes with neurological manifestations, type II or unspecified type, not stated as
       uncontrolled
250.61 Diabetes with neurological manifestations, type I, not stated as uncontrolled


                                                                                                                 Page 137
NATIONAL COVERAGE DETERMINATION                                                               83036

250.62 Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
250.63 Diabetes with neurological manifestations, type I, uncontrolled
250.70 Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
       uncontrolled
250.71 Diabetes with peripheral circulatory disorders, type I, not stated as uncontrolled
250.72 Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
250.73 Diabetes with peripheral circulatory disorders, type I, uncontrolled
250.80 Diabetes with other specified manifestations, type II or unspecified type, not stated as
       uncontrolled
250.81 Diabetes with other specified manifestations, type I, not stated as uncontrolled
250.82 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
250.83 Diabetes with other specified manifestations, type I uncontrolled
250.90 Diabetes with unspecified complication, type II or unspecified type, not stated as
       uncontrolled
250.91 Diabetes with unspecified complication, type I, not stated as uncontrolled
250.92 Diabetes with unspecified complication, type II or unspecified type, uncontrolled
250.93 Diabetes with unspecified complication, type I, uncontrolled
251.0 Hypoglycemic coma
251.1 Other specified hypoglycemia
251.2 Hypoglycemia, unspecified
251.3 Postsurgical hypoinsulinemia
251.4 Abnormality of secretion of glucagon
251.8 Other specified disorders of pancreatic internal secretion
251.9 Unspecified disorder of pancreatic internal secretion
258.01 Multiple endocrine neoplasia [MEN] type I
258.02 Multiple endocrine neoplasia [MEN] type IIA
258.03 Multiple endocrine neoplasia [MEN] type IIB
258.1 Other combinations of endocrine dysfunction
258.8 Other specified polyglandular dysfunction
258.9 Polyglandular dysfunction, unspecified
271.4 Renal glycosuria
275.0 Disorders of iron metabolism
577.1 Chronic pancreatitis
579.3 Other and unspecified postsurgical nonabsorption
648.00 Other conditions of mother complicating pregnancy, diabetes mellitus, unspecified
       episode of care
648.03 Other conditions of mother complicating pregnancy, diabetes mellitus, antepartum
       condition or complication
648.04 Other conditions of mother complicating pregnancy, diabetes mellitus, postpartum
       condition or complication
648.80 Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
       unspecified episode of care
648.83 Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
       antepartum condition or complication
648.84 Other conditions of mother complicating pregnancy, abnormal glucose tolerance,
       postpartum condition or complication
790.21 Impaired fasting glucose
790.22 Impaired glucose tolerance test
790.29 Other abnormal glucose
790.6 Other abnormal blood chemistry
962.3 Poisoning by insulins and antidiabetic agents
V12.2 Personal history of endocrine, metabolic, and immunity disorders
V58.67 Long-term (current) use of insulin



                                                                                           Page 138
NATIONAL COVERAGE DETERMINATION                         83036

V58.69 Long-term (current) use of other medications




                                                      Page 139
NATIONAL COVERAGE DETERMINATION                                                                                           83700


NATIONAL COVERAGE DETERMINATION
83700
83700-Lipoprotein, blood; electrophoretic separation and quantitation




CPT CODE: 83700



CPT CODE DESCRIPTOR: Lipoprotein, blood; electrophoretic separation and quantitation



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                           When monitoring long term anti-lipid dietary or pharmacologic therapy and when
                                           following patients with borderline high total or LDL cholesterol levels, it is
                                           reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a
                                           yearly interval will usually be adequate while measurement of the serum total
                                           cholesterol (CPT code 82465) or a measured LDL (CPT code 83721) should suffice
                                           for interim visits if the patient does not have hypertriglyceridemia (for example,
                                           ICD-9-CM code 272.1, Pure hyperglyceridemia).

                                           Any one component of the panel or a measured LDL may be medically necessary
                                           up to six times the first year for monitoring dietary or pharmacologic therapy. More
                                           frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing
                                           may be indicated for marked elevations or for changes to anti-lipid therapy due to
                                           inadequate initial patient response to dietary or pharma-cologic therapy. The LDL
                                           cholesterol or total cholesterol may be measured three times yearly after treatment
                                           goals have been achieved. If no dietary or pharmacological therapy is advised,
                                           monitoring is not necessary.

                                           When evaluating non-specific chronic abnormalities of the liver (for example,
                                           elevations of transaminase, alkaline phosphatase, abnormal imaging studies, etc.),
                                           a lipid panel would generally not be indicated more than twice per year.



COVERED ICD-9 CODES:
242.00 Toxic diffuse goiter without thyrotoxic crisis or storm
242.01 Toxic diffuse goiter with thyrotoxic crisis or storm
242.10 Toxic uninodular goiter without thyrotoxic crisis or storm
242.11 Toxic uninodular goiter with thyrotoxic crisis or storm
242.20 Toxic multinodular goiter without thyrotoxic crisis or storm
242.21 Toxic multinodular goiter with thyrotoxic crisis or storm
242.30 Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm
242.31 Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40 Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41 Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
242.80 Thyrotoxicosis of other specified origin without thyrotoxic crisis or storm
242.81 Thyrotoxicosis of other specified origin with thyrotoxic crisis or storm
242.90 Thyrotoxicosis without of goiter or other cause without thyrotoxic crisis or storm
242.91 Thyrotoxicosis without goiter or other cause with mention of thyrotoxic crisis or storm
243    Congenital hypothyroidism
244.0 Postsurgical hypothyroidism
244.1 Other postablative hypothyroidism
244.2 Iodine hypothyroidism
244.3 Other iatrogenic hypothyroidism


                                                                                                                       Page 140
NATIONAL COVERAGE DETERMINATION                                                                83700

244.8    Other specified acquired hypothyroidism
244.9    Unspecified hypothyroidism
245.0    Acute thyroiditis
245.1    Subacute thyroiditis
245.2    Chronic lymphocytic thyroiditis
245.3    Chronic fibrous thyroiditis
245.4    Iatrogenic thyroiditis
245.8    Other and unspecified chronic thyroiditis
245.9    Thyroiditis, unspecified
250.00   Diabetes mellitus without complication, type II or unspecified type, not stated as
         uncontrolled
250.01   Diabetes mellitus without complication, type I, not stated as uncontrolled
250.02   Diabetes mellitus without complication, type II or unspecified type, uncontrolled
250.03   Diabetes mellitus without complication, type I, uncontrolled
250.10   Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
250.11   Diabetes with ketoacidosis, type I, not stated as uncontrolled
250.12   Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13   Diabetes with ketoacidosis, type I, uncontrolled
250.20   Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
250.21   Diabetes with hyperosmolarity, type I, not stated as uncontrolled
250.22   Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23   Diabetes with hyperosmolarity, type I, uncontrolled
250.30   Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
250.31   Diabetes with other coma, type I, not stated as uncontrolled
250.32   Diabetes with other coma, type II or unspecified type, uncontrolled
250.33   Diabetes with other coma type I, uncontrolled
250.40   Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41   Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42   Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43   Diabetes with renal manifestations, type I, uncontrolled
250.50   Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
         uncontrolled
250.51   Diabetes with ophthalmic manifestations, type I, not stated as uncontrolled
250.52   Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53   Diabetes with ophthalmic manifestations, type I, uncontrolled
250.60   Diabetes with neurological manifestations, type II or unspecified type, not stated as
         uncontrolled
250.61   Diabetes with neurological manifestations, type I, not stated as uncontrolled
250.62   Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
250.63   Diabetes with neurological manifestations, type I, uncontrolled
250.70   Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
         uncontrolled
250.71   Diabetes with peripheral circulatory disorders, type I, not stated as uncontrolled
250.72   Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
250.73   Diabetes with peripheral circulatory disorders, type I, uncontrolled
250.80   Diabetes with other specified manifestations, type II or unspecified type, not stated as
         uncontrolled
250.81   Diabetes with other specified manifestations, type I, not stated as uncontrolled
250.82   Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
250.83   Diabetes with other specified manifestations, type I uncontrolled
250.90   Diabetes with unspecified complication, type II or unspecified type, not stated as
         uncontrolled
250.91   Diabetes with unspecified complication, type I, not stated as uncontrolled



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NATIONAL COVERAGE DETERMINATION                                                                83700

250.92   Diabetes with unspecified complication, type II or unspecified type, uncontrolled
250.93   Diabetes with unspecified complication, type I, uncontrolled
255.0    Cushing's syndrome
260      Kwashiorkor
261      Nutritional marasmus
262      Other severe protein-calorie malnutrition
263.0    Malnutrition of moderate degree
263.1    Malnutrition of mild degree
263.8    Other protein-calorie malnutrition
263.9    Unspecified protein-calorie malnutrition
270.0    Disturbances of amino-acid transport
271.1    Galactosemia
272.0    Pure hypercholesterolemia
272.1    Pure hyperglyceridemia
272.2    Mixed hyperlipidemia
272.3    Hyperchylomicronemia
272.4    Other and unspecified hyperlipidemia
272.5    Lipoprotein deficiencies
272.6    Lipodystrophy
272.7    Lipidoses
272.8    Other disorders of lipoid metabolism
272.9    Unspecified disorder of lipoid metabolism
277.30   Amyloidosis, unspecified
277.31   Familial Mediterranean fever
277.39   Other amyloidosis
278.00   Obesity, unspecified
278.01   Morbid obesity
278.02   Overweight
303.90   Other and unspecified alcohol dependence, unspecified
303.91   Other and unspecified alcohol dependence, continuous
303.92   Other and unspecified alcohol dependence, episodic
362.10   Background retinopathy, unspecified
362.11   Hypertensive retinopathy
362.12   Exudative retinopathy
362.13   Changes in vascular appearance
362.14   Retinal microaneurysms
362.15   Retinal telangiectasia
362.16   Retinal neovascularization
362.30   Retinal vascular occlusion, unspecified
362.31   Central retinal artery occlusion
362.32   Arterial branch occlusion
362.33   Partial arterial occlusion
362.34   Transient arterial occlusion
362.82   Retinal exudates and deposits
371.41   Senile corneal changes
374.51   Xanthelasma
379.22   Crystalline deposits in vitreous
388.00   Degenerative and vascular disorders, unspecified
388.02   Transient ischemic deafness
401.0    Malignant hypertension
401.1    Benign hypertension
401.9    Unspecified hypertension
402.00   Malignant hypertension without congestive heart failure



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NATIONAL COVERAGE DETERMINATION                                                            83700

402.01   Malignant hypertension with congestive heart failure
402.10   Benign hypertension without congestive heart failure
402.11   Benign hypertension with congestive heart failure
402.90   Unspecified hypertension without congestive heart failure
402.91   Unspecified hypertension with congestive heart failure
403.00   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I
         through stage IV, or unspecified
403.01   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or
         end stage renal disease
403.10   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through
         stage IV, or unspecified
403.11   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end
         stage renal disease
403.90   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I
         through stage IV, or unspecified
403.91   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or
         end stage renal disease
404.00   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.01   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.02   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.03   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.10   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.11   Hypertensive heart and chronic kidney disease, benign, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.12   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.13   Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic
         kidney disease stage V or end stage renal disease
404.90   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage I through stage IV, or unspecified
404.91   Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.92   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage V or end stage renal disease
404.93   Hypertensive heart and chronic kidney disease, unspecified, with heart failure and
         chronic kidney disease stage V or end stage renal disease
405.01   Renovascular hypertensive heart and renal disease
405.09   Other hypertensive heart and renal disease
405.11   Renovascular hypertensive heart and renal disease
405.19   Other hypertensive heart and renal disease
405.91   Renovascular hypertensive heart and renal disease
405.99   Other hypertensive heart and renal disease
410.00   Infarction of anterolateral wall, episode of care unspecified
410.01   Infarction of anterolateral wall, initial episode of care
410.02   Infarction of anterolateral wall, subsequent episode of care
410.10   Infarction of other anterior wall, episode of care unspecified
410.11   Infarction of other anterior wall, initial episode of care
410.12   Infarction of other anterior wall, subsequent episode of care



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NATIONAL COVERAGE DETERMINATION                                                       83700

410.20   Infarction of inferolateral wall, episode of care unspecified
410.21   Infarction of inferolateral wall, initial episode of care
410.22   Infarction of inferolateral wall, subsequent episode of care
410.30   Infarction of inferoposterior wall, episode of care unspecified
410.31   Infarction of inferoposterior wall, initial episode of care
410.32   Infarction of inferoposterior wall,subsequent episode of care
410.40   Infarction of other inferior wall, episode of care unspecified
410.41   Infarction of other inferior wal, initial episode of care
410.42   Infarction of other inferior wall, subsequent episode of care
410.50   Infarction of other lateral wall, episode of care unspecified
410.51   Infarction of other lateral wall, initial episode of care
410.52   Infarction of other lateral wall, subsequent episode of care
410.60   True posterior wall infarction, episode of care unspecified
410.61   True posterior wall infarction, initial episode of care
410.62   True posterior wall infarction, subsequent episode of care
410.70   Subendocardial infarction, episode of care unspecified
410.71   Subendocardial infarction, initial episode of care
410.72   Subendocardial infarction, subsequent episode of care
410.80   Infarction of other specified sites, episode of care unspecified
410.81   Infarction of other specified sites, initial episode of care
410.82   Infarction of other specified sites, subsequent episode of care
410.90   Infarction, unspecified site, episode of care unspecified
410.91   Infarction, unspecified site, initial episode of care
410.92   Infarction, unspecified site, subsequent episode of care
411.0    Postmyocardial infarction syndrome
411.1    Intermediate coronary syndrome
411.81   Coronary occlusion without myocardial infarction
411.89   Other ischemic heart disease
412      Old myocardial infarction
413.0    Angina decubitus
413.1    Prinzmetal angina
413.9    Other and unspecified angina pectoris
414.00   Coronary atherosclerosis of unspecified vessel
414.01   Coronary atherosclerosis of native coronary artery
414.02   Coronary atherosclerosis of autologous biological bypass graft
414.03   Coronary atherosclerosis of nonautologous biological bypass graft
414.04   Coronary atherosclerosis of artery bypass graft
414.05   Coronary atherosclerosis of unspecified bypass graft
414.06   Coronary atherosclerosis of native coronary artery of transplanted heart
414.07   Coronary atherosclerosis, of bypass graft of transplanted heart
414.10   Aneurysm of heart (wall)
414.11   Aneurysm of coronary vessels
414.12   Dissection of coronary artery
414.19   Aneurysm, other
414.8    Other specified forms of chronic ischemic heart disease
414.9    Chronic ischemic heart disease, unspecified
428.0    Congestive heart failure
428.1    Left heart failure
428.20   Systolic heart failure, unspecified
428.21   Systolic heart failure, acute
428.22   Systolic heart failure, chronic
428.23   Systolic heart failure, acute on chronic
428.30   Diastolic heart failure, unspecified



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NATIONAL COVERAGE DETERMINATION                                                                   83700

428.31   Diastolic heart failure, acute
428.32   Diastolic heart failure, chronic
428.33   Diastolic heart failure, acute on chronic
428.40   Combined systolic and diastolic heart failure, unspecified
428.41   Combined systolic and diastolic heart failure, acute
428.42   Combined systolic and diastolic heart failure, chronic
428.43   Combined systolic and diastolic heart failure, acute on chronic
428.9    Heart failure, unspecified
429.2    Cardiovascular disease, unspecified
429.9    Heart disease, unspecified
431      Intracerebral hemorrhage
433.00   Occlusion and stenosis, basilar artery without cerebral infarction
433.01   Occlusion and stenosis, basilar artery with cerebral infarction
433.10   Occlusion and stenosis, carotid artery without cerebral infarction
433.11   Occlusion and stenosis, carotid artery with cerebral infarction
433.20   Occlusion and stenosis, vertebral artery without cerebral infarction
433.21   Occlusion and stenosis, vertebral artery with cerebral infarction
433.30   Occlusion and stenosis, multiple and bilateral without cerebral infarction
433.31   Occlusion and stenosis, multiple and bilateral with cerebral infarction
433.80   Occlusion and stenosis, other specified precerebral artery without cerebral infarction
433.81   Occlusion and stenosis, with cerebral infarction
433.90   Occlusion and stenosis, unspecified precerebral artery without cerebral infarction
433.91   Occlusion and stenosis, unspecified precerebral artery with cerebral infarction
434.00   Cerebral thrombosis without cerebral infarction
434.01   Cerebral thrombosis with cerebral infarction
434.10   Cerebral embolism without cerebral infarction
434.11   Cerebral embolism with cerebral infarction
434.90   Cerebral artery occlusion, unspecified without cerebral infarction
434.91   Cerebral artery occlusion, unspecified with cerebral infarction
435.0    Basilar artery syndrome
435.1    Vertebral artery syndrome
435.2    Subclavian steal syndrome
435.3    Vertebrobasilar artery syndrome
435.8    Other specified transient cerebral ischemias
435.9    Unspecified transient cerebral ischemia
437.0    Cerebral atherosclerosis
437.1    Other generalized ischemic cerebrovascular disease
437.5    Moyamoya disease
438.0    Late effects of cerebrovascular disease, cognitive defects
438.10   Late effects of cerebrovascular disease, speech/language unspecified
438.11   Late effects of cerebrovascular disease, aphasia
438.12   Late effects of cerebrovascular disease, dysphasia
438.19   Late effects of cerebrovascular disease, other speech/language defects
438.20   Late effects of cerebrovascular disease, hemiplegia, unspecified side
438.21   Late effects of cerebrovascular disease, hemiplegia, dominant side
438.22   Late effects of cerebrovascular disease, hemiplegia, non-dominant side
438.30   Late effects of cerebrovascular disease, monoplegia, upper limb, unspecified
438.31   Late effects of cerebrovascular disease, monoplegia, upper limb, dominant side
438.32   Late effects of cerebrovascular disease, monoplegia, upper limb, non-dominant side
438.40   Late effects of cerebrovascular disease, monoplegia, lower limb, unspecified
438.41   Late effects of cerebrovascular disease, monoplegia, lower limb, dominant side
438.42   Late effects of cerebrovascular disease, monoplegia, lower limb, non-dominant side
438.50   Late effects of cerebrovascular disease, other paralytic syndrome, unspecified



                                                                                           Page 145
NATIONAL COVERAGE DETERMINATION                                                            83700

438.51   Late effects of cerebrovascular disease, other paralytic syndrome, dominant side
438.52   Late effects of cerebrovascular disease, other paralytic syndrome, non-dominant side
438.53   Late effects of cerebrovascular disease, other paralytic syndrome, bilateral
438.6    Alterations of sensations
438.7    Disturbances of vision
438.81   Late effects of cerebrovascular disease, aproxia
438.82   Late effects of cerebrovascular disease, dysphagia
438.83   Late effects of cerebrovascular disease, facial weakness
438.84   Late effects of cerebrovascular disease, ataxia
438.85   Late effects of cerebrovascular disease, vertigo
438.89   Late effects of cerebrovascular disease, other
438.9    Late effects of cerebrovascular disease, unspecified
440.0    Atherosclerosis of aorta
440.1    Atherosclerosis of renal artery
440.20   Atherosclerosis of the extremities, unspecified
440.21   Atherosclerosis of the extremities with intermittent claudication
440.22   Atherosclerosis of the extremities with rest pain
440.23   Atherosclerosis of the extremities with ulceration
440.24   Atherosclerosis of the extremities with gangrene
440.29   Other atherosclerosis of the extremities
440.30   Atherosclerosis of unspecified graft
440.31   Atherosclerosis of autologous vein bypass graft
440.32   Atherosclerosis of nonautologous vein bypass graft
440.4    Chronic total occlusion of artery of the extremities
440.8    Atherosclerosis of other specified arteries
440.9    Generalized and unspecified atherosclerosis
441.00   Dissection of aorta, unspecified site
441.01   Dissection of aorta, thoracic
441.02   Dissection of aorta, abdominal
441.03   Dissection of aorta, thoracoabdominal
441.1    Thoracic aneurysm, ruptured
441.2    Thoracic aneurysm without rupture
441.3    Abdominal aneurysm, ruptured
441.4    Abdominal aneurysm without rupture
441.5    Aortic aneurysm of unspecified site, ruptured
441.6    Thoracoabdominal aneurysm, ruptured
441.7    Thoracoabdominal aneurysm, without rupture
441.9    Aortic aneurysm of unspecified site without rupture
442.0    Aneurysm of artery of upper extremity
442.1    Aneurysm of renal artery
442.2    Aneurysm of iliac artery
444.0    Arterial embolism and thrombosis of abdominal aorta
444.1    Arterial embolism and thrombosis of thoracic aorta
444.21   Arterial embolism and thrombosis, upper extremity
444.22   Arterial embolism and thrombosis, lower extremity
444.81   Arterial embolism and thrombosis, iliac artery
444.89   Arterial embolism and thrombosis, other
444.9    Arterial embolism and thrombosis of unspecified artery
557.1    Chronic vascular insufficiency of intestine
571.8    Other chronic nonalcoholic liver disease
571.9    Unspecified chronic liver disease without mention of
573.8    Other specified disorders of liver
573.9    Unspecified disorder of liver



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NATIONAL COVERAGE DETERMINATION                                                              83700

577.0    Acute pancreatitis
577.1    Chronic pancreatitis
577.2    Cyst and pseudocyst of pancreas
577.8    Other specified diseases of pancreas
577.9    Unspecified disease of pancreas
579.3    Other and unspecified postsurgical nonabsorption
579.8    Other specified intestinal malabsorption
581.0    Nephrotic syndrome with lesion of proliferative glomerulonephritis
581.1    Nephrotic syndrome with lesion of membranous glomerulonephritis
581.2    Nephrotic syndrome with lesion of membranoproliferative glomerulonephritis
581.3    Nephrotic syndrome with lesion of minimal change glomerulonephritis
581.81   Nephrotic syndrome in diseases classified elsewhere
581.89   Other nephrotic syndrome
581.9    Nephrotic syndrome with unspecified pathological lesion in
584.5    Acute renal failure with lesion of tubular necrosis
585.4    Chronic kidney disease, Stage IV (severe)
585.5    Chronic kidney disease, Stage V
585.6    End stage renal disease
585.9    Chronic kidney disease, unspecified
588.0    Renal osteodystrophy
588.1    Nephrogenic diabetes insipidus
588.81   Secondary hyperparathyroidism (of renal origin)
588.89   Other specified disorders resulting from impaired renal function
588.9    Unspecified disorder resulting from impaired renal function
607.84   Impotence of organic origin
646.70   Liver disorders in pregnancy, unspecified episode of care
646.71   Liver disorders in pregnancy, delivered, with or without antepartum condition
646.73   Liver disorders in pregnancy, antepartum condition or complication defects
648.10   Other conditions of mother complicating pregnancy, thyroid dysfunction, unspecified
         episode of care
648.11   Other conditions of mother complicating pregnancy, thyroid dysfunction, delivered, with or
         without antepartum condition
648.12   Other conditions of mother complicating pregnancy, thyroid dysfunction, delivered, with
         postpartum complication
648.13   Other conditions of mother complicating pregnancy, thyroid dysfunction, antepartum
         condition or complication
648.14   Other conditions of mother complicating pregnancy, thyroid dysfunction, postpartum
         condition or complication
696.0    Psoriatic arthropathy
696.1    Other psoriasis
751.61   Biliary atresia
764.10   Light-for-dates with signs of fetal malnutrition, unspecified [weight]
764.11   Light-for-dates with signs of fetal malnutrition less than 500 grams
764.12   Light-for-dates with signs of fetal malnutrition 500-749 grams
764.13   Light-for-dates with signs of fetal malnutrition 750-999 grams
764.14   Light-for-dates with signs of fetal malnutrition 1,000-1,249 grams
764.15   Light-for-dates with signs of fetal malnutrition 1,250-1,499 grams
764.16   Light-for-dates with signs of fetal malnutrition 1,500-1,749 grams
764.17   Light-for-dates with signs of fetal malnutrition 1,750-1,999 grams
764.18   Light-for-dates with signs of fetal malnutrition 2,000-2,499 grams
764.19   Light-for-dates with signs of fetal malnutrition 2,500 grams and over
786.50   Chest pain, unspecified
786.51   Precordial pain



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NATIONAL COVERAGE DETERMINATION                                                    83700

786.59   Other chest pain
789.1    Hepatomegaly
790.4    Nonspecific elevation transaminase or lactic acid dehydrogenase [LDH]
790.5    Other nonspecific abnormalserum enzyme levels
790.6    Other abnormal blood chemistry
793.4    Abnormal radiologiocal findings, gastrointestinal tract
987.9    Toxic effect of unspecified gas, fume, or vapor
996.81   Complications, transplanted kidney
V42.0    Organ or tissue replaced by transplant, kidney
V42.7    Organ or tissue replaced by transplant, liver
V58.63   Long-term (current) use of antiplatelet/antithrombotic
V58.64   Long-term (current) use of non-steroidal anti-inflammatories
V58.69   Long-term (current) use of other medications




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NATIONAL COVERAGE DETERMINATION                                                                                                                                                         83701


NATIONAL COVERAGE DETERMINATION
83701
83701-Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (eg, electrophoresis, ultracentrifugation)




CPT CODE: 83701



CPT CODE DESCRIPTOR: Lipoprotein, blood; high resolution fractionation and
      quantitation of lipoproteins including lipoprotein subclasses when performed (eg,
      electrophoresis, ultracentrifugation)



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                            When monitoring long term anti-lipid dietary or pharmacologic therapy and when
                                            following patients with borderline high total or LDL cholesterol levels, it is
                                            reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a
                                            yearly interval will usually be adequate while measurement of the serum total
                                            cholesterol (CPT code 82465) or a measured LDL (CPT code 83721) should suffice
                                            for interim visits if the patient does not have hypertriglyceridemia (for example,
                                            ICD-9-CM code 272.1, Pure hyperglyceridemia).

                                            Any one component of the panel or a measured LDL may be medically necessary
                                            up to six times the first year for monitoring dietary or pharmacologic therapy. More
                                            frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing
                                            may be indicated for marked elevations or for changes to anti-lipid therapy due to
                                            inadequate initial patient response to dietary or pharma-cologic therapy. The LDL
                                            cholesterol or total cholesterol may be measured three times yearly after treatment
                                            goals have been achieved. If no dietary or pharmacological therapy is advised,
                                            monitoring is not necessary.

                                            When evaluating non-specific chronic abnormalities of the liver (for example,
                                            elevations of transaminase, alkaline phosphatase, abnormal imaging studies, etc.),
                                            a lipid panel would generally not be indicated more than twice per year.



COVERED ICD-9 CODES:
242.00 Toxic diffuse goiter without thyrotoxic crisis or storm
242.01 Toxic diffuse goiter with thyrotoxic crisis or storm
242.10 Toxic uninodular goiter without thyrotoxic crisis or storm
242.11 Toxic uninodular goiter with thyrotoxic crisis or storm
242.20 Toxic multinodular goiter without thyrotoxic crisis or storm
242.21 Toxic multinodular goiter with thyrotoxic crisis or storm
242.30 Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm
242.31 Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40 Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41 Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
242.80 Thyrotoxicosis of other specified origin without thyrotoxic crisis or storm
242.81 Thyrotoxicosis of other specified origin with thyrotoxic crisis or storm
242.90 Thyrotoxicosis without of goiter or other cause without thyrotoxic crisis or storm
242.91 Thyrotoxicosis without goiter or other cause with mention of thyrotoxic crisis or storm
243    Congenital hypothyroidism
244.0 Postsurgical hypothyroidism
244.1 Other postablative hypothyroidism


                                                                                                                                                                                      Page 149
NATIONAL COVERAGE DETERMINATION                                                                83701

244.2    Iodine hypothyroidism
244.3    Other iatrogenic hypothyroidism
244.8    Other specified acquired hypothyroidism
244.9    Unspecified hypothyroidism
245.0    Acute thyroiditis
245.1    Subacute thyroiditis
245.2    Chronic lymphocytic thyroiditis
245.3    Chronic fibrous thyroiditis
245.4    Iatrogenic thyroiditis
245.8    Other and unspecified chronic thyroiditis
245.9    Thyroiditis, unspecified
250.00   Diabetes mellitus without complication, type II or unspecified type, not stated as
         uncontrolled
250.01   Diabetes mellitus without complication, type I, not stated as uncontrolled
250.02   Diabetes mellitus without complication, type II or unspecified type, uncontrolled
250.03   Diabetes mellitus without complication, type I, uncontrolled
250.10   Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
250.11   Diabetes with ketoacidosis, type I, not stated as uncontrolled
250.12   Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13   Diabetes with ketoacidosis, type I, uncontrolled
250.20   Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
250.21   Diabetes with hyperosmolarity, type I, not stated as uncontrolled
250.22   Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23   Diabetes with hyperosmolarity, type I, uncontrolled
250.30   Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
250.31   Diabetes with other coma, type I, not stated as uncontrolled
250.32   Diabetes with other coma, type II or unspecified type, uncontrolled
250.33   Diabetes with other coma type I, uncontrolled
250.40   Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41   Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42   Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43   Diabetes with renal manifestations, type I, uncontrolled
250.50   Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
         uncontrolled
250.51   Diabetes with ophthalmic manifestations, type I, not stated as uncontrolled
250.52   Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53   Diabetes with ophthalmic manifestations, type I, uncontrolled
250.60   Diabetes with neurological manifestations, type II or unspecified type, not stated as
         uncontrolled
250.61   Diabetes with neurological manifestations, type I, not stated as uncontrolled
250.62   Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
250.63   Diabetes with neurological manifestations, type I, uncontrolled
250.70   Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
         uncontrolled
250.71   Diabetes with peripheral circulatory disorders, type I, not stated as uncontrolled
250.72   Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
250.73   Diabetes with peripheral circulatory disorders, type I, uncontrolled
250.80   Diabetes with other specified manifestations, type II or unspecified type, not stated as
         uncontrolled
250.81   Diabetes with other specified manifestations, type I, not stated as uncontrolled
250.82   Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
250.83   Diabetes with other specified manifestations, type I uncontrolled




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250.90 Diabetes with unspecified complication, type II or unspecified type, not stated as
       uncontrolled
250.91 Diabetes with unspecified complication, type I, not stated as uncontrolled
250.92 Diabetes with unspecified complication, type II or unspecified type, uncontrolled
250.93 Diabetes with unspecified complication, type I, uncontrolled
255.0 Cushing's syndrome
260    Kwashiorkor
261    Nutritional marasmus
262    Other severe protein-calorie malnutrition
263.0 Malnutrition of moderate degree
263.1 Malnutrition of mild degree
263.8 Other protein-calorie malnutrition
263.9 Unspecified protein-calorie malnutrition
270.0 Disturbances of amino-acid transport
271.1 Galactosemia
272.0 Pure hypercholesterolemia
272.1 Pure hyperglyceridemia
272.2 Mixed hyperlipidemia
272.3 Hyperchylomicronemia
272.4 Other and unspecified hyperlipidemia
272.5 Lipoprotein deficiencies
272.6 Lipodystrophy
272.7 Lipidoses
272.8 Other disorders of lipoid metabolism
272.9 Unspecified disorder of lipoid metabolism
277.30 Amyloidosis, unspecified
277.31 Familial Mediterranean fever
277.39 Other amyloidosis
278.00 Obesity, unspecified
278.01 Morbid obesity
278.02 Overweight
303.90 Other and unspecified alcohol dependence, unspecified
303.91 Other and unspecified alcohol dependence, continuous
303.92 Other and unspecified alcohol dependence, episodic
362.10 Background retinopathy, unspecified
362.11 Hypertensive retinopathy
362.12 Exudative retinopathy
362.13 Changes in vascular appearance
362.14 Retinal microaneurysms
362.15 Retinal telangiectasia
362.16 Retinal neovascularization
362.30 Retinal vascular occlusion, unspecified
362.31 Central retinal artery occlusion
362.32 Arterial branch occlusion
362.33 Partial arterial occlusion
362.34 Transient arterial occlusion
362.82 Retinal exudates and deposits
371.41 Senile corneal changes
374.51 Xanthelasma
379.22 Crystalline deposits in vitreous
388.00 Degenerative and vascular disorders, unspecified
388.02 Transient ischemic deafness
401.0 Malignant hypertension



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401.1    Benign hypertension
401.9    Unspecified hypertension
402.00   Malignant hypertension without congestive heart failure
402.01   Malignant hypertension with congestive heart failure
402.10   Benign hypertension without congestive heart failure
402.11   Benign hypertension with congestive heart failure
402.90   Unspecified hypertension without congestive heart failure
402.91   Unspecified hypertension with congestive heart failure
403.00   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I
         through stage IV, or unspecified
403.01   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or
         end stage renal disease
403.10   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through
         stage IV, or unspecified
403.11   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end
         stage renal disease
403.90   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I
         through stage IV, or unspecified
403.91   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or
         end stage renal disease
404.00   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.01   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.02   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.03   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.10   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.11   Hypertensive heart and chronic kidney disease, benign, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.12   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.13   Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic
         kidney disease stage V or end stage renal disease
404.90   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage I through stage IV, or unspecified
404.91   Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.92   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage V or end stage renal disease
404.93   Hypertensive heart and chronic kidney disease, unspecified, with heart failure and
         chronic kidney disease stage V or end stage renal disease
405.01   Renovascular hypertensive heart and renal disease
405.09   Other hypertensive heart and renal disease
405.11   Renovascular hypertensive heart and renal disease
405.19   Other hypertensive heart and renal disease
405.91   Renovascular hypertensive heart and renal disease
405.99   Other hypertensive heart and renal disease
410.00   Infarction of anterolateral wall, episode of care unspecified
410.01   Infarction of anterolateral wall, initial episode of care
410.02   Infarction of anterolateral wall, subsequent episode of care



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NATIONAL COVERAGE DETERMINATION                                                       83701

410.10   Infarction of other anterior wall, episode of care unspecified
410.11   Infarction of other anterior wall, initial episode of care
410.12   Infarction of other anterior wall, subsequent episode of care
410.20   Infarction of inferolateral wall, episode of care unspecified
410.21   Infarction of inferolateral wall, initial episode of care
410.22   Infarction of inferolateral wall, subsequent episode of care
410.30   Infarction of inferoposterior wall, episode of care unspecified
410.31   Infarction of inferoposterior wall, initial episode of care
410.32   Infarction of inferoposterior wall,subsequent episode of care
410.40   Infarction of other inferior wall, episode of care unspecified
410.41   Infarction of other inferior wal, initial episode of care
410.42   Infarction of other inferior wall, subsequent episode of care
410.50   Infarction of other lateral wall, episode of care unspecified
410.51   Infarction of other lateral wall, initial episode of care
410.52   Infarction of other lateral wall, subsequent episode of care
410.60   True posterior wall infarction, episode of care unspecified
410.61   True posterior wall infarction, initial episode of care
410.62   True posterior wall infarction, subsequent episode of care
410.70   Subendocardial infarction, episode of care unspecified
410.71   Subendocardial infarction, initial episode of care
410.72   Subendocardial infarction, subsequent episode of care
410.80   Infarction of other specified sites, episode of care unspecified
410.81   Infarction of other specified sites, initial episode of care
410.82   Infarction of other specified sites, subsequent episode of care
410.90   Infarction, unspecified site, episode of care unspecified
410.91   Infarction, unspecified site, initial episode of care
410.92   Infarction, unspecified site, subsequent episode of care
411.0    Postmyocardial infarction syndrome
411.1    Intermediate coronary syndrome
411.81   Coronary occlusion without myocardial infarction
411.89   Other ischemic heart disease
412      Old myocardial infarction
413.0    Angina decubitus
413.1    Prinzmetal angina
413.9    Other and unspecified angina pectoris
414.00   Coronary atherosclerosis of unspecified vessel
414.01   Coronary atherosclerosis of native coronary artery
414.02   Coronary atherosclerosis of autologous biological bypass graft
414.03   Coronary atherosclerosis of nonautologous biological bypass graft
414.04   Coronary atherosclerosis of artery bypass graft
414.05   Coronary atherosclerosis of unspecified bypass graft
414.06   Coronary atherosclerosis of native coronary artery of transplanted heart
414.07   Coronary atherosclerosis, of bypass graft of transplanted heart
414.10   Aneurysm of heart (wall)
414.11   Aneurysm of coronary vessels
414.12   Dissection of coronary artery
414.19   Aneurysm, other
414.8    Other specified forms of chronic ischemic heart disease
414.9    Chronic ischemic heart disease, unspecified
428.0    Congestive heart failure
428.1    Left heart failure
428.20   Systolic heart failure, unspecified
428.21   Systolic heart failure, acute



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NATIONAL COVERAGE DETERMINATION                                                                   83701

428.22   Systolic heart failure, chronic
428.23   Systolic heart failure, acute on chronic
428.30   Diastolic heart failure, unspecified
428.31   Diastolic heart failure, acute
428.32   Diastolic heart failure, chronic
428.33   Diastolic heart failure, acute on chronic
428.40   Combined systolic and diastolic heart failure, unspecified
428.41   Combined systolic and diastolic heart failure, acute
428.42   Combined systolic and diastolic heart failure, chronic
428.43   Combined systolic and diastolic heart failure, acute on chronic
428.9    Heart failure, unspecified
429.2    Cardiovascular disease, unspecified
429.9    Heart disease, unspecified
431      Intracerebral hemorrhage
433.00   Occlusion and stenosis, basilar artery without cerebral infarction
433.01   Occlusion and stenosis, basilar artery with cerebral infarction
433.10   Occlusion and stenosis, carotid artery without cerebral infarction
433.11   Occlusion and stenosis, carotid artery with cerebral infarction
433.20   Occlusion and stenosis, vertebral artery without cerebral infarction
433.21   Occlusion and stenosis, vertebral artery with cerebral infarction
433.30   Occlusion and stenosis, multiple and bilateral without cerebral infarction
433.31   Occlusion and stenosis, multiple and bilateral with cerebral infarction
433.80   Occlusion and stenosis, other specified precerebral artery without cerebral infarction
433.81   Occlusion and stenosis, with cerebral infarction
433.90   Occlusion and stenosis, unspecified precerebral artery without cerebral infarction
433.91   Occlusion and stenosis, unspecified precerebral artery with cerebral infarction
434.00   Cerebral thrombosis without cerebral infarction
434.01   Cerebral thrombosis with cerebral infarction
434.10   Cerebral embolism without cerebral infarction
434.11   Cerebral embolism with cerebral infarction
434.90   Cerebral artery occlusion, unspecified without cerebral infarction
434.91   Cerebral artery occlusion, unspecified with cerebral infarction
435.0    Basilar artery syndrome
435.1    Vertebral artery syndrome
435.2    Subclavian steal syndrome
435.3    Vertebrobasilar artery syndrome
435.8    Other specified transient cerebral ischemias
435.9    Unspecified transient cerebral ischemia
437.0    Cerebral atherosclerosis
437.1    Other generalized ischemic cerebrovascular disease
437.5    Moyamoya disease
438.0    Late effects of cerebrovascular disease, cognitive defects
438.10   Late effects of cerebrovascular disease, speech/language unspecified
438.11   Late effects of cerebrovascular disease, aphasia
438.12   Late effects of cerebrovascular disease, dysphasia
438.19   Late effects of cerebrovascular disease, other speech/language defects
438.20   Late effects of cerebrovascular disease, hemiplegia, unspecified side
438.21   Late effects of cerebrovascular disease, hemiplegia, dominant side
438.22   Late effects of cerebrovascular disease, hemiplegia, non-dominant side
438.30   Late effects of cerebrovascular disease, monoplegia, upper limb, unspecified
438.31   Late effects of cerebrovascular disease, monoplegia, upper limb, dominant side
438.32   Late effects of cerebrovascular disease, monoplegia, upper limb, non-dominant side
438.40   Late effects of cerebrovascular disease, monoplegia, lower limb, unspecified



                                                                                           Page 154
NATIONAL COVERAGE DETERMINATION                                                            83701

438.41   Late effects of cerebrovascular disease, monoplegia, lower limb, dominant side
438.42   Late effects of cerebrovascular disease, monoplegia, lower limb, non-dominant side
438.50   Late effects of cerebrovascular disease, other paralytic syndrome, unspecified
438.51   Late effects of cerebrovascular disease, other paralytic syndrome, dominant side
438.52   Late effects of cerebrovascular disease, other paralytic syndrome, non-dominant side
438.53   Late effects of cerebrovascular disease, other paralytic syndrome, bilateral
438.6    Alterations of sensations
438.7    Disturbances of vision
438.81   Late effects of cerebrovascular disease, aproxia
438.82   Late effects of cerebrovascular disease, dysphagia
438.83   Late effects of cerebrovascular disease, facial weakness
438.84   Late effects of cerebrovascular disease, ataxia
438.85   Late effects of cerebrovascular disease, vertigo
438.89   Late effects of cerebrovascular disease, other
438.9    Late effects of cerebrovascular disease, unspecified
440.0    Atherosclerosis of aorta
440.1    Atherosclerosis of renal artery
440.20   Atherosclerosis of the extremities, unspecified
440.21   Atherosclerosis of the extremities with intermittent claudication
440.22   Atherosclerosis of the extremities with rest pain
440.23   Atherosclerosis of the extremities with ulceration
440.24   Atherosclerosis of the extremities with gangrene
440.29   Other atherosclerosis of the extremities
440.30   Atherosclerosis of unspecified graft
440.31   Atherosclerosis of autologous vein bypass graft
440.32   Atherosclerosis of nonautologous vein bypass graft
440.4    Chronic total occlusion of artery of the extremities
440.8    Atherosclerosis of other specified arteries
440.9    Generalized and unspecified atherosclerosis
441.00   Dissection of aorta, unspecified site
441.01   Dissection of aorta, thoracic
441.02   Dissection of aorta, abdominal
441.03   Dissection of aorta, thoracoabdominal
441.1    Thoracic aneurysm, ruptured
441.2    Thoracic aneurysm without rupture
441.3    Abdominal aneurysm, ruptured
441.4    Abdominal aneurysm without rupture
441.5    Aortic aneurysm of unspecified site, ruptured
441.6    Thoracoabdominal aneurysm, ruptured
441.7    Thoracoabdominal aneurysm, without rupture
441.9    Aortic aneurysm of unspecified site without rupture
442.0    Aneurysm of artery of upper extremity
442.1    Aneurysm of renal artery
442.2    Aneurysm of iliac artery
444.0    Arterial embolism and thrombosis of abdominal aorta
444.1    Arterial embolism and thrombosis of thoracic aorta
444.21   Arterial embolism and thrombosis, upper extremity
444.22   Arterial embolism and thrombosis, lower extremity
444.81   Arterial embolism and thrombosis, iliac artery
444.89   Arterial embolism and thrombosis, other
444.9    Arterial embolism and thrombosis of unspecified artery
557.1    Chronic vascular insufficiency of intestine
571.8    Other chronic nonalcoholic liver disease



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571.9    Unspecified chronic liver disease without mention of
573.8    Other specified disorders of liver
573.9    Unspecified disorder of liver
577.0    Acute pancreatitis
577.1    Chronic pancreatitis
577.2    Cyst and pseudocyst of pancreas
577.8    Other specified diseases of pancreas
577.9    Unspecified disease of pancreas
579.3    Other and unspecified postsurgical nonabsorption
579.8    Other specified intestinal malabsorption
581.0    Nephrotic syndrome with lesion of proliferative glomerulonephritis
581.1    Nephrotic syndrome with lesion of membranous glomerulonephritis
581.2    Nephrotic syndrome with lesion of membranoproliferative glomerulonephritis
581.3    Nephrotic syndrome with lesion of minimal change glomerulonephritis
581.81   Nephrotic syndrome in diseases classified elsewhere
581.89   Other nephrotic syndrome
581.9    Nephrotic syndrome with unspecified pathological lesion in
584.5    Acute renal failure with lesion of tubular necrosis
585.4    Chronic kidney disease, Stage IV (severe)
585.5    Chronic kidney disease, Stage V
585.6    End stage renal disease
585.9    Chronic kidney disease, unspecified
588.0    Renal osteodystrophy
588.1    Nephrogenic diabetes insipidus
588.81   Secondary hyperparathyroidism (of renal origin)
588.89   Other specified disorders resulting from impaired renal function
588.9    Unspecified disorder resulting from impaired renal function
607.84   Impotence of organic origin
646.70   Liver disorders in pregnancy, unspecified episode of care
646.71   Liver disorders in pregnancy, delivered, with or without antepartum condition
646.73   Liver disorders in pregnancy, antepartum condition or complication defects
648.10   Other conditions of mother complicating pregnancy, thyroid dysfunction, unspecified
         episode of care
648.11   Other conditions of mother complicating pregnancy, thyroid dysfunction, delivered, with or
         without antepartum condition
648.12   Other conditions of mother complicating pregnancy, thyroid dysfunction, delivered, with
         postpartum complication
648.13   Other conditions of mother complicating pregnancy, thyroid dysfunction, antepartum
         condition or complication
648.14   Other conditions of mother complicating pregnancy, thyroid dysfunction, postpartum
         condition or complication
696.0    Psoriatic arthropathy
696.1    Other psoriasis
751.61   Biliary atresia
764.10   Light-for-dates with signs of fetal malnutrition, unspecified [weight]
764.11   Light-for-dates with signs of fetal malnutrition less than 500 grams
764.12   Light-for-dates with signs of fetal malnutrition 500-749 grams
764.13   Light-for-dates with signs of fetal malnutrition 750-999 grams
764.14   Light-for-dates with signs of fetal malnutrition 1,000-1,249 grams
764.15   Light-for-dates with signs of fetal malnutrition 1,250-1,499 grams
764.16   Light-for-dates with signs of fetal malnutrition 1,500-1,749 grams
764.17   Light-for-dates with signs of fetal malnutrition 1,750-1,999 grams
764.18   Light-for-dates with signs of fetal malnutrition 2,000-2,499 grams



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NATIONAL COVERAGE DETERMINATION                                                    83701

764.19   Light-for-dates with signs of fetal malnutrition 2,500 grams and over
786.50   Chest pain, unspecified
786.51   Precordial pain
786.59   Other chest pain
789.1    Hepatomegaly
790.4    Nonspecific elevation transaminase or lactic acid dehydrogenase [LDH]
790.5    Other nonspecific abnormalserum enzyme levels
790.6    Other abnormal blood chemistry
793.4    Abnormal radiologiocal findings, gastrointestinal tract
987.9    Toxic effect of unspecified gas, fume, or vapor
996.81   Complications, transplanted kidney
V42.0    Organ or tissue replaced by transplant, kidney
V42.7    Organ or tissue replaced by transplant, liver
V58.63   Long-term (current) use of antiplatelet/antithrombotic
V58.64   Long-term (current) use of non-steroidal anti-inflammatories
V58.69   Long-term (current) use of other medications




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NATIONAL COVERAGE DETERMINATION                                                                                                                                 83704


NATIONAL COVERAGE DETERMINATION
83704
83704-Lipoprotein, blood; quantitation of lipoprotein particle numbers and lipoprotein particle subclasses (eg, by nuclear magnetic resonance spectroscopy)




CPT CODE: 83704



CPT CODE DESCRIPTOR: Lipoprotein, blood; quantitation of lipoprotein particle numbers
      and lipoprotein particle subclasses (eg, by nuclear magnetic resonance
      spectroscopy)



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                           When monitoring long term anti-lipid dietary or pharmacologic therapy and when
                                           following patients with borderline high total or LDL cholesterol levels, it is
                                           reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a
                                           yearly interval will usually be adequate while measurement of the serum total
                                           cholesterol (CPT code 82465) or a measured LDL (CPT code 83721) should suffice
                                           for interim visits if the patient does not have hypertriglyceridemia (for example,
                                           ICD-9-CM code 272.1, Pure hyperglyceridemia).

                                           Any one component of the panel or a measured LDL may be medically necessary
                                           up to six times the first year for monitoring dietary or pharmacologic therapy. More
                                           frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing
                                           may be indicated for marked elevations or for changes to anti-lipid therapy due to
                                           inadequate initial patient response to dietary or pharma-cologic therapy. The LDL
                                           cholesterol or total cholesterol may be measured three times yearly after treatment
                                           goals have been achieved. If no dietary or pharmacological therapy is advised,
                                           monitoring is not necessary.

                                           When evaluating non-specific chronic abnormalities of the liver (for example,
                                           elevations of transaminase, alkaline phosphatase, abnormal imaging studies, etc.),
                                           a lipid panel would generally not be indicated more than twice per year.



COVERED ICD-9 CODES:
242.00 Toxic diffuse goiter without thyrotoxic crisis or storm
242.01 Toxic diffuse goiter with thyrotoxic crisis or storm
242.10 Toxic uninodular goiter without thyrotoxic crisis or storm
242.11 Toxic uninodular goiter with thyrotoxic crisis or storm
242.20 Toxic multinodular goiter without thyrotoxic crisis or storm
242.21 Toxic multinodular goiter with thyrotoxic crisis or storm
242.30 Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm
242.31 Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40 Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41 Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
242.80 Thyrotoxicosis of other specified origin without thyrotoxic crisis or storm
242.81 Thyrotoxicosis of other specified origin with thyrotoxic crisis or storm
242.90 Thyrotoxicosis without of goiter or other cause without thyrotoxic crisis or storm
242.91 Thyrotoxicosis without goiter or other cause with mention of thyrotoxic crisis or storm
243    Congenital hypothyroidism
244.0 Postsurgical hypothyroidism
244.1 Other postablative hypothyroidism


                                                                                                                                                              Page 158
NATIONAL COVERAGE DETERMINATION                                                                83704

244.2    Iodine hypothyroidism
244.3    Other iatrogenic hypothyroidism
244.8    Other specified acquired hypothyroidism
244.9    Unspecified hypothyroidism
245.0    Acute thyroiditis
245.1    Subacute thyroiditis
245.2    Chronic lymphocytic thyroiditis
245.3    Chronic fibrous thyroiditis
245.4    Iatrogenic thyroiditis
245.8    Other and unspecified chronic thyroiditis
245.9    Thyroiditis, unspecified
250.00   Diabetes mellitus without complication, type II or unspecified type, not stated as
         uncontrolled
250.01   Diabetes mellitus without complication, type I, not stated as uncontrolled
250.02   Diabetes mellitus without complication, type II or unspecified type, uncontrolled
250.03   Diabetes mellitus without complication, type I, uncontrolled
250.10   Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
250.11   Diabetes with ketoacidosis, type I, not stated as uncontrolled
250.12   Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13   Diabetes with ketoacidosis, type I, uncontrolled
250.20   Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
250.21   Diabetes with hyperosmolarity, type I, not stated as uncontrolled
250.22   Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23   Diabetes with hyperosmolarity, type I, uncontrolled
250.30   Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
250.31   Diabetes with other coma, type I, not stated as uncontrolled
250.32   Diabetes with other coma, type II or unspecified type, uncontrolled
250.33   Diabetes with other coma type I, uncontrolled
250.40   Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41   Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42   Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43   Diabetes with renal manifestations, type I, uncontrolled
250.50   Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
         uncontrolled
250.51   Diabetes with ophthalmic manifestations, type I, not stated as uncontrolled
250.52   Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53   Diabetes with ophthalmic manifestations, type I, uncontrolled
250.60   Diabetes with neurological manifestations, type II or unspecified type, not stated as
         uncontrolled
250.61   Diabetes with neurological manifestations, type I, not stated as uncontrolled
250.62   Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
250.63   Diabetes with neurological manifestations, type I, uncontrolled
250.70   Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
         uncontrolled
250.71   Diabetes with peripheral circulatory disorders, type I, not stated as uncontrolled
250.72   Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
250.73   Diabetes with peripheral circulatory disorders, type I, uncontrolled
250.80   Diabetes with other specified manifestations, type II or unspecified type, not stated as
         uncontrolled
250.81   Diabetes with other specified manifestations, type I, not stated as uncontrolled
250.82   Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
250.83   Diabetes with other specified manifestations, type I uncontrolled




                                                                                           Page 159
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250.90 Diabetes with unspecified complication, type II or unspecified type, not stated as
       uncontrolled
250.91 Diabetes with unspecified complication, type I, not stated as uncontrolled
250.92 Diabetes with unspecified complication, type II or unspecified type, uncontrolled
250.93 Diabetes with unspecified complication, type I, uncontrolled
255.0 Cushing's syndrome
260    Kwashiorkor
261    Nutritional marasmus
262    Other severe protein-calorie malnutrition
263.0 Malnutrition of moderate degree
263.1 Malnutrition of mild degree
263.8 Other protein-calorie malnutrition
263.9 Unspecified protein-calorie malnutrition
270.0 Disturbances of amino-acid transport
271.1 Galactosemia
272.0 Pure hypercholesterolemia
272.1 Pure hyperglyceridemia
272.2 Mixed hyperlipidemia
272.3 Hyperchylomicronemia
272.4 Other and unspecified hyperlipidemia
272.5 Lipoprotein deficiencies
272.6 Lipodystrophy
272.7 Lipidoses
272.8 Other disorders of lipoid metabolism
272.9 Unspecified disorder of lipoid metabolism
277.30 Amyloidosis, unspecified
277.31 Familial Mediterranean fever
277.39 Other amyloidosis
278.00 Obesity, unspecified
278.01 Morbid obesity
278.02 Overweight
303.90 Other and unspecified alcohol dependence, unspecified
303.91 Other and unspecified alcohol dependence, continuous
303.92 Other and unspecified alcohol dependence, episodic
362.10 Background retinopathy, unspecified
362.11 Hypertensive retinopathy
362.12 Exudative retinopathy
362.13 Changes in vascular appearance
362.14 Retinal microaneurysms
362.15 Retinal telangiectasia
362.16 Retinal neovascularization
362.30 Retinal vascular occlusion, unspecified
362.31 Central retinal artery occlusion
362.32 Arterial branch occlusion
362.33 Partial arterial occlusion
362.34 Transient arterial occlusion
362.82 Retinal exudates and deposits
371.41 Senile corneal changes
374.51 Xanthelasma
379.22 Crystalline deposits in vitreous
388.00 Degenerative and vascular disorders, unspecified
388.02 Transient ischemic deafness
401.0 Malignant hypertension



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NATIONAL COVERAGE DETERMINATION                                                            83704

401.1    Benign hypertension
401.9    Unspecified hypertension
402.00   Malignant hypertension without congestive heart failure
402.01   Malignant hypertension with congestive heart failure
402.10   Benign hypertension without congestive heart failure
402.11   Benign hypertension with congestive heart failure
402.90   Unspecified hypertension without congestive heart failure
402.91   Unspecified hypertension with congestive heart failure
403.00   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I
         through stage IV, or unspecified
403.01   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or
         end stage renal disease
403.10   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through
         stage IV, or unspecified
403.11   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end
         stage renal disease
403.90   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I
         through stage IV, or unspecified
403.91   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or
         end stage renal disease
404.00   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.01   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.02   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.03   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.10   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.11   Hypertensive heart and chronic kidney disease, benign, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.12   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.13   Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic
         kidney disease stage V or end stage renal disease
404.90   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage I through stage IV, or unspecified
404.91   Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.92   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage V or end stage renal disease
404.93   Hypertensive heart and chronic kidney disease, unspecified, with heart failure and
         chronic kidney disease stage V or end stage renal disease
405.01   Renovascular hypertensive heart and renal disease
405.09   Other hypertensive heart and renal disease
405.11   Renovascular hypertensive heart and renal disease
405.19   Other hypertensive heart and renal disease
405.91   Renovascular hypertensive heart and renal disease
405.99   Other hypertensive heart and renal disease
410.00   Infarction of anterolateral wall, episode of care unspecified
410.01   Infarction of anterolateral wall, initial episode of care
410.02   Infarction of anterolateral wall, subsequent episode of care



                                                                                        Page 161
NATIONAL COVERAGE DETERMINATION                                                       83704

410.10   Infarction of other anterior wall, episode of care unspecified
410.11   Infarction of other anterior wall, initial episode of care
410.12   Infarction of other anterior wall, subsequent episode of care
410.20   Infarction of inferolateral wall, episode of care unspecified
410.21   Infarction of inferolateral wall, initial episode of care
410.22   Infarction of inferolateral wall, subsequent episode of care
410.30   Infarction of inferoposterior wall, episode of care unspecified
410.31   Infarction of inferoposterior wall, initial episode of care
410.32   Infarction of inferoposterior wall,subsequent episode of care
410.40   Infarction of other inferior wall, episode of care unspecified
410.41   Infarction of other inferior wal, initial episode of care
410.42   Infarction of other inferior wall, subsequent episode of care
410.50   Infarction of other lateral wall, episode of care unspecified
410.51   Infarction of other lateral wall, initial episode of care
410.52   Infarction of other lateral wall, subsequent episode of care
410.60   True posterior wall infarction, episode of care unspecified
410.61   True posterior wall infarction, initial episode of care
410.62   True posterior wall infarction, subsequent episode of care
410.70   Subendocardial infarction, episode of care unspecified
410.71   Subendocardial infarction, initial episode of care
410.72   Subendocardial infarction, subsequent episode of care
410.80   Infarction of other specified sites, episode of care unspecified
410.81   Infarction of other specified sites, initial episode of care
410.82   Infarction of other specified sites, subsequent episode of care
410.90   Infarction, unspecified site, episode of care unspecified
410.91   Infarction, unspecified site, initial episode of care
410.92   Infarction, unspecified site, subsequent episode of care
411.0    Postmyocardial infarction syndrome
411.1    Intermediate coronary syndrome
411.81   Coronary occlusion without myocardial infarction
411.89   Other ischemic heart disease
412      Old myocardial infarction
413.0    Angina decubitus
413.1    Prinzmetal angina
413.9    Other and unspecified angina pectoris
414.00   Coronary atherosclerosis of unspecified vessel
414.01   Coronary atherosclerosis of native coronary artery
414.02   Coronary atherosclerosis of autologous biological bypass graft
414.03   Coronary atherosclerosis of nonautologous biological bypass graft
414.04   Coronary atherosclerosis of artery bypass graft
414.05   Coronary atherosclerosis of unspecified bypass graft
414.06   Coronary atherosclerosis of native coronary artery of transplanted heart
414.07   Coronary atherosclerosis, of bypass graft of transplanted heart
414.10   Aneurysm of heart (wall)
414.11   Aneurysm of coronary vessels
414.12   Dissection of coronary artery
414.19   Aneurysm, other
414.8    Other specified forms of chronic ischemic heart disease
414.9    Chronic ischemic heart disease, unspecified
428.0    Congestive heart failure
428.1    Left heart failure
428.20   Systolic heart failure, unspecified
428.21   Systolic heart failure, acute



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NATIONAL COVERAGE DETERMINATION                                                                   83704

428.22   Systolic heart failure, chronic
428.23   Systolic heart failure, acute on chronic
428.30   Diastolic heart failure, unspecified
428.31   Diastolic heart failure, acute
428.32   Diastolic heart failure, chronic
428.33   Diastolic heart failure, acute on chronic
428.40   Combined systolic and diastolic heart failure, unspecified
428.41   Combined systolic and diastolic heart failure, acute
428.42   Combined systolic and diastolic heart failure, chronic
428.43   Combined systolic and diastolic heart failure, acute on chronic
428.9    Heart failure, unspecified
429.2    Cardiovascular disease, unspecified
429.9    Heart disease, unspecified
431      Intracerebral hemorrhage
433.00   Occlusion and stenosis, basilar artery without cerebral infarction
433.01   Occlusion and stenosis, basilar artery with cerebral infarction
433.10   Occlusion and stenosis, carotid artery without cerebral infarction
433.11   Occlusion and stenosis, carotid artery with cerebral infarction
433.20   Occlusion and stenosis, vertebral artery without cerebral infarction
433.21   Occlusion and stenosis, vertebral artery with cerebral infarction
433.30   Occlusion and stenosis, multiple and bilateral without cerebral infarction
433.31   Occlusion and stenosis, multiple and bilateral with cerebral infarction
433.80   Occlusion and stenosis, other specified precerebral artery without cerebral infarction
433.81   Occlusion and stenosis, with cerebral infarction
433.90   Occlusion and stenosis, unspecified precerebral artery without cerebral infarction
433.91   Occlusion and stenosis, unspecified precerebral artery with cerebral infarction
434.00   Cerebral thrombosis without cerebral infarction
434.01   Cerebral thrombosis with cerebral infarction
434.10   Cerebral embolism without cerebral infarction
434.11   Cerebral embolism with cerebral infarction
434.90   Cerebral artery occlusion, unspecified without cerebral infarction
434.91   Cerebral artery occlusion, unspecified with cerebral infarction
435.0    Basilar artery syndrome
435.1    Vertebral artery syndrome
435.2    Subclavian steal syndrome
435.3    Vertebrobasilar artery syndrome
435.8    Other specified transient cerebral ischemias
435.9    Unspecified transient cerebral ischemia
437.0    Cerebral atherosclerosis
437.1    Other generalized ischemic cerebrovascular disease
437.5    Moyamoya disease
438.0    Late effects of cerebrovascular disease, cognitive defects
438.10   Late effects of cerebrovascular disease, speech/language unspecified
438.11   Late effects of cerebrovascular disease, aphasia
438.12   Late effects of cerebrovascular disease, dysphasia
438.19   Late effects of cerebrovascular disease, other speech/language defects
438.20   Late effects of cerebrovascular disease, hemiplegia, unspecified side
438.21   Late effects of cerebrovascular disease, hemiplegia, dominant side
438.22   Late effects of cerebrovascular disease, hemiplegia, non-dominant side
438.30   Late effects of cerebrovascular disease, monoplegia, upper limb, unspecified
438.31   Late effects of cerebrovascular disease, monoplegia, upper limb, dominant side
438.32   Late effects of cerebrovascular disease, monoplegia, upper limb, non-dominant side
438.40   Late effects of cerebrovascular disease, monoplegia, lower limb, unspecified



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NATIONAL COVERAGE DETERMINATION                                                            83704

438.41   Late effects of cerebrovascular disease, monoplegia, lower limb, dominant side
438.42   Late effects of cerebrovascular disease, monoplegia, lower limb, non-dominant side
438.50   Late effects of cerebrovascular disease, other paralytic syndrome, unspecified
438.51   Late effects of cerebrovascular disease, other paralytic syndrome, dominant side
438.52   Late effects of cerebrovascular disease, other paralytic syndrome, non-dominant side
438.53   Late effects of cerebrovascular disease, other paralytic syndrome, bilateral
438.6    Alterations of sensations
438.7    Disturbances of vision
438.81   Late effects of cerebrovascular disease, aproxia
438.82   Late effects of cerebrovascular disease, dysphagia
438.83   Late effects of cerebrovascular disease, facial weakness
438.84   Late effects of cerebrovascular disease, ataxia
438.85   Late effects of cerebrovascular disease, vertigo
438.89   Late effects of cerebrovascular disease, other
438.9    Late effects of cerebrovascular disease, unspecified
440.0    Atherosclerosis of aorta
440.1    Atherosclerosis of renal artery
440.20   Atherosclerosis of the extremities, unspecified
440.21   Atherosclerosis of the extremities with intermittent claudication
440.22   Atherosclerosis of the extremities with rest pain
440.23   Atherosclerosis of the extremities with ulceration
440.24   Atherosclerosis of the extremities with gangrene
440.29   Other atherosclerosis of the extremities
440.30   Atherosclerosis of unspecified graft
440.31   Atherosclerosis of autologous vein bypass graft
440.32   Atherosclerosis of nonautologous vein bypass graft
440.4    Chronic total occlusion of artery of the extremities
440.8    Atherosclerosis of other specified arteries
440.9    Generalized and unspecified atherosclerosis
441.00   Dissection of aorta, unspecified site
441.01   Dissection of aorta, thoracic
441.02   Dissection of aorta, abdominal
441.03   Dissection of aorta, thoracoabdominal
441.1    Thoracic aneurysm, ruptured
441.2    Thoracic aneurysm without rupture
441.3    Abdominal aneurysm, ruptured
441.4    Abdominal aneurysm without rupture
441.5    Aortic aneurysm of unspecified site, ruptured
441.6    Thoracoabdominal aneurysm, ruptured
441.7    Thoracoabdominal aneurysm, without rupture
441.9    Aortic aneurysm of unspecified site without rupture
442.0    Aneurysm of artery of upper extremity
442.1    Aneurysm of renal artery
442.2    Aneurysm of iliac artery
444.0    Arterial embolism and thrombosis of abdominal aorta
444.1    Arterial embolism and thrombosis of thoracic aorta
444.21   Arterial embolism and thrombosis, upper extremity
444.22   Arterial embolism and thrombosis, lower extremity
444.81   Arterial embolism and thrombosis, iliac artery
444.89   Arterial embolism and thrombosis, other
444.9    Arterial embolism and thrombosis of unspecified artery
557.1    Chronic vascular insufficiency of intestine
571.8    Other chronic nonalcoholic liver disease



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571.9    Unspecified chronic liver disease without mention of
573.8    Other specified disorders of liver
573.9    Unspecified disorder of liver
577.0    Acute pancreatitis
577.1    Chronic pancreatitis
577.2    Cyst and pseudocyst of pancreas
577.8    Other specified diseases of pancreas
577.9    Unspecified disease of pancreas
579.3    Other and unspecified postsurgical nonabsorption
579.8    Other specified intestinal malabsorption
581.0    Nephrotic syndrome with lesion of proliferative glomerulonephritis
581.1    Nephrotic syndrome with lesion of membranous glomerulonephritis
581.2    Nephrotic syndrome with lesion of membranoproliferative glomerulonephritis
581.3    Nephrotic syndrome with lesion of minimal change glomerulonephritis
581.81   Nephrotic syndrome in diseases classified elsewhere
581.89   Other nephrotic syndrome
581.9    Nephrotic syndrome with unspecified pathological lesion in
584.5    Acute renal failure with lesion of tubular necrosis
585.4    Chronic kidney disease, Stage IV (severe)
585.5    Chronic kidney disease, Stage V
585.6    End stage renal disease
585.9    Chronic kidney disease, unspecified
588.0    Renal osteodystrophy
588.1    Nephrogenic diabetes insipidus
588.81   Secondary hyperparathyroidism (of renal origin)
588.89   Other specified disorders resulting from impaired renal function
588.9    Unspecified disorder resulting from impaired renal function
607.84   Impotence of organic origin
646.70   Liver disorders in pregnancy, unspecified episode of care
646.71   Liver disorders in pregnancy, delivered, with or without antepartum condition
646.73   Liver disorders in pregnancy, antepartum condition or complication defects
648.10   Other conditions of mother complicating pregnancy, thyroid dysfunction, unspecified
         episode of care
648.11   Other conditions of mother complicating pregnancy, thyroid dysfunction, delivered, with or
         without antepartum condition
648.12   Other conditions of mother complicating pregnancy, thyroid dysfunction, delivered, with
         postpartum complication
648.13   Other conditions of mother complicating pregnancy, thyroid dysfunction, antepartum
         condition or complication
648.14   Other conditions of mother complicating pregnancy, thyroid dysfunction, postpartum
         condition or complication
696.0    Psoriatic arthropathy
696.1    Other psoriasis
751.61   Biliary atresia
764.10   Light-for-dates with signs of fetal malnutrition, unspecified [weight]
764.11   Light-for-dates with signs of fetal malnutrition less than 500 grams
764.12   Light-for-dates with signs of fetal malnutrition 500-749 grams
764.13   Light-for-dates with signs of fetal malnutrition 750-999 grams
764.14   Light-for-dates with signs of fetal malnutrition 1,000-1,249 grams
764.15   Light-for-dates with signs of fetal malnutrition 1,250-1,499 grams
764.16   Light-for-dates with signs of fetal malnutrition 1,500-1,749 grams
764.17   Light-for-dates with signs of fetal malnutrition 1,750-1,999 grams
764.18   Light-for-dates with signs of fetal malnutrition 2,000-2,499 grams



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NATIONAL COVERAGE DETERMINATION                                                    83704

764.19   Light-for-dates with signs of fetal malnutrition 2,500 grams and over
786.50   Chest pain, unspecified
786.51   Precordial pain
786.59   Other chest pain
789.1    Hepatomegaly
790.4    Nonspecific elevation transaminase or lactic acid dehydrogenase [LDH]
790.5    Other nonspecific abnormalserum enzyme levels
790.6    Other abnormal blood chemistry
793.4    Abnormal radiologiocal findings, gastrointestinal tract
987.9    Toxic effect of unspecified gas, fume, or vapor
996.81   Complications, transplanted kidney
V42.0    Organ or tissue replaced by transplant, kidney
V42.7    Organ or tissue replaced by transplant, liver
V58.63   Long-term (current) use of antiplatelet/antithrombotic
V58.64   Long-term (current) use of non-steroidal anti-inflammatories
V58.69   Long-term (current) use of other medications




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NATIONAL COVERAGE DETERMINATION                                                                                         83721


NATIONAL COVERAGE DETERMINATION
83721
83721-Lipoprotein, direct measurement; direct measurement, LDL cholesterol




CPT CODE: 83721



CPT CODE DESCRIPTOR: Lipoprotein, direct measurement; direct measurement, LDL
      cholesterol



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                         When monitoring long term anti-lipid dietary or pharmacologic therapy and when
                                         following patients with borderline high total or LDL cholesterol levels, it is
                                         reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a
                                         yearly interval will usually be adequate while measurement of the serum total
                                         cholesterol (CPT code 82465) or a measured LDL (CPT code 83721) should suffice
                                         for interim visits if the patient does not have hypertriglyceridemia (for example,
                                         ICD-9-CM code 272.1, Pure hyperglyceridemia).

                                         Any one component of the panel or a measured LDL may be medically necessary
                                         up to six times the first year for monitoring dietary or pharmacologic therapy. More
                                         frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing
                                         may be indicated for marked elevations or for changes to anti-lipid therapy due to
                                         inadequate initial patient response to dietary or pharma-cologic therapy. The LDL
                                         cholesterol or total cholesterol may be measured three times yearly after treatment
                                         goals have been achieved. If no dietary or pharmacological therapy is advised,
                                         monitoring is not necessary.

                                         When evaluating non-specific chronic abnormalities of the liver (for example,
                                         elevations of transaminase, alkaline phosphatase, abnormal imaging studies, etc.),
                                         a lipid panel would generally not be indicated more than twice per year.



COVERED ICD-9 CODES:
242.00 Toxic diffuse goiter without thyrotoxic crisis or storm
242.01 Toxic diffuse goiter with thyrotoxic crisis or storm
242.10 Toxic uninodular goiter without thyrotoxic crisis or storm
242.11 Toxic uninodular goiter with thyrotoxic crisis or storm
242.20 Toxic multinodular goiter without thyrotoxic crisis or storm
242.21 Toxic multinodular goiter with thyrotoxic crisis or storm
242.30 Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm
242.31 Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40 Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41 Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
242.80 Thyrotoxicosis of other specified origin without thyrotoxic crisis or storm
242.81 Thyrotoxicosis of other specified origin with thyrotoxic crisis or storm
242.90 Thyrotoxicosis without of goiter or other cause without thyrotoxic crisis or storm
242.91 Thyrotoxicosis without goiter or other cause with mention of thyrotoxic crisis or storm
243    Congenital hypothyroidism
244.0 Postsurgical hypothyroidism
244.1 Other postablative hypothyroidism
244.2 Iodine hypothyroidism


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244.3    Other iatrogenic hypothyroidism
244.8    Other specified acquired hypothyroidism
244.9    Unspecified hypothyroidism
245.0    Acute thyroiditis
245.1    Subacute thyroiditis
245.2    Chronic lymphocytic thyroiditis
245.3    Chronic fibrous thyroiditis
245.4    Iatrogenic thyroiditis
245.8    Other and unspecified chronic thyroiditis
245.9    Thyroiditis, unspecified
250.00   Diabetes mellitus without complication, type II or unspecified type, not stated as
         uncontrolled
250.01   Diabetes mellitus without complication, type I, not stated as uncontrolled
250.02   Diabetes mellitus without complication, type II or unspecified type, uncontrolled
250.03   Diabetes mellitus without complication, type I, uncontrolled
250.10   Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
250.11   Diabetes with ketoacidosis, type I, not stated as uncontrolled
250.12   Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13   Diabetes with ketoacidosis, type I, uncontrolled
250.20   Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
250.21   Diabetes with hyperosmolarity, type I, not stated as uncontrolled
250.22   Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23   Diabetes with hyperosmolarity, type I, uncontrolled
250.30   Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
250.31   Diabetes with other coma, type I, not stated as uncontrolled
250.32   Diabetes with other coma, type II or unspecified type, uncontrolled
250.33   Diabetes with other coma type I, uncontrolled
250.40   Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41   Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42   Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43   Diabetes with renal manifestations, type I, uncontrolled
250.50   Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
         uncontrolled
250.51   Diabetes with ophthalmic manifestations, type I, not stated as uncontrolled
250.52   Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53   Diabetes with ophthalmic manifestations, type I, uncontrolled
250.60   Diabetes with neurological manifestations, type II or unspecified type, not stated as
         uncontrolled
250.61   Diabetes with neurological manifestations, type I, not stated as uncontrolled
250.62   Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
250.63   Diabetes with neurological manifestations, type I, uncontrolled
250.70   Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
         uncontrolled
250.71   Diabetes with peripheral circulatory disorders, type I, not stated as uncontrolled
250.72   Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
250.73   Diabetes with peripheral circulatory disorders, type I, uncontrolled
250.80   Diabetes with other specified manifestations, type II or unspecified type, not stated as
         uncontrolled
250.81   Diabetes with other specified manifestations, type I, not stated as uncontrolled
250.82   Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
250.83   Diabetes with other specified manifestations, type I uncontrolled
250.90   Diabetes with unspecified complication, type II or unspecified type, not stated as
         uncontrolled



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250.91   Diabetes with unspecified complication, type I, not stated as uncontrolled
250.92   Diabetes with unspecified complication, type II or unspecified type, uncontrolled
250.93   Diabetes with unspecified complication, type I, uncontrolled
255.0    Cushing's syndrome
260      Kwashiorkor
261      Nutritional marasmus
262      Other severe protein-calorie malnutrition
263.0    Malnutrition of moderate degree
263.1    Malnutrition of mild degree
263.8    Other protein-calorie malnutrition
263.9    Unspecified protein-calorie malnutrition
270.0    Disturbances of amino-acid transport
271.1    Galactosemia
272.0    Pure hypercholesterolemia
272.1    Pure hyperglyceridemia
272.2    Mixed hyperlipidemia
272.3    Hyperchylomicronemia
272.4    Other and unspecified hyperlipidemia
272.5    Lipoprotein deficiencies
272.6    Lipodystrophy
272.7    Lipidoses
272.8    Other disorders of lipoid metabolism
272.9    Unspecified disorder of lipoid metabolism
277.30   Amyloidosis, unspecified
277.31   Familial Mediterranean fever
277.39   Other amyloidosis
278.00   Obesity, unspecified
278.01   Morbid obesity
278.02   Overweight
303.90   Other and unspecified alcohol dependence, unspecified
303.91   Other and unspecified alcohol dependence, continuous
303.92   Other and unspecified alcohol dependence, episodic
362.10   Background retinopathy, unspecified
362.11   Hypertensive retinopathy
362.12   Exudative retinopathy
362.13   Changes in vascular appearance
362.14   Retinal microaneurysms
362.15   Retinal telangiectasia
362.16   Retinal neovascularization
362.30   Retinal vascular occlusion, unspecified
362.31   Central retinal artery occlusion
362.32   Arterial branch occlusion
362.33   Partial arterial occlusion
362.34   Transient arterial occlusion
362.82   Retinal exudates and deposits
371.41   Senile corneal changes
374.51   Xanthelasma
379.22   Crystalline deposits in vitreous
388.00   Degenerative and vascular disorders, unspecified
388.02   Transient ischemic deafness
401.0    Malignant hypertension
401.1    Benign hypertension
401.9    Unspecified hypertension



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402.00   Malignant hypertension without congestive heart failure
402.01   Malignant hypertension with congestive heart failure
402.10   Benign hypertension without congestive heart failure
402.11   Benign hypertension with congestive heart failure
402.90   Unspecified hypertension without congestive heart failure
402.91   Unspecified hypertension with congestive heart failure
403.00   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I
         through stage IV, or unspecified
403.01   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or
         end stage renal disease
403.10   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through
         stage IV, or unspecified
403.11   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end
         stage renal disease
403.90   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I
         through stage IV, or unspecified
403.91   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or
         end stage renal disease
404.00   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.01   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.02   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.03   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.10   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.11   Hypertensive heart and chronic kidney disease, benign, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.12   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.13   Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic
         kidney disease stage V or end stage renal disease
404.90   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage I through stage IV, or unspecified
404.91   Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.92   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage V or end stage renal disease
404.93   Hypertensive heart and chronic kidney disease, unspecified, with heart failure and
         chronic kidney disease stage V or end stage renal disease
405.01   Renovascular hypertensive heart and renal disease
405.09   Other hypertensive heart and renal disease
405.11   Renovascular hypertensive heart and renal disease
405.19   Other hypertensive heart and renal disease
405.91   Renovascular hypertensive heart and renal disease
405.99   Other hypertensive heart and renal disease
410.00   Infarction of anterolateral wall, episode of care unspecified
410.01   Infarction of anterolateral wall, initial episode of care
410.02   Infarction of anterolateral wall, subsequent episode of care
410.10   Infarction of other anterior wall, episode of care unspecified
410.11   Infarction of other anterior wall, initial episode of care



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410.12   Infarction of other anterior wall, subsequent episode of care
410.20   Infarction of inferolateral wall, episode of care unspecified
410.21   Infarction of inferolateral wall, initial episode of care
410.22   Infarction of inferolateral wall, subsequent episode of care
410.30   Infarction of inferoposterior wall, episode of care unspecified
410.31   Infarction of inferoposterior wall, initial episode of care
410.32   Infarction of inferoposterior wall,subsequent episode of care
410.40   Infarction of other inferior wall, episode of care unspecified
410.41   Infarction of other inferior wal, initial episode of care
410.42   Infarction of other inferior wall, subsequent episode of care
410.50   Infarction of other lateral wall, episode of care unspecified
410.51   Infarction of other lateral wall, initial episode of care
410.52   Infarction of other lateral wall, subsequent episode of care
410.60   True posterior wall infarction, episode of care unspecified
410.61   True posterior wall infarction, initial episode of care
410.62   True posterior wall infarction, subsequent episode of care
410.70   Subendocardial infarction, episode of care unspecified
410.71   Subendocardial infarction, initial episode of care
410.72   Subendocardial infarction, subsequent episode of care
410.80   Infarction of other specified sites, episode of care unspecified
410.81   Infarction of other specified sites, initial episode of care
410.82   Infarction of other specified sites, subsequent episode of care
410.90   Infarction, unspecified site, episode of care unspecified
410.91   Infarction, unspecified site, initial episode of care
410.92   Infarction, unspecified site, subsequent episode of care
411.0    Postmyocardial infarction syndrome
411.1    Intermediate coronary syndrome
411.81   Coronary occlusion without myocardial infarction
411.89   Other ischemic heart disease
412      Old myocardial infarction
413.0    Angina decubitus
413.1    Prinzmetal angina
413.9    Other and unspecified angina pectoris
414.00   Coronary atherosclerosis of unspecified vessel
414.01   Coronary atherosclerosis of native coronary artery
414.02   Coronary atherosclerosis of autologous biological bypass graft
414.03   Coronary atherosclerosis of nonautologous biological bypass graft
414.04   Coronary atherosclerosis of artery bypass graft
414.05   Coronary atherosclerosis of unspecified bypass graft
414.06   Coronary atherosclerosis of native coronary artery of transplanted heart
414.07   Coronary atherosclerosis, of bypass graft of transplanted heart
414.10   Aneurysm of heart (wall)
414.11   Aneurysm of coronary vessels
414.12   Dissection of coronary artery
414.19   Aneurysm, other
414.8    Other specified forms of chronic ischemic heart disease
414.9    Chronic ischemic heart disease, unspecified
428.0    Congestive heart failure
428.1    Left heart failure
428.20   Systolic heart failure, unspecified
428.21   Systolic heart failure, acute
428.22   Systolic heart failure, chronic
428.23   Systolic heart failure, acute on chronic



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428.30   Diastolic heart failure, unspecified
428.31   Diastolic heart failure, acute
428.32   Diastolic heart failure, chronic
428.33   Diastolic heart failure, acute on chronic
428.40   Combined systolic and diastolic heart failure, unspecified
428.41   Combined systolic and diastolic heart failure, acute
428.42   Combined systolic and diastolic heart failure, chronic
428.43   Combined systolic and diastolic heart failure, acute on chronic
428.9    Heart failure, unspecified
429.2    Cardiovascular disease, unspecified
429.9    Heart disease, unspecified
431      Intracerebral hemorrhage
433.00   Occlusion and stenosis, basilar artery without cerebral infarction
433.01   Occlusion and stenosis, basilar artery with cerebral infarction
433.10   Occlusion and stenosis, carotid artery without cerebral infarction
433.11   Occlusion and stenosis, carotid artery with cerebral infarction
433.20   Occlusion and stenosis, vertebral artery without cerebral infarction
433.21   Occlusion and stenosis, vertebral artery with cerebral infarction
433.30   Occlusion and stenosis, multiple and bilateral without cerebral infarction
433.31   Occlusion and stenosis, multiple and bilateral with cerebral infarction
433.80   Occlusion and stenosis, other specified precerebral artery without cerebral infarction
433.81   Occlusion and stenosis, with cerebral infarction
433.90   Occlusion and stenosis, unspecified precerebral artery without cerebral infarction
433.91   Occlusion and stenosis, unspecified precerebral artery with cerebral infarction
434.00   Cerebral thrombosis without cerebral infarction
434.01   Cerebral thrombosis with cerebral infarction
434.10   Cerebral embolism without cerebral infarction
434.11   Cerebral embolism with cerebral infarction
434.90   Cerebral artery occlusion, unspecified without cerebral infarction
434.91   Cerebral artery occlusion, unspecified with cerebral infarction
435.0    Basilar artery syndrome
435.1    Vertebral artery syndrome
435.2    Subclavian steal syndrome
435.3    Vertebrobasilar artery syndrome
435.8    Other specified transient cerebral ischemias
435.9    Unspecified transient cerebral ischemia
437.0    Cerebral atherosclerosis
437.1    Other generalized ischemic cerebrovascular disease
437.5    Moyamoya disease
438.0    Late effects of cerebrovascular disease, cognitive defects
438.10   Late effects of cerebrovascular disease, speech/language unspecified
438.11   Late effects of cerebrovascular disease, aphasia
438.12   Late effects of cerebrovascular disease, dysphasia
438.19   Late effects of cerebrovascular disease, other speech/language defects
438.20   Late effects of cerebrovascular disease, hemiplegia, unspecified side
438.21   Late effects of cerebrovascular disease, hemiplegia, dominant side
438.22   Late effects of cerebrovascular disease, hemiplegia, non-dominant side
438.30   Late effects of cerebrovascular disease, monoplegia, upper limb, unspecified
438.31   Late effects of cerebrovascular disease, monoplegia, upper limb, dominant side
438.32   Late effects of cerebrovascular disease, monoplegia, upper limb, non-dominant side
438.40   Late effects of cerebrovascular disease, monoplegia, lower limb, unspecified
438.41   Late effects of cerebrovascular disease, monoplegia, lower limb, dominant side
438.42   Late effects of cerebrovascular disease, monoplegia, lower limb, non-dominant side



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438.50   Late effects of cerebrovascular disease, other paralytic syndrome, unspecified
438.51   Late effects of cerebrovascular disease, other paralytic syndrome, dominant side
438.52   Late effects of cerebrovascular disease, other paralytic syndrome, non-dominant side
438.53   Late effects of cerebrovascular disease, other paralytic syndrome, bilateral
438.6    Alterations of sensations
438.7    Disturbances of vision
438.81   Late effects of cerebrovascular disease, aproxia
438.82   Late effects of cerebrovascular disease, dysphagia
438.83   Late effects of cerebrovascular disease, facial weakness
438.84   Late effects of cerebrovascular disease, ataxia
438.85   Late effects of cerebrovascular disease, vertigo
438.89   Late effects of cerebrovascular disease, other
438.9    Late effects of cerebrovascular disease, unspecified
440.0    Atherosclerosis of aorta
440.1    Atherosclerosis of renal artery
440.20   Atherosclerosis of the extremities, unspecified
440.21   Atherosclerosis of the extremities with intermittent claudication
440.22   Atherosclerosis of the extremities with rest pain
440.23   Atherosclerosis of the extremities with ulceration
440.24   Atherosclerosis of the extremities with gangrene
440.29   Other atherosclerosis of the extremities
440.30   Atherosclerosis of unspecified graft
440.31   Atherosclerosis of autologous vein bypass graft
440.32   Atherosclerosis of nonautologous vein bypass graft
440.4    Chronic total occlusion of artery of the extremities
440.8    Atherosclerosis of other specified arteries
440.9    Generalized and unspecified atherosclerosis
441.00   Dissection of aorta, unspecified site
441.01   Dissection of aorta, thoracic
441.02   Dissection of aorta, abdominal
441.03   Dissection of aorta, thoracoabdominal
441.1    Thoracic aneurysm, ruptured
441.2    Thoracic aneurysm without rupture
441.3    Abdominal aneurysm, ruptured
441.4    Abdominal aneurysm without rupture
441.5    Aortic aneurysm of unspecified site, ruptured
441.6    Thoracoabdominal aneurysm, ruptured
441.7    Thoracoabdominal aneurysm, without rupture
441.9    Aortic aneurysm of unspecified site without rupture
442.0    Aneurysm of artery of upper extremity
442.1    Aneurysm of renal artery
442.2    Aneurysm of iliac artery
444.0    Arterial embolism and thrombosis of abdominal aorta
444.1    Arterial embolism and thrombosis of thoracic aorta
444.21   Arterial embolism and thrombosis, upper extremity
444.22   Arterial embolism and thrombosis, lower extremity
444.81   Arterial embolism and thrombosis, iliac artery
444.89   Arterial embolism and thrombosis, other
444.9    Arterial embolism and thrombosis of unspecified artery
557.1    Chronic vascular insufficiency of intestine
571.8    Other chronic nonalcoholic liver disease
571.9    Unspecified chronic liver disease without mention of
573.8    Other specified disorders of liver



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NATIONAL COVERAGE DETERMINATION                                                              83721

573.9    Unspecified disorder of liver
577.0    Acute pancreatitis
577.1    Chronic pancreatitis
577.2    Cyst and pseudocyst of pancreas
577.8    Other specified diseases of pancreas
577.9    Unspecified disease of pancreas
579.3    Other and unspecified postsurgical nonabsorption
579.8    Other specified intestinal malabsorption
581.0    Nephrotic syndrome with lesion of proliferative glomerulonephritis
581.1    Nephrotic syndrome with lesion of membranous glomerulonephritis
581.2    Nephrotic syndrome with lesion of membranoproliferative glomerulonephritis
581.3    Nephrotic syndrome with lesion of minimal change glomerulonephritis
581.81   Nephrotic syndrome in diseases classified elsewhere
581.89   Other nephrotic syndrome
581.9    Nephrotic syndrome with unspecified pathological lesion in
584.5    Acute renal failure with lesion of tubular necrosis
585.4    Chronic kidney disease, Stage IV (severe)
585.5    Chronic kidney disease, Stage V
585.6    End stage renal disease
585.9    Chronic kidney disease, unspecified
588.0    Renal osteodystrophy
588.1    Nephrogenic diabetes insipidus
588.81   Secondary hyperparathyroidism (of renal origin)
588.89   Other specified disorders resulting from impaired renal function
588.9    Unspecified disorder resulting from impaired renal function
607.84   Impotence of organic origin
646.70   Liver disorders in pregnancy, unspecified episode of care
646.71   Liver disorders in pregnancy, delivered, with or without antepartum condition
646.73   Liver disorders in pregnancy, antepartum condition or complication defects
648.10   Other conditions of mother complicating pregnancy, thyroid dysfunction, unspecified
         episode of care
648.11   Other conditions of mother complicating pregnancy, thyroid dysfunction, delivered, with or
         without antepartum condition
648.12   Other conditions of mother complicating pregnancy, thyroid dysfunction, delivered, with
         postpartum complication
648.13   Other conditions of mother complicating pregnancy, thyroid dysfunction, antepartum
         condition or complication
648.14   Other conditions of mother complicating pregnancy, thyroid dysfunction, postpartum
         condition or complication
696.0    Psoriatic arthropathy
696.1    Other psoriasis
751.61   Biliary atresia
764.10   Light-for-dates with signs of fetal malnutrition, unspecified [weight]
764.11   Light-for-dates with signs of fetal malnutrition less than 500 grams
764.12   Light-for-dates with signs of fetal malnutrition 500-749 grams
764.13   Light-for-dates with signs of fetal malnutrition 750-999 grams
764.14   Light-for-dates with signs of fetal malnutrition 1,000-1,249 grams
764.15   Light-for-dates with signs of fetal malnutrition 1,250-1,499 grams
764.16   Light-for-dates with signs of fetal malnutrition 1,500-1,749 grams
764.17   Light-for-dates with signs of fetal malnutrition 1,750-1,999 grams
764.18   Light-for-dates with signs of fetal malnutrition 2,000-2,499 grams
764.19   Light-for-dates with signs of fetal malnutrition 2,500 grams and over
786.50   Chest pain, unspecified



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786.51   Precordial pain
786.59   Other chest pain
789.1    Hepatomegaly
790.4    Nonspecific elevation transaminase or lactic acid dehydrogenase [LDH]
790.5    Other nonspecific abnormalserum enzyme levels
790.6    Other abnormal blood chemistry
793.4    Abnormal radiologiocal findings, gastrointestinal tract
987.9    Toxic effect of unspecified gas, fume, or vapor
996.81   Complications, transplanted kidney
V42.0    Organ or tissue replaced by transplant, kidney
V42.7    Organ or tissue replaced by transplant, liver
V58.63   Long-term (current) use of antiplatelet/antithrombotic
V58.64   Long-term (current) use of non-steroidal anti-inflammatories
V58.69   Long-term (current) use of other medications




                                                                                 Page 175
NATIONAL COVERAGE DETERMINATION                                                                                            84153


NATIONAL COVERAGE DETERMINATION
84153
84153-Prostate specific antigen (PSA); total




CPT CODE: 84153



CPT CODE DESCRIPTOR: Prostate specific antigen (PSA); total



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                               For patients with lower urinary tract signs or symptoms, total PSA is performed
                                               only once per year unless there is a change in the patient's medical condition.
                                               Medicare covers a screening total PSA test one each year for men over 50 years of
                                               age.



COVERED ICD-9 CODES:
185    Malignant neoplasm of prostate
188.5 Malignant neoplasm of bladder neck
196.5 Secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and
       lower limb
196.6 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes
196.8 Secondary and unspecified malignant neoplasm, lymph nodes of multiple sites
198.5 Secondary malignant neoplasm of bone and bone marrow
198.82 Secondary malignant neoplasm of genital organs
233.4 Carcinoma in situ of prostate
236.5 Neoplasm of uncertain behavior of prostate
239.5 Neoplasms of unspecified nature of other genitourinary organs
596.0 Bladder neck obstruction
599.60 Urinary obstruction, unspecified
599.69 Urinary obstruction, not elsewhere classified
599.7 Hematuria
600.00 Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract
       symptoms (LUTS)
600.01 Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract
       symptoms (LUTS)
600.10 Nodular prostate without urinary obstruction
600.11 Nodular prostate with urinary obstruction
600.21 Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary
       tract symptoms (LUTS)
601.9 Prostatitis, unspecified
602.9 Unspecified disorder of prostate
788.20 Retention of urine, unspecified
788.21 Incomplete bladder emptying
788.30 Urinary incontinence, unspecified
788.41 Urinary frequency
788.43 Nocturia
788.62 Slowing of urinary stream
788.63 Urgency of urination
788.64 Urinary hesitancy
788.65 Straining on urination
790.93 Elevated prostate specific antigen [PSA]


                                                                                                                        Page 176
NATIONAL COVERAGE DETERMINATION                                                         84153

793.6    Abnormal radiologiocal findings, abdominal area, including retroperitoneum
793.7    Abnormal radiologiocal findings, musculoskeletal system
794.9    Abnormal results of function studies, other
V10.46   Personal history of malignant neoplasm, prostate




                                                                                      Page 177
NATIONAL COVERAGE DETERMINATION                                                                             Thyroid Testing


NATIONAL COVERAGE DETERMINATION
Thyroid Testing
84436, 84439, 84443, 84479-Thyroid Testing




CPT CODE: 84436, 84439, 84443, 84479



CPT CODE DESCRIPTOR:

                                         84436 Thyroxine; total

                                         84439 Thyroxine; free

                                         84443 Thyroid stimulating hormone (TSH)

                                         84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR)



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                         Testing may be covered up to two times a year in clinically stable patients; more
                                         frequent testing may be reasonable and necessary for patients whose thyroid
                                         therapy has been altered or in whom symptoms or signs of hyper- or
                                         hypothyroidism are noted.



COVERED ICD-9 CODES:
017.50 Tuberculosis of thyroid gland, unspecified
017.51 Tuberculosis of thyroid gland, bacteriological or histological exam not done
017.52 Tuberculosis of thyroid gland, bacteriological or histological exam unknown (at present)
017.53 Tuberculosis of thyroid gland, tubercle bacilli found (in sputum) by microscopy
017.54 Tuberculosis of thyroid gland, tubercle bacilli not found (in sputum) by microscopy, but
       found by bacterial culture
017.55 Tuberculosis of thyroid gland, tubercle bacilli not found by bacteriological exam, but
       tuberculosis confirmed histologically
017.56 Tuberculosis of thyroid gland, tubercle bacilli not found by bacteriological or histological
       exam, but tuberculosis confirmed by other methods
183.0 Malignant neoplasm of ovary
193    Malignant neoplasm of thyroid gland
194.8 Malignant neoplasm of other endocrine gland
198.89 Secondary malignant neoplasm of other sites
220    Benign neoplasm of ovary
226    Benign neoplasm of thyroid glands
227.3 Benign neoplasm of pituitary gland and craniopharyngeal
234.8 Carcinoma in situ of other specified sites
237.4 Neoplasm of uncertain behavior of other and unspecified endocrine glands
239.7 Neoplasms of unspecified nature of endocrine glands and other parts of nervous system
240.0 Goiter, simple
240.9 Goiter, unspecified
241.0 Nontoxic uninodular goiter
241.1 Nontoxic multinodular goiter
241.9 Unspecified nontoxic nodular goiter
242.00 Toxic diffuse goiter without thyrotoxic crisis or storm
242.01 Toxic diffuse goiter with thyrotoxic crisis or storm


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NATIONAL COVERAGE DETERMINATION                                                   Thyroid Testing

242.10   Toxic uninodular goiter without thyrotoxic crisis or storm
242.11   Toxic uninodular goiter with thyrotoxic crisis or storm
242.20   Toxic multinodular goiter without thyrotoxic crisis or storm
242.21   Toxic multinodular goiter with thyrotoxic crisis or storm
242.30   Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm
242.31   Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40   Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41   Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
242.80   Thyrotoxicosis of other specified origin without thyrotoxic crisis or storm
242.81   Thyrotoxicosis of other specified origin with thyrotoxic crisis or storm
242.90   Thyrotoxicosis without of goiter or other cause without thyrotoxic crisis or storm
242.91   Thyrotoxicosis without goiter or other cause with mention of thyrotoxic crisis or storm
243      Congenital hypothyroidism
244.0    Postsurgical hypothyroidism
244.1    Other postablative hypothyroidism
244.2    Iodine hypothyroidism
244.3    Other iatrogenic hypothyroidism
244.8    Other specified acquired hypothyroidism
244.9    Unspecified hypothyroidism
245.0    Acute thyroiditis
245.1    Subacute thyroiditis
245.2    Chronic lymphocytic thyroiditis
245.3    Chronic fibrous thyroiditis
245.4    Iatrogenic thyroiditis
245.8    Other and unspecified chronic thyroiditis
245.9    Thyroiditis, unspecified
246.0    Disorders of thyrocalcitonin secretion
246.1    Dyshormonogenic goiter
246.2    Cyst of thyroid
246.3    Hemorrhage and infarction of thyroid
246.8    Other specified disorders of thyroid
246.9    Unspecified disorder of thyroid
250.00   Diabetes mellitus without complication, type II or unspecified type, not stated as
         uncontrolled
250.01   Diabetes mellitus without complication, type I, not stated as uncontrolled
250.02   Diabetes mellitus without complication, type II or unspecified type, uncontrolled
250.03   Diabetes mellitus without complication, type I, uncontrolled
250.10   Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
250.11   Diabetes with ketoacidosis, type I, not stated as uncontrolled
250.12   Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13   Diabetes with ketoacidosis, type I, uncontrolled
250.20   Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
250.21   Diabetes with hyperosmolarity, type I, not stated as uncontrolled
250.22   Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23   Diabetes with hyperosmolarity, type I, uncontrolled
250.30   Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
250.31   Diabetes with other coma, type I, not stated as uncontrolled
250.32   Diabetes with other coma, type II or unspecified type, uncontrolled
250.33   Diabetes with other coma type I, uncontrolled
250.40   Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41   Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42   Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43   Diabetes with renal manifestations, type I, uncontrolled



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250.50 Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
       uncontrolled
250.51 Diabetes with ophthalmic manifestations, type I, not stated as uncontrolled
250.52 Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53 Diabetes with ophthalmic manifestations, type I, uncontrolled
250.60 Diabetes with neurological manifestations, type II or unspecified type, not stated as
       uncontrolled
250.61 Diabetes with neurological manifestations, type I, not stated as uncontrolled
250.62 Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
250.63 Diabetes with neurological manifestations, type I, uncontrolled
250.70 Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
       uncontrolled
250.71 Diabetes with peripheral circulatory disorders, type I, not stated as uncontrolled
250.72 Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
250.73 Diabetes with peripheral circulatory disorders, type I, uncontrolled
250.80 Diabetes with other specified manifestations, type II or unspecified type, not stated as
       uncontrolled
250.81 Diabetes with other specified manifestations, type I, not stated as uncontrolled
250.82 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
250.83 Diabetes with other specified manifestations, type I uncontrolled
250.90 Diabetes with unspecified complication, type II or unspecified type, not stated as
       uncontrolled
250.91 Diabetes with unspecified complication, type I, not stated as uncontrolled
250.92 Diabetes with unspecified complication, type II or unspecified type, uncontrolled
250.93 Diabetes with unspecified complication, type I, uncontrolled
252.1 Hypoparathyroidism
253.1 Other and unspecified anterior pituitary hyperfunction
253.2 Panhypopituitarism
253.3 Pituitary dwarfism
253.4 Other anterior pituitary disorders
253.7 Iatrogenic pituitary disorders
255.2 Adrenogenital disorders
255.41 Glucocorticoid deficiency
255.42 Mineralocorticoid deficiency
256.31 Premature menopause
256.39 Other ovarian failure
257.2 Other testicular hypofunction
258.01 Multiple endocrine neoplasia [MEN] type I
258.02 Multiple endocrine neoplasia [MEN] type IIA
258.03 Multiple endocrine neoplasia [MEN] type IIB
258.1 Other combinations of endocrine dysfunction
258.8 Other specified polyglandular dysfunction
258.9 Polyglandular dysfunction, unspecified
262    Other severe protein-calorie malnutrition
263.0 Malnutrition of moderate degree
263.1 Malnutrition of mild degree
263.2 Arrested development following protein-calorie malnutrition
263.8 Other protein-calorie malnutrition
263.9 Unspecified protein-calorie malnutrition
266.0 Ariboflavinosis
272.0 Pure hypercholesterolemia
272.2 Mixed hyperlipidemia
272.4 Other and unspecified hyperlipidemia



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NATIONAL COVERAGE DETERMINATION                                                  Thyroid Testing

275.40   Disorders of calcium metabolism, unspecified
275.41   Hypocalcemia
275.42   Hypercalcemia
275.49   Other disorders of calcium metabolism
276.0    Hyperosmolality and/or hypernatremia
276.1    Hyposmolality and/or hyponatremia
278.3    Hypercarotinemia
279.4    Autoimmune disease, not elsewhere classified
281.0    Pernicious anemia
281.9    Unspecified deficiency anemia
283.0    Autoimmune hemolytic anemias
285.9    Anemia, unspecified
290.0    Senile dementia, uncomplicated
290.10   Presenile dementia, uncomplicated
290.11   Presenile dementia with delirium
290.12   Presenile dementia with delusional features
290.13   Presenile dementia with depressive features
290.20   Senile dementia with delusional features
290.21   Senile dementia with depressive features
290.3    Senile dementia with delirium
293.0    Delirium due to conditions classified elsewhere
293.1    Subacute delirium
293.81   Psychotic disorder with delusions in conditions classified elsewhere
293.82   Psychotic disorder with hallucinations in conditions classified elsewhere
293.83   Mood disorder in conditions classified elsewhere
293.84   Anxiety disorder in conditions classified elsewhere
293.89   Other transient organic syndrome
294.8    Other persistent mental disorders due to conditions classified elsewhere
296.00   Bipolar I disorder, single manic episode, unspecified
296.01   Bipolar I disorder, single manic episode, mild
296.02   Bipolar I disorder, single manic episode, moderate
296.03   Bipolar I disorder, single manic episode, severe, without mention of psychotic behavior
296.04   Bipolar I disorder, single manic episode, severe, specified as with psychotic behavior
296.05   Bipolar I disorder, single manic episode, in partial or unspecified remission
296.06   Bipolar I disorder, single manic episode, in full remission
296.10   Manic disorder, recurrent episod, unspecified
296.11   Manic disorder, recurrent episode, mild
296.12   Manic disorder, recurrent episode, moderate
296.13   Manic disorder, recurrent episode, severe, without psychotic behavior
296.14   Manic disorder, recurrent episode severe, specified as with psychotic behavior
296.15   Manic disorder, recurrent episode in partial or unspecified remission
296.16   Manic disorder, recurrent episode in full remission
296.20   Major depressive disorder, single episode, unspecified
296.21   Major depressive disorder, single episode, mild
296.22   Major depressive disorder, single episode, moderate
296.23   Major depressive disorder, single episode, severe, without psychotic behavior
296.24   Major depressive disorder, single episode severe, specified as with psychotic behavior
296.25   Major depressive disorder, single episode in partial or unspecified remission
296.26   Major depressive disorder, single episode in full remission
296.30   Major depressive disorder, recurrent episode, unspecified
296.31   Major depressive disorder, recurrent episode, mild
296.32   Major depressive disorder, recurrent episode, moderate
296.33   Major depressive disorder, recurrent episode, severe, without psychotic behavior



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NATIONAL COVERAGE DETERMINATION                                                Thyroid Testing

296.34 Major depressive disorder, recurrent episode, severe, specified as with psychotic
       behavior
296.35 Major depressive disorder, recurrent episode in partial or unspecified remission
296.36 Major depressive disorder, recurrent episode in full remission
296.40 Bipolar I disorder, most recent episode (or current) manic, unspecified
296.41 Bipolar I disorder, most recent episode (or current) manic, mild
296.42 Bipolar I disorder, most recent episode (or current) manic, moderate
296.43 Bipolar I disorder, most recent episode (or current) manic, severe, without mention of
       psychotic behavior
296.44 Bipolar I disorder, most recent episode (or current) manic, severe, specified as with
       psychotic behavior
296.45 Bipolar I disorder, most recent episode (or current) manic, in partial or unspecified
       remission
296.46 Bipolar I disorder, most recent episode (or current) manic, in full remission
296.50 Bipolar I disorder, most recent episode (or current) depressed, unspecified
296.51 Bipolar I disorder, most recent episode (or current) depressed, mild
296.52 Bipolar I disorder, most recent episode (or current) depressed, moderate
296.53 Bipolar I disorder, most recent episode (or current) depressed, severe, without mention of
       psychotic behavior
296.54 Bipolar I disorder, most recent episode (or current) depressed, severe, specified as with
       psychotic behavior
296.55 Bipolar I disorder, most recent episode (or current) depressed, in partial or unspecified
       remission
296.56 Bipolar I disorder, most recent episode (or current) depressed, in full remission
296.60 Bipolar I disorder, most recent episode (or current) mixed, unspecified
296.61 Bipolar I disorder, most recent episode (or current) mixed, mild
296.62 Bipolar I disorder, most recent episode (or current) mixed, moderate
296.63 Bipolar I disorder, most recent episode (or current) mixed, severe, without mention of
       psychotic behavior
296.64 Bipolar I disorder, most recent episode (or current) mixed, severe, specified as with
       psychotic behavior
296.65 Bipolar I disorder, most recent episode (or current) mixed, in partial or unspecified
       remission
296.66 Bipolar I disorder, most recent episode (or current) mixed, in full remission
296.7 Bipolar I disorder, most recent episode (or current) unspecified
296.80 Bipolar disorder, unspecified
296.81 Atypical manic disorder
296.82 Atypical depressive disorder
296.89 Other bipolar disorders
296.90 Unspecified episodic mood disorder
296.99 Other specified episodic mood disorder
297.0 Paranoid state, simple
297.1 Delusional disorder
297.9 Unspecified paranoid state
298.3 Acute paranoid reaction
300.00 Anxiety state, unspecified
300.01 Panic disorder without agoraphobia
300.02 Generalized anxiety disorder
300.09 Other anxiety, dissociative and somatoform disorders
307.9 Other and unspecified special symptoms or syndromes, not
310.1 Personality change due to conditions classified elsewhere
311    Depressive disorder, not elsewhere classified
327.00 Organic insomnia, unspecified



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NATIONAL COVERAGE DETERMINATION                                                Thyroid Testing

327.01   Insomnia due to medical condition classified elsewhere
327.09   Other organic insomnia
327.29   Other organic sleep apnea
327.52   Sleep related leg cramps
327.8    Other organic sleep disorders
331.0    Alzheimer's disease
331.11   Pick's disease
331.19   Other frontotemporal dementia
331.2    Senile degeneration of brain
331.83   Mild cognitive impairment, so stated
333.1    Essential and other specified forms of tremor
333.99   Other extrapyramidal disease
354.0    Carpal tunnel syndrome
356.9    Unspecified idiopathic peripheral neuropathy
358.1    Myasthenic syndromes indiseases classified elsewhere
359.5    Myopathy in endocrinediseases classified elsewhere
359.9    Myopathy, unspecified
368.2    Diplopia
372.71   Hyperemia of conjunctiva
372.73   Conjunctival edema
374.41   Lid retraction or lag
374.82   Edema of eyelid
376.21   Thyrotoxic exophthalmos
376.22   Exophthalmic ophthalmoplegia
376.30   Exophthalmos, unspecified
376.31   Constant exophthalmos
376.33   Orbital edema or congestion
376.34   Intermittent exophthalmos
378.50   Paralytic strabismus, unspecified
378.51   Third or oculomotor nerve palsy, partial
378.52   Third or oculomotor nerve palsy, total
378.53   Fourth or trochlear nerve palsy
378.54   Sixth or abducens nerve palsy
378.55   External ophthalmoplegia
401.0    Malignant hypertension
401.1    Benign hypertension
401.9    Unspecified hypertension
403.00   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I
         through stage IV, or unspecified
403.01   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or
         end stage renal disease
403.10   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through
         stage IV, or unspecified
403.11   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end
         stage renal disease
403.90   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I
         through stage IV, or unspecified
403.91   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or
         end stage renal disease
404.00   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified
404.01   Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
         chronic kidney disease stage I through stage IV, or unspecified



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NATIONAL COVERAGE DETERMINATION                                                Thyroid Testing

404.02 Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
       chronic kidney disease stage V or end stage renal disease
404.03 Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
       chronic kidney disease stage V or end stage renal disease
404.10 Hypertensive heart and chronic kidney disease, benign, without heart failure and with
       chronic kidney disease stage I through stage IV, or unspecified
404.11 Hypertensive heart and chronic kidney disease, benign, with heart failure and with
       chronic kidney disease stage I through stage IV, or unspecified
404.12 Hypertensive heart and chronic kidney disease, benign, without heart failure and with
       chronic kidney disease stage V or end stage renal disease
404.13 Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic
       kidney disease stage V or end stage renal disease
404.90 Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
       with chronic kidney disease stage I through stage IV, or unspecified
404.91 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with
       chronic kidney disease stage I through stage IV, or unspecified
404.92 Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
       with chronic kidney disease stage V or end stage renal disease
404.93 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and
       chronic kidney disease stage V or end stage renal disease
423.9 Unspecified disease of pericardium
425.7 Nutritional and metabolic cardiomyopathy
427.0 Paroxysmal supraventricular tachycardia
427.2 Paroxysmal tachycardia, unspecified
427.31 Atrial fibrillation
427.89 Other node dysfunction
427.9 Cardiac dysrhythmia, unspecified
428.0 Congestive heart failure
428.1 Left heart failure
429.3 Cardiomegaly
511.9 Unspecified pleural effusion
518.81 Respiratory failure
529.8 Other specified conditions of the tongue
560.1 Paralytic ileus
564.00 Constipation, unspecified
564.01 Slow transit constipation
564.02 Outlet dysfunction constipation
564.09 Other constipation
564.7 Megacolon, other than Hirschsprung's
568.82 Peritoneal effusion (chronic)
625.3 Dysmenorrhea
626.0 Absence of menstruation
626.1 Scanty or infrequent menstruation
626.2 Excessive or frequent menstruation
626.4 Irregular menstrual cycle
648.10 Other conditions of mother complicating pregnancy, thyroid dysfunction, unspecified
       episode of care
648.11 Other conditions of mother complicating pregnancy, thyroid dysfunction, delivered, with or
       without antepartum condition
648.12 Other conditions of mother complicating pregnancy, thyroid dysfunction, delivered, with
       postpartum complication
648.13 Other conditions of mother complicating pregnancy, thyroid dysfunction, antepartum
       condition or complication



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NATIONAL COVERAGE DETERMINATION                                              Thyroid Testing

648.14 Other conditions of mother complicating pregnancy, thyroid dysfunction, postpartum
       condition or complication
676.20 Engorgement of breasts, unspecified episode of care
676.21 Engorgement of breasts, delivered, with or without antepartum condition
676.22 Engorgement of breasts, delivered, with postpartum complication
676.23 Engorgement of breasts, antepartum condition or complication
676.24 Engorgement of breasts, postpartum condition or complication
698.9 Unspecified pruritic disorder
701.1 Keratoderma, acquired
703.8 Other specified diseases of nail
704.00 Alopecia, unspecified
704.01 Alopecia areata
704.02 Telogen effluvium
704.09 Other alopecia
709.01 Vitiligo
710.0 Systemic lupus erythematosus
710.1 Systemic sclerosis
710.2 Sicca syndrome
710.3 Dermatomyositis
710.4 Polymyositis
710.5 Eosinophilia myalgia syndrome
710.8 Other specified diffuse diseases of connective tissue
710.9 Unspecified diffuse connective tissue disease
728.2 Muscular wasting and disuse atrophy, not elsewhere
728.87 Muscle weakness (generalized)
728.9 Unspecified disorder of muscle, ligament, and fascia
729.1 Mylagia and myositis, unspecified
729.82 Cramp referable to limbs
730.30 Periostitis without mention of ostemyelitis, site unspecified
730.31 Periostitis without mention of ostemyelitis, shoulder region
730.32 Periostitis without mention of ostemyelitis, upper arm
730.33 Periostitis without mention of ostemyelitis, forearm
730.34 Periostitis without mention of ostemyelitis, hand
730.35 Periostitis without mention of ostemyelitis, pelvic region and thigh
730.36 Periostitis without mention of ostemyelitis, lower leg
730.37 Periostitis without mention of ostemyelitis, ankle and foot
730.38 Periostitis without mention of ostemyelitis, other specified sites
730.39 Periostitis without mention of ostemyelitis, multiple sites
733.02 Idiopathic osteoporosis
733.09 Other osteoporosis
750.15 Macroglossia
759.2 Anomalies of other endocrine glands
780.01 Coma
780.02 Transient alteration of awareness
780.09 Other alteration of awareness
780.50 Sleep disturbance, unspecified
780.51 Insomnia with sleep apnea, unspecified
780.52 Insomnia, unspecified
780.6 Fever
780.71 Chronic fatigue syndrome
780.79 Other malaise and fatigue
780.8 Generalized hyperhidrosis
780.93 Memory loss



                                                                                      Page 185
NATIONAL COVERAGE DETERMINATION                                                Thyroid Testing

780.94   Early satiety
780.96   Generalized pain
780.97   Altered mental status
780.99   Other general symptoms
781.0    Abnormal involuntary movements
781.3    Lack of coordination
782.0    Disturbance of skin sensation
782.3    Edema
782.8    Changes in skin texture
782.9    Other symptoms involving skin and integumentary tissues
783.0    Anorexia
783.1    Abnormal weight gain
783.21   Abnormal loss of weight
783.6    Polyphagia
784.1    Throat pain
784.49   Other voice disturbance
784.5    Other speech disturbance
785.0    Tachycardia, unspecified
785.1    Palpitations
785.9    Other symptoms involving cardiovascular system
786.09   Other respiratory abnormality
786.1    Stridor
787.20   Dysphagia, unspecified
787.21   Dysphagia, oral phase
787.22   Dysphagia, oropharyngeal phase
787.23   Dysphagia, pharyngeal phase
787.24   Dysphagia, pharyngoesophageal phase
787.29   Other dysphagia
787.91   Diarrhea
787.99   Other bowel symptoms
789.51   Malignant ascites
789.59   Other ascites
793.99   Other nonspecific abnormal findings on radiological and other examinations of body
         structure
794.5    Abnormal results of function studies, thyroid
796.1    Abnormal reflex
799.2    Nervousness
990      Effects of radiation, unspecified
V10.87   Personal history of malignant neoplasm, thyroid
V10.88   Personal history of malignant neoplasm, other endocrine glands and related structures
V12.2    Personal history of endocrine, metabolic, and immunity disorders
V58.69   Long-term (current) use of other medications
V67.00   Examination following surgery, unspecified
V67.01   Examination following vaginal pap smear
V67.09   Examination following other specified surgery
V67.1    Follow-up examination following radiotherapy
V67.2    Follow-up examination following chemotherapy
V67.3    Follow-up examination following psychotherapy and other
V67.4    Follow-up examination following treatment of fracture
V67.51   Follow-up examination following completed treatment with high-risk medication, not
         elsewhere classified
V67.59   Follow-up examination following completed treatment with high-risk medication, other
V67.6    Follow-up examination following combined treatment



                                                                                        Page 186
NATIONAL COVERAGE DETERMINATION                                    Thyroid Testing

V67.9   Follow-up examination, unspecified follow-up examination




                                                                         Page 187
NATIONAL COVERAGE DETERMINATION                                                                                     84702


NATIONAL COVERAGE DETERMINATION
84702
84702-Gonadotropin, chorionic (hCG); quantitative




CPT CODE: 84702



CPT CODE DESCRIPTOR: Gonadotropin, chorionic (hCG); quantitative



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                                         It is not reasonable and necessary to perform hCG testing more than once per
                                         month for diagnostic purposes. It may be performed as needed for monitoring of
                                         patient progress and treatment. Qualitative hCG assays are not appropriate for
                                         medically managing patients with known or suspected germ cell neoplasms.



COVERED ICD-9 CODES:
158.0 Malignant neoplasm, retroperitoneum
158.8 Malignant neoplasm, specified parts of peritoneum
164.2 Malignant neoplasm of anterior mediastinum
164.3 Malignant neoplasm of posterior mediastinum
164.8 Other malignant neoplasm of thymus, heart, and mediastinum
164.9 Malignant neoplasm of mediastinum, part unspecified
181    Malignant neoplasm of placenta
183.0 Malignant neoplasm of ovary
183.8 Malignant neoplasm of other specified sites of uterine adnexa
186.0 Malignant neoplasm of undescended testis
186.9 Malignant neoplasm of other and unspecified testis
194.4 Malignant neoplasm of pineal gland
197.1 Secondary malignant neoplasm of mediastinum
197.6 Secondary malignant neoplasm of retroperitoneum and peritoneum
198.6 Secondary malignant neoplasm of ovary
198.82 Secondary malignant neoplasm of genital organs
236.1 Neoplasm of uncertain behavior of placenta
338.3 Neoplasm related pain (acute) (chronic)
623.8 Other specified noninflammatory disorders of vagina
625.9 Unspecified symptom associated with female genital organs
630    Hydatidiform mole
631    Other abnormal product of conception
632    Missed abortion
633.90 Unspecified ectopic pregnancy without intrauterine pregnancy
633.91 Unspecified ectopic pregnancy with intrauterine pregnancy
634.00 Spontaneous abortion complicated by genital tract and pelvic infection, unspecified
634.01 Spontaneous abortion complicated by genital tract and pelvic infection, incomplete
634.02 Spontaneous abortion complicated by genital tract and pelvic infection, complete
640.00 Threatened abortion, unspecified
640.01 Threatened abortion, delivered, with or without antepartum condition
640.03 Threatened abortion, antepartum condition or complication
642.30 Transient hypertension of pregnancy, unspecified as to episode of care or not applicable
642.31 Transient hypertension of pregnancy, delivered, with or without mention of antepartum
       condition
642.32 Transient hypertension of pregnancy, delivered, with mention of postpartum complication


                                                                                                                 Page 188
NATIONAL COVERAGE DETERMINATION                                                            84702

642.33   Transient hypertension of pregnancy, antepartum condition or complication
642.34   Transient hypertension of pregnancy, postpartum condition or complication
642.40   Mild or unspecified pre-eclampsia, unspecified as to episode of care or not applicable
642.41   Mild or unspecified pre-eclampsia, delivered, with or without antepartum condition
642.42   Mild or unspecified pre-eclampsia, delivered, with postpartum complication
642.43   Mild or unspecified pre-eclampsia, antepartum condition or complication
642.44   Mild or unspecified pre-eclampsia, postpartum condition or complication
642.50   Severe pre-eclampsia, unspecified as to episode of care or not applicable
642.51   Severe pre-eclampsia, delivered, with or without antepartum condition
642.52   Severe pre-eclampsia, delivered, with postpartum complication
642.53   Severe pre-eclampsia, antepartum condition or complication
642.54   Severe pre-eclampsia, postpartum condition or complication
642.60   Eclampsia, unspecified as to episode of care or not applicable
642.61   Eclampsia, delivered, with or without antepartum condition
642.62   Eclampsia, delivered, with postpartum complication
642.63   Eclampsia, antepartum condition or complication
642.64   Eclampsia, postpartum condition or complication
642.70   Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, unspecified as
         to episode of care or not applicable
642.71   Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, delivered, with
         or without antepartum condition
642.72   Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, delivered, with
         postpartum complication
642.73   Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, antepartum
         condition or complication
642.74   Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, postpartum
         condition or complication
642.90   Unspecified hypertension complicating pregnancy, childbirth, or the puerperium,
         unspecified as to episode of care or not applicable
642.91   Unspecified hypertension complicating pregnancy, childbirth, or the puerperium,
         delivered, with or without antepartum condition
642.92   Unspecified hypertension complicating pregnancy, childbirth, or the puerperium,
         delivered, with postpartum complication
642.93   Unspecified hypertension complicating pregnancy, childbirth, or the puerperium,
         antepartum condition or complication
642.94   Unspecified hypertension complicating pregnancy, childbirth, or the puerperium,
         postpartum condition or complication
795.89   Other abnormal tumor markers
V10.09   Personal history of malignant neoplasm, other
V10.29   Personal history of malignant neoplasm, other respiratory organ
V10.43   Personal history of malignant neoplasm, ovary
V10.47   Personal history of malignant neoplasm, testis
V22.0    Supervision of normal first pregnancy
V22.1    Supervision of other normal pregnancy




                                                                                        Page 189
NATIONAL COVERAGE DETERMINATION                                                                     Complete Blood Count


NATIONAL COVERAGE DETERMINATION
Complete Blood Count
85004, 85007, 85008, 85013, 85014, 85018, 85025, 85027, 85032, 85048, 85049 -Complete Blood Count




CPT CODE: 85004, 85007, 85008, 85013, 85014, 85018, 85025, 85027, 85032, 85048, 85049



CPT CODE DESCRIPTOR:

                                             85004 Blood count; automated differential WBC count

                                          85007 Blood count; manual differential WBC count (includes RBC morphology and
                                          platelet estimation)

                                          85008 Blood count; manual blood smear examination without differential
                                          parameters

                                             85013 Blood count; spun microhematocrit

                                             85014 Blood count; other than spun hematocrit

                                             85018 Blood count; hemoglobin

                                           85025 Blood count; hemogram and platelet count, automated, and automated
                                          complete differential WBC count (CBC)

                                             85027 Blood count; hemogram and platelet count, automated

                                             85032 Blood count; manual cell count, each

                                             85048 Blood count; white blood cell (WBC)

                                             85049 Blood count; platelet, automated




NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS: None

The following ICD-9 diagnosis codes are NOT COVERED for complete
blood counts and related procedures. Use of any of the ICD-9 codes listed
below will result in denial of the claim.

COVERED ICD-9 CODES:
078.10 Viral warts, unspecified
078.11 Condyloma acuminatum
078.19 Other specified viral warts
210.0 Benign neoplasm of lip
210.1 Benign neoplasm of tongue
210.2 Benign neoplasm of major salivary glands
210.3 Benign neoplasm of floor of mouth
210.4 Benign neoplasm of other and unspecified parts of mouth
210.5 Benign neoplasm of tonsil
210.6 Benign neoplasm of other parts of oropharynx
210.7 Benign neoplasm of nasopharynx

                                                                                                                   Page 190
NATIONAL COVERAGE DETERMINATION                                             Complete Blood Count

210.8    Benign neoplasm of hypopharynx
210.9    Benign neoplasm of pharynx, unspecified
214.0    Lipoma, skin and subcutaneous tissue of face
216.0    Benign neoplasm of skin of lip
216.1    Benign neoplasm of eyelid, including canthus
216.2    Benign neoplasm of Ear and external auditory canal
216.3    Benign neoplasm of skin of other and unspecified parts of face
216.4    Benign neoplasm of scalp and skin of neck
216.5    Benign neoplasm of skin of trunk, except scrotum
216.6    Benign neoplasm of skin of upper limb, including shoulder
216.7    Benign neoplasm of skin of lower limb, including hip
216.8    Benign neoplasm of other specified sites of skin
216.9    Benign neoplasm of skin, site unspecified
217      Benign neoplasm of breast
222.0    Benign neoplasm of testis
222.1    Benign neoplasm of penis
222.2    Benign neoplasm of prostate
222.3    Benign neoplasm of epididymis
222.4    Benign neoplasm of scrotum
222.8    Benign neoplasm of other specified sites of male genital organs
222.9    Benign neoplasm of male genital organ, site unspecified
224.0    Benign neoplasm of eyeball, except conjunctiva, cornea,
230.0    Carcinoma in situ of lip, oral cavity, and pharynx
232.0    Carcinoma in situ of skin of lip
232.1    Carcinoma in situ of eyelid, including canthus
232.2    Carcinoma in situ of ear and external auditory canal
232.3    Carcinoma in situ of skin of other and unspecified parts of face
232.4    Carcinoma in situ of scalp and skin of neck
232.5    Carcinoma in situ of skin of trunk, except scrotum
232.6    Carcinoma in situ of skin of upper limb, including shoulder
232.7    Carcinoma in situ of skin of lower limb, including hip
232.8    Carcinoma in situ of other specified sites of skin
232.9    Carcinoma in situ of skin, site unspecified
300.00   Anxiety state, unspecified
300.01   Panic disorder without agoraphobia
300.02   Generalized anxiety disorder
300.09   Other anxiety, dissociative and somatoform disorders
301.0    Paranoid personality disorder
301.10   Affective personality disorder, unspecified
301.11   Chronic hypomanic personality disorder
301.12   Chronic depressive personality disorder
301.13   Cyclothymic disorder
301.20   Schizoid personality disorder, unspecified
301.21   Introverted personality
301.22   Schizotypal personality disorder
301.3    Explosive personality disorder
301.4    Obsessive-compulsive personality disorder
301.50   Histrionic personality disorder, unspecified
301.51   Chronic factitious illness with physical symptoms
301.59   Other histrionic personality disorder
301.6    Dependent personality disorder
301.7    Antisocial personality disorder
301.81   Narcissistic personality disorder



                                                                                        Page 191
NATIONAL COVERAGE DETERMINATION                                        Complete Blood Count

301.82   Avoidant personality disorder
301.83   Borderline personality disorder
301.84   Passive-aggressive personality
301.89   Other personality disorders
301.9    Unspecified personality disorder
302.0    Ego-dystonic sexual orientation
302.1    Zoophilia
302.2    Pedophilia
302.3    Transvestic fetishism
302.4    Exhibitionism
302.50   Trans-sexualism with unspecified sexual history
302.51   Trans-sexualism with asexual history
302.52   Trans-sexualism with homosexual history
302.53   Trans-sexualism with heterosexual history
302.6    Gender identity disorder in children
302.70   Psychosexual dysfunction, unspecified
302.71   Hypoactive sexual desire disorder
302.72   Psychosexual dysfunction with inhibited sexual excitement
302.73   Female orgasmic disorder
302.74   Male orgasmic disorder
302.75   Premature ejaculation
302.76   Dyspareunia, psychogenic
302.79   Psychosexual dysfunction, with other specified psychosexual dysfunctions
302.81   Fetishism
302.82   Voyeurism
302.83   Sexual masochism
302.84   Sexual sadism
302.85   Gender identity disorder in adolescents or adults
302.89   Other specified psychosexual disorder
302.9    Unspecified psychosexual disorder
307.0    Stuttering
307.20   Tic disorder, unspecified
307.21   Transient tic disorder
307.22   Chronic motor or vocal tic disorder
307.23   Tourette's disorder
307.3    Stereotypic movement disorder
307.80   Psychogenic pain, site unspecified
307.81   Tension headache
307.89   Pain disorders related to psychological factors, other
312.00   Undersocialized conduct disorder, aggressive type, unspecified
312.01   Undersocialized conduct disorder, aggressive type, mild
312.02   Undersocialized conduct disorder, aggressive type, moderate
312.03   Undersocialized conduct disorder, aggressive type severe
312.10   Undersocialized conduct disorder, unaggressive type, unspecified
312.11   Undersocialized conduct disorder, unaggressive type, mild,
312.12   Undersocialized conduct disorder, unaggressive type, moderate
312.13   Undersocialized conduct disorder, unaggressive type, severe
312.20   Socialized conduct disorder, unspecified
312.21   Socialized conduct disorder, mild
312.22   Socialized conduct disorder, moderate
312.23   Socialized conduct disorder, severe
312.30   Impulse control disorder, unspecified
312.31   Pathological gambling



                                                                                    Page 192
NATIONAL COVERAGE DETERMINATION                                         Complete Blood Count

312.32   Kleptomania
312.33   Pyromania
312.34   Intermittent explosive disorder
312.35   Isolated explosive disorder
312.39   Other social disorder
312.4    Mixed disturbance of conduct and emotions
312.81   Conduct disorder, childhood onset type
312.82   Conduct disorder, adolescent onset type
312.89   Other conduct disorder
312.9    Unspecified disturbance of conduct
313.0    Overanxious disorder
313.1    Misery and unhappiness disorder
313.21   Shyness disorder of childhood
313.22   Introverted disorder of childhood
313.23   Selective mutism
313.3    Relationship problems
313.81   Oppositional defiant disorder
313.82   Emotional disturbances of childhood or adolescence, identity disorder
313.83   Academic underachievement disorder
313.89   Other or mixed emotional disturbances of childhood or adolescence
313.9    Unspecified emotional disturbance of childhood or adolescence
314.00   Attention deficit disorder without mention of hyperactivity
314.01   Attention deficit disorder with hyperactivity
314.1    Hyperkinesis with developmental delay
314.2    Hyperkinetic conduct disorder
314.8    Other specified manifestations of hyperkinetic syndrome
314.9    Unspecified hyperkinetic syndrome
338.0    Central pain syndrome
338.11   Acute pain due to trauma
338.12   Acute post-thoracotomy pain
338.18   Other acute postoperative pain
338.19   Other acute pain
338.21   Chronic pain due to trauma
338.22   Chronic post-thoracotomy pain
338.28   Other chronic postoperative pain
338.29   Other chronic pain
338.4    Chronic pain syndrome
363.30   Chorioretinal scar, unspecified
363.31   Solar retinopathy
363.32   Other macular scars
363.33   Other scars of posterior pole
363.34   Peripheral scars
363.35   Disseminated scars
363.40   Choroidal degeneration, unspecified
363.41   Senile atrophy of choroid
363.42   Diffuse secondary atrophy of choroid
363.43   Angioid streaks of choroid
363.50   Hereditary choroidal dystrophy or atrophy, unspecified
363.51   Circumpapillary dystrophy of choroid, partial
363.52   Circumpapillary dystrophy of choroid, total
363.53   Central dystrophy of choroid, partial
363.54   Central choroidal atrophy, total
363.55   Choroideremia



                                                                                    Page 193
NATIONAL COVERAGE DETERMINATION                                             Complete Blood Count

363.56   Other diffuse or generalized dystrophy, partial
363.57   Other diffuse or generalized dystrophy, total
363.70   Choroidal detachment, unspecified
363.71   Serous choroidal detachment
363.72   Hemorrhagic choroidal detachment
363.8    Other disorders of choroid
363.9    Unspecified disorder of choroid
366.00   Nonsenile cataract, unspecified
366.01   Anterior subcapsular polar cataract
366.02   Posterior subcapsular polar cataract
366.03   Cortical, lamellar, or zonular cataract
366.04   Nuclear cataract
366.09   Other and combined forms of nonsenile cataract
366.10   Senile cataract, unspecified
366.11   Pseudoexfoliation of lens capsule
366.12   Incipient cataract
366.13   Anterior subcapsular polar senile cataract
366.14   Posterior subcapsular polar senile cataract
366.15   Cortical senile cataract
366.16   Nuclear sclerosis
366.17   Total or mature cataract
366.18   Hypermature cataract
366.19   Other and combined forms of senile cataract
366.20   Traumatic cataract, unspecified
366.21   Localized traumatic opacities
366.22   Total traumatic cataract
366.23   Partially resolved traumatic cataract
366.30   Cataracta complicata, unspecified
366.31   Glaucomatous flecks (subcapsular)
366.32   Cataract in inflammatory disorders
366.33   Cataract with neovascularization
366.34   Cataract in degenerative disorders
366.41   Diabetic cataract
366.42   Tetanic cataract
366.43   Myotonic cataract
366.44   Cataract associated with other syndromes
366.45   Toxic cataract
366.46   Cataract associated with radiation and other physical influences
366.50   After-cataract, unspecified
366.51   Soemmering's ring
366.52   Other after-cataract, not obscuring vision
366.53   After-cataract, obscuring vision
366.8    Other cataract
366.9    Unspecified cataract
367.0    Hypermetropia
367.1    Myopia
367.20   Astigmatism, unspecified
367.21   Regular astigmatism
367.22   Irregular astigmatism
367.31   Anisometropia
367.32   Aniseikonia
367.4    Presbyopia
367.51   Paresis of accommodation



                                                                                        Page 194
NATIONAL COVERAGE DETERMINATION                                 Complete Blood Count

367.52   Total or complete internal ophthalmoplegia
367.53   Spasm of accommodation
367.81   Transient refractive change
367.89   Other refractive change
367.9    Unspecified disorder of refraction and accommodation
371.00   Corneal opacity, unspecified
371.01   Minor opacity of cornea
371.02   Peripheral opacity of cornea
371.03   Central opacity of cornea
371.04   Adherent leucoma
371.05   Phthisical cornea
371.10   Corneal deposit, unspecified
371.11   Anterior pigmentations
371.12   Stromal pigmentations
371.13   Posterior pigmentations
371.14   Kayser-Fleischer ring
371.15   Other deposits associated with metabolic disorders
371.16   Argentous deposits
371.20   Corneal edema, unspecified
371.21   Idiopathic corneal edema
371.22   Secondary corneal edema
371.23   Bullous keratopathy
371.24   Corneal edema due to wearing of contact lenses
371.30   Corneal membrane change, unspecified
371.31   Folds and rupture of Bowman's membrane
371.32   Folds in Descemet's membrane
371.33   Rupture in Descemet's membrane
371.40   Corneal degeneration, unspecified
371.41   Senile corneal changes
371.42   Recurrent erosion of cornea
371.43   Band-shaped keratopathy
371.44   Other calcerous degenerations of cornea
371.45   Keratomalacia not otherwise specified
371.46   Nodular degeneration of cornea
371.48   Peripheral degenerations of cornea
371.49   Other degeneration of cornea
371.50   Corneal dystrophy, unspecified
371.51   Juvenile epithelial corneal dystrophy
371.52   Other anterior corneal dystrophies
371.53   Granular corneal dystrophy
371.54   Lattice corneal dystrophy
371.55   Macular corneal dystrophy
371.56   Other stromal corneal dystrophies
371.57   Endothelial corneal dystrophy
371.58   Other posterior corneal dystrophies
371.60   Keratoconus, unspecified
371.61   Keratoconus, stable condition
371.62   Keratoconus, acute hydrops
371.70   Corneal deformity, unspecified
371.71   Corneal ectasia
371.72   Descemetocele
371.73   Corneal staphyloma
371.81   Corneal anesthesia and hypoesthesia



                                                                            Page 195
NATIONAL COVERAGE DETERMINATION                                           Complete Blood Count

371.82   Corneal disorder due to contact lens
371.89   Other Corneal disorder
371.9    Unspecified corneal disorder
373.00   Blepharitis, unspecified
373.01   Ulcerative blepharitis
373.02   Squamous blepharitis
373.11   Hordeolum externum
373.12   Hordeolum internum
373.13   Abscess of eyelid
373.2    Chalazion
373.31   Eczematous dermatitis of eyelid
373.32   Contact and allergic dermatitis of eyelid
373.33   Xeroderma of eyelid
373.34   Discoid lupus erythematosus of eyelid
373.4    Infective dermatitis of eyelid of types resulting in deformity
373.5    Other infective dermatitis of eyelid
373.6    Parasitic infestation of eyelid
373.8    Other inflammations of eyelids
373.9    Unspecified inflammation of eyelid
375.00   Dacryoadenitis, unspecified
375.01   Acute dacryoadenitis
375.02   Chronic dacryoadenitis
375.03   Chronic enlargement of lacrimal gland
375.11   Dacryops
375.12   Other lacrimal cysts and cystic degeneration
375.13   Primary lacrimal atrophy
375.14   Secondary lacrimal atrophy
375.15   Tear film insufficiency, unspecified
375.16   Dislocation of lacrimal gland
375.20   Epiphora, unspecified as to cause
375.21   Epiphora due to excess lacrimation
375.22   Epiphora due to insufficient drainage
375.30   Dacryocystitis, unspecified
375.31   Acute canaliculitis, lacrimal
375.32   Acute dacryocystitis
375.33   Phlegmonous dacryocystitis
375.41   Chronic canaliculitis
375.42   Chronic dacryocystitis
375.43   Lacrimal mucocele
375.51   Eversion of lacrimal punctum
375.52   Stenosis of lacrimal punctum
375.53   Stenosis of lacrimal canaliculi
375.54   Stenosis of lacrimal sac
375.55   Obstruction of nasolacrimal duct, neonatal
375.56   Stenosis of nasolacrimal duct, acquired
375.57   Dacryolith
375.61   Lacrimal fistula
375.69   Other changes of lacrimal passages
375.81   Granuloma of lacrimal passages
375.89   Other disorders of lacrimal system
375.9    Unspecified disorder of lacrimal system
376.21   Thyrotoxic exophthalmos
376.22   Exophthalmic ophthalmoplegia



                                                                                      Page 196
NATIONAL COVERAGE DETERMINATION                                      Complete Blood Count

376.30   Exophthalmos, unspecified
376.31   Constant exophthalmos
376.32   Orbital hemorrhage
376.33   Orbital edema or congestion
376.34   Intermittent exophthalmos
376.35   Pulsating exophthalmos
376.36   Lateral displacement of globe
376.40   Deformity of orbit, unspecified
376.41   Hypertelorism of orbit
376.42   Exostosis of orbit
376.43   Local deformities of orbit, due to bone disease
376.44   Orbital deformities associated with craniofacial deformities
376.45   Atrophy of orbit
376.46   Enlargement of orbit
376.47   Deformity of orbit, due to trauma or surgery
376.50   Enophthalmos, unspecified as to cause
376.51   Enophthalmos due to atrophy of orbital tissue
376.52   Enophthalmos due to trauma or surgery
376.6    Retained (old) foreign body following penetrating wound of orbit
376.81   Orbital cysts
376.82   Myopathy of extraocular muscles
376.89   Other disorder of orbit
376.9    Unspecified disorder of orbit
377.10   Optic atrophy, unspecified
377.11   Primary optic atrophy
377.12   Postinflammatory optic atrophy
377.13   Optic atrophy associated with retinal dystrophies
377.14   Glaucomatous atrophy [cupping] of optic disc
377.15   Partial optic atrophy
377.16   Hereditary optic atrophy
377.21   Drusen of optic disc
377.22   Crater-like holes of optic disc
377.23   Coloboma of optic disc
377.24   Pseudopapilledema
384.20   Perforation of tympanic membrane, unspecified
384.21   Central perforation of tympanic membrane
384.22   Attic perforation of tympanic membrane
384.23   Other marginal perforation of tympanic membrane
384.24   Multiple perforations of tympanic membrane
384.25   Total perforation of tympanic membrane
384.81   Atrophic flaccid tympanic membrane
384.82   Atrophic nonflaccid tympanic membrane
385.00   Tympanosclerosis, unspecified as to involvement
385.01   Tympanosclerosis involving tympanic membrane only
385.02   Tympanosclerosis involving tympanic membrane and ear ossicles
385.03   Tympanosclerosis involving tympanic membrane, ear ossicles, and middle ear
385.09   Tympanosclerosis involving other combination of structures
385.10   Adhesive middle ear disease, unspecified as to involvement
385.11   Adhesions of drum head to incus
385.12   Adhesions of drum head to stapes
385.13   Adhesions of drum head to promontorium
385.19   Other adhesions and combinations
385.21   Impaired mobility of malleus



                                                                                      Page 197
NATIONAL COVERAGE DETERMINATION                                Complete Blood Count

385.22   Impaired mobility of other ear ossicles
385.23   Discontinuity or dislocation of ear ossicles
385.24   Partial loss or necrosis of ear ossicles
385.30   Cholesteatoma, unspecified
385.31   Cholesteatoma of attic
385.32   Cholesteatoma of middle ear
385.33   Cholesteatoma of middle ear and mastoid
385.35   Diffuse cholesteatosis
385.82   Cholesterin granuloma
385.83   Retained foreign body of middle ear
385.89   Other disorder of middle ear and mastoid
385.9    Unspecified disorder of middle ear and mastoid
387.0    Otosclerosis involving oval window, nonobliterative
387.1    Otosclerosis involving oval window, obliterative
387.2    Cochlear otosclerosis
387.8    Other otosclerosis
387.9    Otosclerosis, unspecified
388.00   Degenerative and vascular disorders, unspecified
388.01   Presbyacusis
388.02   Transient ischemic deafness
388.10   Noise effects on inner ear, unspecified
388.11   Acoustic trauma (explosive) to ear
388.12   Noise-induced hearing loss
388.2    Sudden hearing loss, unspecified
388.30   Tinnitus, unspecified
388.31   Subjective tinnitus
388.32   Objective tinnitus
388.40   Abnormal auditory perception, unspecified
388.41   Diplacusis
388.42   Hyperacusis
388.43   Impairment of auditory discrimination
388.44   Recruitment
388.45   Acquired auditory processing disorder
388.5    Disorders of acoustic nerve
389.00   Conductive hearing loss, unspecified
389.01   Conductive hearing loss, external ear
389.02   Conductive hearing loss, tympanic membrane
389.03   Conductive hearing loss, middle ear
389.04   Conductive hearing loss, inner ear
389.08   Conductive hearing loss of combined types
389.10   Sensorineural hearing loss, unspecified
389.11   Sensory hearing loss, bilateral
389.12   Neural hearing loss, bilateral
389.14   Central hearing loss
389.15   Sensorineural hearing loss, unilateral
389.16   Sensorineural hearing loss, asymmetrical
389.18   Sensorineural hearing loss, bilateral
389.20   Mixed hearing loss, unspecified
389.21   Mixed hearing loss, unilateral
389.22   Mixed hearing loss, bilateral
389.7    Deaf, nonspeaking, not elsewhere classifiable
389.8    Other specified forms of hearing loss
389.9    Unspecified hearing loss



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NATIONAL COVERAGE DETERMINATION                                            Complete Blood Count

440.0    Atherosclerosis of aorta
440.1    Atherosclerosis of renal artery
443.81   Peripheral angiopathy in diseases classified elsewhere
443.82   Erythromelalgia
443.89   Other peripheral angiopathy
443.9    Peripheral vascular disease, unspecified
448.1    Nevus, non-neoplastic
457.0    Postmastectomy lymphedema syndrome
470      Deviated nasal septum
471.0    Polyp of nasal cavity
471.1    Polypoid sinus degeneration
471.8    Other polyp of sinus
471.9    Unspecified nasal polyp
478.0    Hypertrophy of nasal turbinates
478.11   Nasal mucositis (ulcerative)
478.19   Other disease of nasal cavity and sinuses
478.4    Polyp of vocal cord or larynx
520.0    Anodontia
520.1    Supernumerary teeth
520.2    Abnormalities of size and form of teeth
520.3    Mottled teeth
520.4    Disturbances of tooth formation
520.5    Hereditary disturbances in tooth structure, not elsewhere classified
520.6    Disturbances in tooth eruption
520.7    Teething syndrome
520.8    Other specified disorders of tooth development and eruption
520.9    Unspecified disorder of tooth development and eruption
521.00   Dental caries, unspecified
521.01   Dental caries limited to enamel
521.02   Dental caries extending into dentine
521.03   Dental caries extending into pulp
521.04   Arrested dental caries
521.05   Odontoclasia
521.06   Dental caries pit and fissure
521.07   Dental caries of smooth surface
521.08   Dental caries of root surface
521.09   Other dental caries
521.10   Diseases of hard tissue of teeth, excessive attrition, unspecified
521.11   Diseases of hard tissue of teeth, excessive attrition, limited to enamel
521.12   Diseases of hard tissue of teeth, excessive attrition, extending into dentine
521.13   Diseases of hard tissue of teeth, excessive attrition, extending into pulp
521.14   Diseases of hard tissue of teeth, excessive attrition, localized
521.15   Diseases of hard tissue of teeth, excessive attrition, generalized
521.20   Diseases of hard tissue of teeth, abrasion, unspecified
521.21   Diseases of hard tissue of teeth, abrasion, limited to enamel
521.22   Diseases of hard tissue of teeth, abrasion, extending into dentine
521.23   Diseases of hard tissue of teeth, abrasion, extending into pulp
521.24   Diseases of hard tissue of teeth, abrasion, localized
521.25   Diseases of hard tissue of teeth, abrasion, generalized
521.30   Diseases of hard tissue of teeth, erosion, unspecified
521.31   Diseases of hard tissue of teeth, erosion, limited to enamel
521.32   Diseases of hard tissue of teeth, erosion, extending into dentine
521.33   Diseases of hard tissue of teeth, erosion, extending into pulp



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NATIONAL COVERAGE DETERMINATION                                           Complete Blood Count

521.34   Diseases of hard tissue of teeth, erosion, localized
521.35   Diseases of hard tissue of teeth, erosion, generalized
521.40   Diseases of hard tissue of teeth, pathological resorption, unspecified
521.41   Diseases of hard tissue of teeth, pathological resorption, internal
521.42   Diseases of hard tissue of teeth, pathological resorption, external
521.49   Diseases of hard tissue of teeth, pathological resorption, other
521.5    Hypercementosis
521.6    Ankylosis of teeth
521.7    Intrinsic posteruptive color changes
521.81   Cracked tooth
521.89   Other specific diseases of hard tissues of teeth
521.9    Unspecified disease of hard tissues of teeth
524.00   Unspecified anomaly of jaw
524.01   Maxillary hyperplasia
524.02   Mandibular hyperplasia
524.03   Maxillary hypoplasia
524.04   Mandibular hypoplasia
524.05   Macrogenia
524.06   Microgenia
524.07   Excessive tuberosity of jaw
524.09   Other specified anomaly of jaw
524.10   Unspecified anomaly of relationship of jaw to cranial base
524.11   Maxillary asymmetry
524.12   Other jaw asymmetry
524.19   Other specified anomaly
524.20   Unspecified anomaly of dental arch relationship
524.21   Malocclusion, Angle's class I
524.22   Malocclusion, Angle's class II
524.23   Malocclusion, Angle's class III
524.24   Anomalies of dental arch relationship, open anterior occlusal relationship
524.25   Anomalies of dental arch relationship, open posterior occlusal relationship
524.26   Anomalies of dental arch relationship, excessive horizontal overlap
524.27   Anomalies of dental arch relationship, reverse articulation
524.28   Anomalies of interarch distance
524.29   Anomalies of dental arch relationship, other
524.30   Unspecified anomaly of tooth position
524.31   Crowding of teeth
524.32   Excessive spacing of teeth
524.33   Horizontal displacement of teeth
524.34   Vertical displacement of teeth
524.35   Rotation of tooth/teeth
524.36   Insufficient interocclusal distance of teeth (ridge)
524.37   Excessive interocclusal distance of teeth
524.39   Other anomalies of tooth position
524.4    Malocclusion, unspecified
524.50   Dentofacial functional abnormality, unspecified
524.51   Abnormal jaw closure
524.52   Limited mandibular range of motion
524.53   Deviation in opening and closing of the mandible
524.54   Insufficient anterior guidance
524.55   Centric occlusion maximum intercuspation discrepancy
524.56   Non-working side interference
524.57   Lack of posterior occlusal support



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NATIONAL COVERAGE DETERMINATION                                             Complete Blood Count

524.59   Other dentofacial functional abnormalties
524.60   Temporomandibular joint disorders, unspecified
524.61   Temporomandibular joint adhesions and ankylosis (bony or fibrous)
524.62   Arthralgia of temporomandibular joint
524.63   Articular disc disorder (reducing or nonreducing)
524.64   Temporomandibular joint sounds on opening and/or closing the jaw
524.69   Other specified temporomandibular joint disorders
524.70   Unspecified alveolar anomaly
524.71   Alveolar maxillary hyperplasia
524.72   Alveolar mandibular hyperplasia
524.73   Alveolar maxillary hypoplasia
524.74   Alveolar mandibular hypoplasia
524.75   Vertical displacement of alveolus and teeth
524.76   Occlusal plane deviation
524.79   Other specified alveolar anomaly
524.81   Other specified dentofacial anomalies, anterior soft tissue impingement
524.82   Other specified dentofacial anomalies, posterior soft tissue impingement
524.89   Other specified dentofacial anomalies
524.9    Unspecified dentofacial anomalies
525.0    Exfoliation of teeth due to systemic causes
525.10   Acquired absence of teeth, unspecified
525.11   Loss of teeth due to trauma
525.12   Loss of teeth due to periodontal disease
525.13   Loss of teeth due to caries
525.19   Other loss of teeth
525.20   Unspecified atrophy of edentulous alveolar ridge
525.21   Minimal atrophy of the mandible
525.22   Moderate atrophy of the mandible
525.23   Severe atrophy of the mandible
525.24   Minimal atrophy of the maxilla
525.25   Moderate atrophy of the maxilla
525.26   Severe atrophy of the maxilla
525.3    Retained dental root
525.40   Complete edentulism, unspecified
525.41   Complete edentulism, class I
525.42   Complete edentulism, class II
525.43   Complete edentulism, class III
525.44   Complete edentulism, class IV
525.50   Partial edentulism, unspecified
525.51   Partial edentulism, class I
525.52   Partial edentulism, class II
525.53   Partial edentulism, class III
525.54   Partial edentulism, class IV
525.60   Unspecified unsatisfactory restoration of tooth
525.61   Open restoration margins
525.62   Unrepairable overhanging of dental restorative materials
525.63   Fractured dental restorative material without loss of material
525.64   Fractured dental restorative material with loss of material
525.65   Contour of existing restoration of tooth biologically incompatible with oral health
525.66   Allergy to existing dental restorative material
525.67   Poor aesthetics of existing restoration
525.69   Other unsatisfactory restoration of existing tooth
525.8    Other specified disorders of the teeth and supporting structures



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NATIONAL COVERAGE DETERMINATION                                            Complete Blood Count

525.9    Unspecified disorder of the teeth and supporting structures
526.0    Developmental odontogenic cysts
526.1    Fissural cysts of jaw
526.2    Other cysts of jaws
526.3    Central giant cell (reparative) granuloma
526.61   Perforation of root canal space
526.62   Endodontic overfill
526.63   Endodontic underfill
526.69   Other periradicular pathology associated with previous endodontic treatment
527.6    Mucocele of salivary glands
527.7    Disturbance of salivary secretion
527.8    Other specified diseases of the salivary glands
527.9    Unspecified disease of the salivary glands
575.6    Cholesterolosis of gallbladder
600.00   Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract
         symptoms (LUTS)
600.01   Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract
         symptoms (LUTS)
600.10   Nodular prostate without urinary obstruction
600.11   Nodular prostate with urinary obstruction
600.20   Benign localized hyperplasia of prostate without urinary obstruction and other lower
         urinary tract symptoms (LUTS)
600.21   Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary
         tract symptoms (LUTS)
600.3    Cyst of prostate
600.90   Hyperplasia of prostate, unspecified, without urinary obstruction and other lower urinary
         tract symptoms (LUTS)
600.91   Hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary tract
         symptoms (LUTS)
603.0    Encysted hydrocele
603.8    Other specified types of hydrocele
603.9    Hydrocele, unspecified
605      Redundant prepuce and phimosis
606.0    Azoospermia
606.1    Oligospermia
608.1    Spermatocele
608.20   Torsion of testis, unspecified
608.21   Extravaginal torsion of spermatic cord
608.22   Intravaginal torsion of spermatic cord
608.23   Torsion of appendix testis
608.24   Torsion of appendix epididymis
608.3    Atrophy of testis
610.0    Solitary cyst of breast
610.1    Diffuse cystic mastopathy
610.2    Fibroadenosis of breast
610.3    Fibrosclerosis of breast
610.4    Mammary duct ectasia
610.8    Other specified benign mammary dysplasias
610.9    Benign mammary dysplasia, unspecified
611.1    Hypertrophy of breast
611.2    Fissure of nipple
611.3    Fat necrosis of breast
611.4    Atrophy of breast



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NATIONAL COVERAGE DETERMINATION                                          Complete Blood Count

611.5    Galactocele
611.6    Galactorrhea not associated with childbirth
611.9    Unspecified breast disorder
616.2    Cyst of Bartholin's gland
618.00   Prolapse of vaginal walls without mention of uterine prolapse, unspecified
618.01   Prolapse of vaginal walls without mention of uterine prolapse, cystocele, midline
618.02   Prolapse of vaginal walls without mention of uterine prolapse, cystocele, lateral
618.03   Prolapse of vaginal walls without mention of uterine prolapse, urethrocele
618.04   Prolapse of vaginal walls without mention of uterine prolapse, rectocele
618.05   Prolapse of vaginal walls without mention of uterine prolapse, perineocele
618.09   Other prolapse of vaginal walls without mention of uterine prolapse
618.1    Uterine prolapse without vaginal wall prolapse
618.2    Uterovaginal prolapse, incomplete
618.3    Uterovaginal prolapse, complete
618.4    Uterovaginal prolapse, unspecified
618.5    Prolapse of vaginal vault after hysterectomy
618.6    Vaginal enterocele, congenital or acquired
618.7    Old laceration of muscles of pelvic floor
618.81   Incompetence or weakening of pubocervical tissue
618.82   Incompetence or weakening of rectovaginal tissue
618.83   Pelvic muscle wasting
618.84   Cervical stump prolapse
618.89   Other specified genital prolapse
618.9    Unspecified genital prolapse
620.0    Follicular cyst of ovary
620.1    Corpus luteum cyst or hematoma
620.2    Other and unspecified ovarian cyst
620.3    Acquired atrophy of ovary and fallopian tube
621.6    Malposition of uterus
621.7    Chronic inversion of uterus
627.2    Menopausal or female climacteric states
627.3    Postmenopausal atrophic vaginitis
627.4    States associated with artificial menopause
627.8    Other specified menopausal and postmenopausal disorders
627.9    Unspecified menopausal and postmenopausal ydisorder
628.0    Infertility, female, associated with anovulation
628.1    Infertility, female, of pituitary-hypothalamic origin
628.2    Infertility, female, of tubal origin
628.3    Infertility, female, of uterine origin
628.4    Infertility, female, of cervical or vaginal origin
628.8    Infertility, female, of other specified origin
628.9    Infertility, female, of unspecified origin
676.00   Retracted nipple associated with childbirth, unspecified episode of care
676.01   Retracted nipple associated with childbirth, delivered, with or without antepartum
         condition
676.02   Retracted nipple associated with childbirth, delivered, with postpartum complication
676.03   Retracted nipple associated with childbirth, antepartum condition or complication
676.04   Retracted nipple associated with childbirth, postpartum condition or complication
676.10   Cracked nipple associated with childbirth, unspecified episode of care
676.11   Cracked nipple associated with childbirth, delivered, with or without antepartum condition
676.12   Cracked nipple associated with childbirth, delivered, with postpartum complication
676.13   Cracked nipple associated with childbirth, antepartum condition or complication
676.14   Cracked nipple associated with childbirth, postpartum condition or complication



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NATIONAL COVERAGE DETERMINATION                                          Complete Blood Count

676.20   Engorgement of breasts, unspecified episode of care
676.21   Engorgement of breasts, delivered, with or without antepartum condition
676.22   Engorgement of breasts, delivered, with postpartum complication
676.23   Engorgement of breasts, antepartum condition or complication
676.24   Engorgement of breasts, postpartum condition or complication
676.30   Other and unspecified disorder of breast, unspecified episode of care
676.31   Other and unspecified disorder of breast, delivered, with or without antepartum condition
676.32   Other and unspecified disorder of breast, delivered, with postpartum complication
676.33   Other and unspecified disorder of breast, antepartum condition or complication
676.34   Other and unspecified disorder of breast, postpartum condition or complication
676.40   Failure of lactation, unspecified episode of care
676.41   Failure of lactation, delivered, with or without antepartum condition
676.42   Failure of lactation, delivered, with postpartum complication
676.43   Failure of lactation, antepartum condition or complication
676.44   Failure of lactation, postpartum condition or complication
676.50   Suppressed lactation, unspecified episode of care
676.51   Suppressed lactation, delivered, with or without antepartum condition
676.52   Suppressed lactation, delivered, with postpartum complication
676.53   Suppressed lactation, antepartum condition or complication
676.54   Suppressed lactation, postpartum condition or complication
676.60   Galactorrhea, unspecified episode of care
676.61   Galactorrhea, delivered, with or without antepartum condition
676.62   Galactorrhea, delivered, with postpartum complication
676.63   Galactorrhea, antepartum condition or complication
676.64   Galactorrhea, postpartum condition or complication
676.80   Other disorders of lactation, unspecified episode of care
676.81   Other disorders of lactation, delivered, with or without antepartum condition
676.82   Other disorders of lactation, delivered, with postpartum complication
676.83   Other disorders of lactation, antepartum condition or complication
676.84   Other disorders of lactation, postpartum condition or complication
676.90   Unspecified disorder of lactation, unspecified episode of care
676.91   Unspecified disorder of lactation, delivered, with or without antepartum condition
676.92   Unspecified disorder of lactation, delivered, with postpartum complication
676.93   Unspecified disorder of lactation, antepartum condition or complication
676.94   Unspecified disorder of lactation, postpartum condition or complication
691.0    Diaper rash
691.8    Other atopic dermatitis and related conditions
692.0    Contact dermatitis and other eczema due to detergents
692.1    Contact dermatitis and other eczema due to oils and greases
692.2    Contact dermatitis and other eczema due to solvents
692.3    Contact dermatitis and other eczema due to drugs and medicines in contact with skin
692.4    Contact dermatitis and other eczema due to other chemical products
692.5    Contact dermatitis and other eczema due to food in contact with skin
692.6    Contact dermatitis and other eczema due to plants [except food]
692.70   Unspecified dermatitis due to sun
692.71   Sunburn
692.72   Acute dermatitis due to solar radiation
692.73   Actinic reticuloid and actinic granuloma
692.74   Other chronic dermatitis due to solar radiation
692.75   Disseminated superficial actinic porokeratosis (DSAP)
692.76   Sunburn of second degree
692.77   Sunburn of third degree
692.79   Other dermatitis due to solar radiation



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NATIONAL COVERAGE DETERMINATION                                        Complete Blood Count

692.81   Dermatitis due to cosmetics
692.82   Dermatitis due to other radiation
692.83   Dermatitis due to metals
692.84   Contact dermatitis and other eczema due to animal (cat) (dog) dander
692.89   Other dermatitis
692.9    Contact dermatitis and other eczema, unspecified cause
700      Corns and callosities
701.0    Circumscribed scleroderma
701.1    Keratoderma, acquired
701.2    Acquired acanthosis nigricans
701.3    Striae atrophicae
701.4    Keloid scar
701.5    Other abnormal granulation tissue
701.8    Other specified hypertrophic and atrophic conditions of skin
701.9    Unspecified hypertrophic and atrophic conditions of skin
702.0    Actinic keratosis
702.11   Inflamed seborrheic keratosis
702.19   Other seborrheic keratosis
702.8    Other specified dermatoses
703.9    Unspecified disease of nail
706.0    Acne varioliformis
706.1    Other acne
706.2    Sebaceous cyst
706.3    Seborrhea
706.8    Other specified diseases of sebaceous glands
706.9    Unspecified disease of sebaceous glands
709.00   Dyschromia, unspecified
709.01   Vitiligo
709.09   Other disorders of skin and subcutaneous tissue
709.1    Vascular disorders of skin
709.2    Scar conditions and fibrosis of skin
709.3    Degenerative skin disorders
709.4    Foreign body granuloma of skin and subcutaneous tissue
715.00   Osteoarthrosis, generalized, site unspecified
715.04   Osteoarthrosis, generalized, hand
715.09   Osteoarthrosis, generalized, multiple sites
715.10   Osteoarthrosis, localized, primary, site unspecified
715.11   Osteoarthrosis, localized, primary, shoulder region
715.12   Osteoarthrosis, localized, primary, upper arm
715.13   Osteoarthrosis, localized, primary, forearm
715.14   Osteoarthrosis, localized, primary, hand
715.15   Osteoarthrosis, localized, primary, pelvic region and thigh
715.16   Osteoarthrosis, localized, primary, lower leg
715.17   Osteoarthrosis, localized, primary, ankle and foot
715.18   Osteoarthrosis, localized, primary, other specified sites
715.20   Osteoarthrosis, localized, secondary, site unspecified
715.21   Osteoarthrosis, localized, secondary, shoulder region
715.22   Osteoarthrosis, localized, secondary, upper arm
715.23   Osteoarthrosis, localized, secondary, forearm
715.24   Osteoarthrosis, localized, secondary, hand
715.25   Osteoarthrosis, localized, secondary, pelvic region and thigh
715.26   Osteoarthrosis, localized, secondary, lower leg
715.27   Osteoarthrosis, localized, secondary, ankle and foot



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NATIONAL COVERAGE DETERMINATION                                          Complete Blood Count

715.28   Osteoarthrosis, localized, secondary, other specified sites
715.30   Osteoarthrosis, localized, not specified whether primary or secondary, site unspecified
715.31   Osteoarthrosis, localized, not specified whether primary or secondary, shoulder region
715.32   Osteoarthrosis, localized, not specified whether primary or secondary, upper arm
715.33   Osteoarthrosis, localized, not specified whether primary or secondary, forearm
715.34   Osteoarthrosis, localized, not specified whether primary or secondary, hand
715.35   Osteoarthrosis, localized, not specified whether primary or secondary, pelvic region and
         thigh
715.36   Osteoarthrosis, localized, not specified whether primary or secondary, lower leg
715.37   Osteoarthrosis, localized, not specified whether primary or secondary, ankle and foot
715.38   Osteoarthrosis, localized, not specified whether primary or secondary, other specified
         sites
715.80   Osteoarthrosis involving more than one site, but not specified as generalized, site
         unspecified
715.89   Osteoarthrosis involving more than one site, but not specified as generalized, multiple
         sites
715.90   Osteoarthrosis, unspecified whether generalized, site unspecified
715.91   Osteoarthrosis, unspecified whether generalized, shoulder region
715.92   Osteoarthrosis, unspecified whether generalized, upper arm
715.93   Osteoarthrosis, unspecified whether generalized, forearm
715.94   Osteoarthrosis, unspecified whether generalized, hand
715.95   Osteoarthrosis, unspecified whether generalized, pelvic region and thigh
715.96   Osteoarthrosis, unspecified whether generalized, lower leg
715.97   Osteoarthrosis, unspecified whether generalized, ankle and foot
715.98   Osteoarthrosis, unspecified whether generalized, other specified sites localized
716.00   Kaschin-Beck disease, site unspecified
716.01   Kaschin-Beck disease, shoulder region
716.02   Kaschin-Beck disease, upper arm
716.03   Kaschin-Beck disease, forearm
716.04   Kaschin-Beck disease, hand
716.05   Kaschin-Beck disease, pelvic region and thigh
716.06   Kaschin-Beck disease, lower leg
716.07   Kaschin-Beck disease, ankle and foot
716.08   Kaschin-Beck disease, other specified sites
716.09   Kaschin-Beck disease, multiple sites
716.10   Traumatic arthropathy, site unspecified
716.11   Traumatic arthropathy, shoulder region
716.12   Traumatic arthropathy, upper arm
716.13   Traumatic arthropathy, forearm
716.14   Traumatic arthropathy, hand
716.15   Traumatic arthropathy, pelvic region and thigh
716.16   Traumatic arthropathy, lower leg
716.17   Traumatic arthropathy, ankle and foot
716.18   Traumatic arthropathy, other specified sites
716.19   Traumatic arthropathy, multiple sites
716.20   Allergic arthritis, site unspecified
716.21   Allergic arthritis, shoulder region
716.22   Allergic arthritis, upper arm
716.23   Allergic arthritis, forearm
716.24   Allergic arthritis, hand
716.25   Allergic arthritis, pelvic region and thigh
716.26   Allergic arthritis, lower leg
716.27   Allergic arthritis, ankle and foot



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NATIONAL COVERAGE DETERMINATION                                            Complete Blood Count

716.28   Allergic arthritis, other specified sites
716.29   Allergic arthritis, multiple sites
716.30   Climacteric arthritis, site unspecified
716.31   Climacteric arthritis, shoulder region
716.32   Climacteric arthritis, upper arm
716.33   Climacteric arthritis, forearm
716.34   Climacteric arthritis, hand
716.35   Climacteric arthritis, pelvic region and thigh
716.36   Climacteric arthritis, lower leg
716.37   Climacteric arthritis, ankle and foot
716.38   Climacteric arthritis, other specified sites
716.39   Climacteric arthritis, multiple sites
716.40   Transient arthropathy, site unspecified
716.41   Transient arthropathy, shoulder region
716.42   Transient arthropath,y upper arm
716.43   Transient arthropathy, forearm
716.44   Transient arthropathy, hand
716.45   Transient arthropathy, pelvic region and thigh
716.46   Transient arthropathy, lower leg
716.47   Transient arthropathy, ankle and foot
716.48   Transient arthropathy, other specified sites
716.49   Transient arthropathy, multiple sites
716.50   Unspecified polyarthropathy or polyarthritis, site unspecified
716.51   Unspecified polyarthropathy or polyarthritis, shoulder region
716.52   Unspecified polyarthropathy or polyarthritis, upper arm
716.53   Unspecified polyarthropathy or polyarthritis, forearm
716.54   Unspecified polyarthropathy or polyarthritis, hand
716.55   Unspecified polyarthropathy or polyarthritis, pelvic region and thigh
716.56   Unspecified polyarthropathy or polyarthritis, lower leg
716.57   Unspecified polyarthropathy or polyarthritis, ankle and foot
716.58   Unspecified polyarthropathy or polyarthritis, other specified sites
716.59   Unspecified polyarthropathy or polyarthritis, multiple sites
716.60   Unspecified monoarthritis, site unspecified
716.61   Unspecified monoarthritis, shoulder region
716.62   Unspecified monoarthritis, upper arm
716.63   Unspecified monoarthritis, forearm
716.64   Unspecified monoarthritis, hand
716.65   Unspecified monoarthritis, pelvic region and thigh
716.66   Unspecified monoarthritis, lower leg
716.67   Unspecified monoarthritis, ankle and foot
716.68   Unspecified monoarthritis, other specified sites
716.80   Other specified arthropathy, site unspecified
716.81   Other specified arthropathy, shoulder region
716.82   Other specified arthropathy, upper arm
716.83   Other specified arthropathy, forearm
716.84   Other specified arthropathy, hand
716.85   Other specified arthropathy, pelvic region and thigh
716.86   Other specified arthropathy, lower leg
716.87   Other specified arthropathy, ankle and foot
716.88   Other specified arthropathy, other specified sites
716.89   Other specified arthropathy, multiple sites
716.90   Arthropathy, unspecified, site unspecified
716.91   Arthropathy, unspecified, shoulder region



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NATIONAL COVERAGE DETERMINATION                                    Complete Blood Count

716.92   Arthropathy, unspecified, upper arm
716.93   Arthropathy, unspecified, forearm
716.94   Arthropathy, unspecified, hand
716.95   Arthropathy, unspecified, pelvic region and thigh
716.96   Arthropathy, unspecified, lower leg
716.97   Arthropathy, unspecified, ankle and foot
716.98   Arthropathy, unspecified, other specified sites
716.99   Arthropathy, unspecified, multiple sites
718.00   Articular cartilage disorder, site unspecified
718.01   Articular cartilage disorder, shoulder region
718.02   Articular cartilage disorder, upper arm
718.03   Articular cartilage disorde, forearm
718.04   Articular cartilage disorder, hand
718.05   Articular cartilage disorder, pelvic region and thigh
718.07   Articular cartilage disorder, ankle and foot
718.08   Articular cartilage disorder, other specified sites
718.09   Articular cartilage disorder, multiple sites
718.10   Loose body in joint, site unspecified
718.11   Loose body in joint, shoulder region
718.12   Loose body in joint, upper arm
718.13   Loose body in joint, forearm
718.14   Loose body in joint, hand
718.15   Loose body in joint, pelvic region and thigh
718.17   Loose body in joint, ankle and foot
718.18   Loose body in joint, other specified sites
718.19   Loose body in joint, multiple sites
718.20   Pathological dislocation, site unspecified
718.21   Pathological dislocation, shoulder region
718.22   Pathological dislocation, upper arm
718.23   Pathological dislocation, forearm
718.24   Pathological dislocation, hand
718.25   Pathological dislocation, pelvic region and thigh
718.26   Pathological dislocation, lower leg
718.27   Pathological dislocation, ankle and foot
718.28   Pathological dislocation, other specified sites
718.29   Pathological dislocation, multiple sites
718.30   Recurrent dislocation of joint, site unspecified
718.31   Recurrent dislocation of joint shoulder region
718.32   Recurrent dislocation of joint, upper arm
718.33   Recurrent dislocation of joint, forearm
718.34   Recurrent dislocation of joint, hand
718.35   Recurrent dislocation of joint, pelvic region and thigh
718.36   Recurrent dislocation of joint, lower leg
718.37   Recurrent dislocation of joint, ankle and foot
718.38   Recurrent dislocation of joint, other specified sites
718.39   Recurrent dislocation of joint, multiple sites
718.40   Contracture of joint, site unspecified
718.41   Contracture of joint, shoulder region
718.42   Contracture of joint, upper arm
718.43   Contracture of joint, forearm
718.44   Contracture of joint, hand
718.45   Contracture of joint, pelvic region and thigh
718.46   Contracture of joint, lower leg



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NATIONAL COVERAGE DETERMINATION                                          Complete Blood Count

718.47   Contracture of joint, ankle and foot
718.48   Contracture of joint, other specified sites
718.49   Contracture of joint, multiple sites
718.50   Ankylosis of joint, site unspecified
718.51   Ankylosis of joint, shoulder region
718.52   Ankylosis of joint, upper arm
718.53   Ankylosis of joint, forearm
718.54   Ankylosis of joint, hand
718.55   Ankylosis of joint, pelvic region and thigh
718.56   Ankylosis of joint, lower leg
718.57   Ankylosis of joint, ankle and foot
718.58   Ankylosis of joint, other specified sites
718.59   Ankylosis of joint, multiple sites
718.60   Unspecified intrapelvic protrusion of acetabulum, site unspecified
718.65   Unspecified intrapelvic protrusion of acetabulum, pelvic region and thigh
718.70   Developmental dislocation of joint, site unspecified
718.71   Developmental dislocation of joint, shoulder region
718.72   Developmental dislocation of joint, upper arm
718.73   Developmental dislocation of joint, forearm
718.74   Developmental dislocation of joint, hand
718.75   Developmental dislocation of joint, pelvic region and thigh
718.76   Developmental dislocation of joint, lower leg
718.77   Developmental dislocation of joint, ankle and foot
718.78   Developmental dislocation of joint, other specified sites
718.79   Developmental dislocation of joint, multiple sites
718.80   Other joint derangement, not elsewhere classified, site unspecified
718.81   Other joint derangement, not elsewhere classified, shoulder region
718.82   Other joint derangement, not elsewhere classified, upper arm
718.83   Other joint derangement, not elsewhere classified, forearm
718.84   Other joint derangement, not elsewhere classified, hand
718.85   Other joint derangement, not elsewhere classified, pelvic region and thigh
718.86   Other joint derangement, not elsewhere classified, lower leg
718.87   Other joint derangement, not elsewhere classified, ankle and foot
718.88   Other joint derangement, not elsewhere classified, other specified sites
718.89   Other joint derangement, not elsewhere classified, multiple sites
718.90   Unspecified derangement of joint, site unspecified
718.91   Unspecified derangement of joint, shoulder region
718.92   Unspecified derangement of joint, upper arm
718.93   Unspecified derangement of joint, forearm
718.94   Unspecified derangement of joint, hand
718.95   Unspecified derangement of joint, pelvic region and thigh
718.97   Unspecified derangement of joint, ankle and foot
718.98   Unspecified derangement of joint, other specified sites
718.99   Unspecified derangement of joint, multiple sites
726.0    Adhesive capsulitis of shoulder
726.10   Disorders of bursae and tendons in shoulder region, unspecified
726.11   Calcifying tendinitis of shoulder
726.12   Bicipital tenosynovitis
726.19   Other specified shoulder disorders
726.2    Other affections of shoulder region, not elsewhere classified
726.30   Enthesopathy of elbow, unspecified
726.31   Medial epicondylitis
726.32   Lateral epicondylitis



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NATIONAL COVERAGE DETERMINATION                                         Complete Blood Count

726.33   Olecranon bursitis
726.39   Other elbow epicondylitis
726.4    Enthesopathy of wrist and carpus
726.5    Enthesopathy of hip region
726.60   Enthesopathy of knee, unspecified
726.61   Pes anserinus tendinitis or bursitis
726.62   Tibial collateral ligament bursitis
726.63   Fibular collateral ligament bursitis
726.64   Patellar tendinitis
726.65   Prepatellar bursitis
726.69   Other bursitis
726.70   Enthesopathy of ankle and tarsus, unspecified
726.71   Achilles bursitis or tendinitis
726.72   Tibialis tendinitis
726.73   Calcaneal spur
726.79   Other enthesopathy of ankle and tarsus
726.8    Other peripheral enthesopathies
726.90   Enthesopathy of specified site
726.91   Exostosis of unspecified site
727.00   Synovitis and tenosynovitis, unspecified
727.01   Synovitis and tenosynovitis in diseases classified elsewhere
727.02   Giant cell tumor of tendon sheath
727.03   Trigger finger (acquired)
727.04   Radial styloid tenosynovitis
727.05   Other tenosynovitis of hand and wrist
727.06   Tenosynovitis of foot and ankle
727.09   Other tenosynovitis
727.1    Bunion
727.2    Specific bursitides often of occupational origin
727.3    Other bursitis
727.40   Synovial cyst, unspecified
727.41   Ganglion of joint
727.42   Ganglion of tendon sheath
727.43   Ganglion, unspecified
727.49   Other ganglion, cyst of synovium, tendon, bursa
727.50   Rupture of synovium, unspecified
727.51   Synovial cyst of popliteal space
727.59   Other rupture of synovium
727.60   Nontraumatic rupture of unspecified tendon
727.61   Complete rupture of rotator cuff
727.62   Rupture, tendons of biceps (long head)
727.63   Rupture, extensor tendons of hand and wrist
727.64   Rupture, flexor tendons of hand and wrist
727.65   Rupture, quadriceps tendon
727.66   Rupture, patellar tendon
727.67   Rupture, achilles tendon
727.68   Rupture, other tendons of foot and ankle
727.69   Rupture of tendon, other
727.81   Contracture of tendon (sheath)
727.82   Calcium deposits in tendon and bursa
727.83   Plica syndrome
727.89   Other disorders of synovium, tendon, bursa
727.9    Unspecified disorder of synovium, tendon, and bursa



                                                                                    Page 210
NATIONAL COVERAGE DETERMINATION                                             Complete Blood Count

728.10   Muscular calcification and ossification, unspecified
728.11   Progressive myositis ossificans
728.12   Traumatic myositis ossifications
728.13   Postoperative heterotopic calcification
728.19   Other Muscular calcification and ossification
728.2    Muscular wasting and disuse atrophy, not elsewhere
728.3    Other specific muscle disorders
728.4    Laxity of ligament
728.5    Hypermobility syndrome
728.6    Contracture of palmar fascia
728.71   Plantar fascial fibromatosis
728.79   Other fascial fibromatosis
728.81   Interstitial myositis
728.82   Foreign body granuloma of muscle
728.83   Rupture of muscle, nontraumatic
728.84   Diastasis of muscle
728.85   Spasm of muscle
732.0    Juvenile osteochondrosis of spine
732.1    Juvenile osteochondrosis of hip and pelvis
732.2    Nontraumatic slipped upper femoral epiphysis
732.3    Juvenile osteochondrosis of upper extremity
732.4    Juvenile osteochondrosis of lower extremity, excluding foot
732.5    Juvenile osteochondrosis of foot
732.6    Other juvenile osteochondrosis
732.7    Osteochondritis dissecans
732.8    Other specified forms of osteochondropathy
732.9    Unspecified osteochondropathy
733.00   Osteoporosis, unspecified
733.01   Senile osteoporosis
733.02   Idiopathic osteoporosis
733.03   Disuse osteoporosis
733.09   Other osteoporosis
734      Flat foot
735.0    Hallux valgus (acquired)
735.1    Hallux varus (acquired)
735.2    Hallux rigidus
735.3    Hallux malleus
735.4    Other hammer toe (acquired)
735.5    Claw toe (acquired)
735.8    Other acquired deformities of toe
735.9    Unspecified acquired deformity of toe
736.00   Acquired deformities of forearm, excluding fingers, ,unspecified
736.01   Cubitus valgus (acquired)
736.02   Cubitus varus (acquired)
736.03   Valgus deformity of wrist (acquired)
736.04   Varus deformity of wrist (acquired)
736.05   Wrist drop (acquired)
736.06   Claw hand (acquired)
736.07   Club hand (acquired)
736.09   Other acquired deformities of forearm
736.1    Mallet finger
736.20   Unspecified deformity of finger
736.21   Boutonniere deformity



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NATIONAL COVERAGE DETERMINATION                               Complete Blood Count

736.22   Swan-neck deformity
736.29   Other deformity of finger
736.30   Unspecified deformity of hip
736.31   Coxa valga (acquired)
736.32   Coxa vara (acquired)
736.39   Other deformity of hip
736.41   Genu valgum (acquired)
736.42   Genu varum (acquired)
736.5    Genu recurvatum (acquired)
736.6    Other acquired deformities of knee
736.70   Unspecified deformity of ankle and foot, acquired
736.71   Acquired equinovarus deformity
736.72   Equinus deformity of foot, acquired
736.73   Cavus deformity of foot
736.74   Claw foot, acquired
736.75   Cavovarus deformity of foot, acquired
736.76   Other calcaneus deformity
736.79   Other deformity of foot
736.81   Unequal leg length (acquired)
736.89   Other acquired deformities of other parts of limbs
736.9    Acquired deformity of limb, site unspecified
737.0    Adolescent postural kyphosis
737.10   Kyphosis (acquired) (postural)
737.11   Kyphosis due to radiation
737.12   Kyphosis, postlaminectomy
737.19   Other kyphosis
737.20   Lordosis (acquired) (postural)
737.21   Lordosis, postlaminectomy
737.22   Other postsurgical lordosis
737.29   Other Lordosis
737.30   Scoliosis and kyphoscoliosis, idiopathic
737.31   Resolving infantile idiopathic scoliosis
737.32   Progressive infantile idiopathic scoliosis
737.33   Scoliosis due to radiation
737.34   Thoracogenic scoliosis
737.39   Other scoliosis
737.40   Curvature of spine, unspecified
737.41   Kyphosis
737.42   Lordosis
737.43   Scoliosis
737.8    Other curvatures of spine
737.9    Unspecified curvature of spine
738.0    Acquired deformity of nose
738.10   Unspecified deformity of head
738.11   Zygomatic hyperplasia
738.12   Zygomatic hypoplasia
738.19   Other specified deformity of head
738.2    Acquired deformity of neck
738.3    Acquired deformity of chest and rib
738.4    Acquired spondylolisthesis
738.5    Other acquired deformity of back or spine
738.6    Acquired deformity of pelvis
738.7    Cauliflower ear



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NATIONAL COVERAGE DETERMINATION                                              Complete Blood Count

738.8    Acquired deformity of other specified site
738.9    Acquired deformity of unspecified site
739.0    Nonallopathic lesions, head region
739.1    Nonallopathic lesions, cervical region
739.2    Nonallopathic lesions, thoracic region
739.3    Nonallopathic lesions, lumbar region
739.4    Nonallopathic lesions, sacral region
739.5    Nonallopathic lesions, pelvic region
739.6    Nonallopathic lesions, lower extremities
739.7    Nonallopathic lesions, upper extremities
739.8    Nonallopathic lesions, rib cage
739.9    Nonallopathic lesions, abdomen and other
798.0    Sudden infant death syndrome
798.1    Instantaneous death
798.2    Death occurring in less than 24 hours from onset of symptoms
798.9    Unattended death
799.81   Decreased libido
830.0    Dislocation of jaw, closed
830.1    Dislocation of jaw, open
831.00   Dislocation of shoulder, closed, shoulder, unspecified
831.01   Dislocation of shoulder, closed, anterior dislocation of humerus
831.02   Dislocation of shoulder, closed, posterior dislocation of humerus
831.03   Dislocation of shoulder, closed, inferior dislocation of humerus
831.04   Dislocation of shoulder, closed, acromioclavicular (joint)
831.09   Dislocation of shoulder, closed, other
831.10   Dislocation of shoulder, open, shoulder, unspecified
831.11   Dislocation of shoulder, open, anterior dislocation of humerus
831.12   Dislocation of shoulder, open, posterior dislocation of humerus
831.13   Dislocation of shoulder, open, inferior dislocation of humerus
831.14   Dislocation of shoulder, open, acromioclavicular (joint)
831.19   Dislocation of shoulder, open, other
832.00   Dislocation of elbow, closed, unspecified
832.01   Dislocation of elbow, closed, anterior
832.02   Dislocation of elbow, closed, posterior
832.03   Dislocation of elbow, closed, medial
832.04   Dislocation of elbow, closed, lateral
832.09   Dislocation of elbow, closed, other
832.10   Dislocation of elbow, open, unspecified
832.11   Dislocation of elbow, open, anterior
832.12   Dislocation of elbow, open, posterior
832.13   Dislocation of elbow, open, medial
832.14   Dislocation of elbow, open, lateral
832.19   Dislocation of elbow, open, other
833.00   Dislocation of wrist, closed, unspecified part
833.01   Dislocation of wrist, closed, radioulnar (joint), distal
833.02   Dislocation of wrist, closed, radiocarpal (joint)
833.03   Dislocation of wrist, closed, midcarpal (joint)
833.04   Dislocation of wrist, closed, carpometacarpal (joint)
833.05   Dislocation of wrist, closed, metacarpal (bone), proximal end
833.09   Dislocation of wrist, closed, other
833.10   Dislocation of wrist, open, unspecified part
833.11   Dislocation of wrist, open, radioulnar (joint), distal
833.12   Dislocation of wrist, open, radiocarpal (joint)



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NATIONAL COVERAGE DETERMINATION                                             Complete Blood Count

833.13   Dislocation of wrist, open, midcarpal (joint)
833.14   Dislocation of wrist, open, carpometacarpal (joint)
833.15   Dislocation of wrist, open, metacarpal (bone), proximal end
833.19   Dislocation of wrist, open, other
834.00   Dislocation of finger, closed, unspecified part
834.01   Dislocation of finger, closed, metacarpophalangeal (joint)
834.02   Dislocation of finger, closed, interphalangeal (joint), hand
834.10   Dislocation of finger, open, unspecified part
834.11   Dislocation of finger, open, metacarpophalangeal (joint)
834.12   Dislocation of finger, open, interphalangeal (joint), hand
835.00   Dislocation of hip, closed, dislocation of hip, unspecified
835.01   Dislocation of hip, closed, posterior dislocation
835.02   Dislocation of hip, closed, obturator dislocation
835.03   Dislocation of hip, closed, other anterior dislocation
835.10   Dislocation of hip, open, dislocation of hip, unspecified
835.11   Dislocation of hip, open, posterior dislocation
835.12   Dislocation of hip, open, obturator dislocation
835.13   Dislocation of hip, open, other anterior dislocation
836.0    Tear of medial cartilage or meniscus of knee, current
836.1    Tear of lateral cartilage or meniscus of knee, current
836.2    Other tear of cartilage or meniscus of knee, current
836.3    Dislocation of patella, closed
836.4    Dislocation of patella, open
836.50   Dislocation of knee, unspecified
836.51   Anterior dislocation of tibia, proximal end
836.52   Posterior dislocation of tibia, proximal end
836.53   Medial dislocation of tibia, proximal end
836.54   Lateral dislocation of tibia, proximal end
836.59   Other dislocation of knee
836.60   Dislocation of knee, open, unspecified
836.61   Anterior dislocation of tibia, proximal end, open,
836.62   Posterior dislocation of tibia, open,proximal end
836.63   Medial dislocation of tibia, open,proximal end
836.64   Lateral dislocation of tibia, open,proximal end
836.69   Other dislocation of knee, open,
837.0    Closed dislocation of ankle
837.1    Open dislocation of ankle
838.00   Closed dislocation of foot, unspecified
838.01   Closed dislocation of foot, tarsal (bone), joint unspecified
838.02   Closed dislocation of foot, midtarsal (joint)
838.03   Closed dislocation of foot, tarsometatarsal (joint)
838.04   Closed dislocation of foot, metatarsal (bone), joint unspecified
838.05   Closed dislocation of foot, metatarsophalangeal (joint)
838.06   Closed dislocation of foot, interphalangeal (joint), foot
838.09   Closed dislocation of foot, other
838.10   Open dislocation, foot, unspecified
838.11   Open dislocation, foot, tarsal (bone), joint unspecified
838.12   Open dislocation, foot, midtarsal (joint)
838.13   Open dislocation, foot, tarsometatarsal (joint)
838.14   Open dislocation, foot, metatarsal (bone), joint unspecified
838.15   Open dislocation, foot, metatarsophalangeal (joint)
838.16   Open dislocation, foot, interphalangeal (joint), foot
838.19   Open dislocation, foot, other



                                                                                        Page 214
NATIONAL COVERAGE DETERMINATION                                          Complete Blood Count

839.00   Dislocation, cervical vertebra, closed, unspecified
839.01   Dislocation, closed, first cervical vertebra
839.02   Dislocation, closed, second cervical vertebra
839.03   Dislocation, closed, third cervical vertebra
839.04   Dislocation, closed, fourth cervical vertebra
839.05   Dislocation, closed, fifth cervical vertebra
839.06   Dislocation, closed, sixth cervical vertebra
839.07   Dislocation, closed, seventh cervical vertebra
839.08   Dislocation, closed, multiple cervical vertebrae
839.10   Dislocation, open, cervical vertebra, unspecified
839.11   Dislocation, open, first cervical vertebra
839.12   Dislocation, open, second cervical vertebra
839.13   Dislocation, open, third cervical vertebra
839.14   Dislocation, open, fourth cervical vertebra
839.15   Dislocation, open, fifth cervical vertebra
839.16   Dislocation, open, sixth cervical vertebra
839.17   Dislocation, open, seventh cervical vertebra
839.18   Dislocation, open, multiple cervical vertebrae
839.20   Dislocation, closed, lumbar vertebra
839.21   Dislocation, closed, thoracic vertebra
839.30   Dislocation, open, lumbar vertebra
839.31   Dislocation, open, thoracic vertebra
839.40   Dislocation, closed, vertebra, unspecified site
839.41   Dislocation, closed, coccyx
839.42   Dislocation, closed, sacrum
839.49   Dislocation, closed, other
839.50   Dislocation, open, vertebra, unspecified site
839.51   Dislocation, open, coccyx
839.52   Dislocation, open, sacrum
839.59   Dislocation, open, other
839.61   Dislocation, closed, sternum
839.69   Dislocation, closed, other
839.71   Dislocation, open, sternum
839.79   Dislocation, open, Other
839.8    Dislocation, multiple and ill-defined, closed
839.9    Dislocation, multiple and ill-defined, open
840.0    Sprains and strains of acromioclavicular (joint) (ligament)
840.1    Sprains and strains of coracoclavicular (ligament)
840.2    Sprains and strains of coracohumeral (ligament)
840.3    Sprains and strains of infraspinatus (muscle) (tendon)
840.4    Sprains and strains of rotator cuff (capsule)
840.5    Sprains and strains of subscapularis (muscle)
840.6    Sprains and strains of supraspinatus (muscle) (tendon)
840.7    Superior glenoid labrum lesion
840.8    Sprains and strains of other specified sites of shoulder and upper arm
840.9    Sprains and strains of unspecified site of shoulder and upper arm
841.0    Sprains and strains of radial collateral ligament
841.1    Sprains and strains of ulnar collateral ligament
841.2    Sprains and strains of radiohumeral (joint)
841.3    Sprains and strains of ulnohumeral (joint)
841.8    Sprains and strains of other specified sites of elbow and forearm
841.9    Sprains and strains of unspecified site of elbow and forearm
842.00   Sprains and strains of wrist and hand, unspecified site



                                                                                     Page 215
NATIONAL COVERAGE DETERMINATION                                            Complete Blood Count

842.01   Sprains and strains of carpal (joint)
842.02   Sprains and strains of radiocarpal (joint) (ligament)
842.09   Other sprains and strains of wrist and hand
842.10   Sprains and strains of hand, unspecified site
842.11   Sprains and strains of carpometacarpal (joint)
842.12   Sprains and strains of metacarpophalangeal (joint)
842.13   Sprains and strains of interphalangeal (joint)
842.19   Other sprains and strains of hand
843.0    Sprains and strains of iliofemoral (ligament)
843.1    Sprains and strains of ischiocapsular (ligament)
843.8    Sprains and strains of other specified sites of hip and thigh
843.9    Sprains and strains of unspecified site of hip and thigh
844.0    Sprains and strains of lateral collateral ligament of knee
844.1    Sprains and strains of medial collateral ligament of knee
844.2    Sprains and strains of cruciate ligament of knee
844.3    Sprains and strains of tibiofibular (joint) (ligament), superior
844.8    Sprains and strains of other specified sites of knee and leg
844.9    Sprains and strains of unspecified site of knee and leg
845.00   Sprains and strains of unspecified site of ankle
845.01   Sprains and strains of deltoid (ligament), ankle
845.02   Sprains and strains of ankle, calcaneofibular (ligament)
845.03   Sprains and strains of ankle, tibiofibular (ligament), distal
845.09   Sprains and strains of ankle, other
845.10   Sprains and strains of foot, unspecified site
845.11   Sprains and strains of foot, tarsometatarsal (joint) (ligament)
845.12   Sprains and strains of foot, metatarsophalangeal (joint)
845.13   Sprains and strains of foot, interphalangeal (joint), toe
845.19   Sprains and strains of foot, other
846.0    Sprains and strains of sacroiliac region, lumbosacral (joint) (ligament)
846.1    Sprains and strains of sacroiliac ligament
846.2    Sprains and strains of sacrospinatus (ligament)
846.3    Sprains and strains of sacrotuberous (ligament)
846.8    Sprains and strains of other specified sites of sacroiliac region
846.9    Sprains and strains of unspecified site of sacroiliac region
847.0    Sprains and strains of neck
847.1    Sprains and strains of back, thoracic
847.2    Sprains and strains of back, lumbar
847.3    Sprains and strains of back, sacrum
847.4    Sprains and strains of coccyx
847.9    Sprains and strains of unspecified site of back
848.0    Sprains and strains of septal cartilage of nose
848.1    Sprains and strains of jaw
848.2    Sprains and strains of thyroid region
848.3    Sprains and strains of ribs
848.40   Sprains and strains of sternum, unspecified site
848.41   Sprains and strains of sternum, sternoclavicular (joint) (ligament)
848.42   Sprains and strains of sternum, chondrosternal (joint)
848.49   Sprains and strains of sternum, other
848.5    Sprains and strains of pelvis
848.8    Other specified sites of sprains and strains
848.9    Unspecified site of sprain and strain
905.0    Late effect of fracture of skull and face bones
905.1    Late effect of fracture of spine and trunk without of spinal cord lesion



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NATIONAL COVERAGE DETERMINATION                                          Complete Blood Count

905.2   Late effect of fracture of upper extremities
905.3   Late effect of fracture of neck of femur
905.4   Late effect of fracture of lower extremities
905.5   Late effect of fracture of multiple and unspecified bones
905.6   Late effect of dislocation
905.7   Late effect of sprain and strain without tendon injury
905.8   Late effect of tendon injury
905.9   Late effect of traumatic amputation
906.0   Late effect of open wound of head, neck, and trunk
906.1   Late effect of open wound of extremities without tendon injury
906.2   Late effect of superficial injury
906.3   Late effect of contusion
906.4   Late effect of crushing
906.5   Late effect of burn of eye, face, head, and neck
906.6   Late effect of burn of wrist and hand
906.7   Late effect of burn of other extremities
906.8   Late effect of burns of other specified sites
906.9   Late effect of burn of unspecified site
907.0   Late effect of intracranial injury without skull fracture
907.1   Late effect of injury to cranial nerve
907.2   Late effect of spinal cord injury
907.3   Late effect of injury to nerve root(s), spinal plexus(es), and other nerves of trunk
907.4   Late effect of injury to peripheral nerve of shoulder girdle and upper limb
907.5   Late effect of injury to peripheral nerve of pelvic girdle and lower limb
907.9   Late effect of injury to other and unspecified nerve
908.0   Late effect of internal injury to chest
908.1   Late effect of internal injury to intra-abdominal organs
908.2   Late effect of internal injury to other internal organs
908.3   Late effect of injury to blood vessel of head, neck, and extremities
908.4   Late effect of injury to blood vessel of thorax, abdomen, and pelvis
908.5   Late effect of foreign body in orifice
908.6   Late effect of certain complications of trauma
908.9   Late effect of unspecified injury
909.0   Late effect of poisoning due to drug, medicinal or biological substance
909.1   Late effect of toxic effects of nonmedical substances
909.2   Late effect of radiation
909.3   Late effect of complications of surgical and medical care
909.4   Late effect of certain other external causes
909.5   Late effect of adverse effect of drug, medicinal or biological substance
909.9   Late effect of other and unspecified external causes
910.0   Abrasion or friction burn without infection, neck/face/scalp
910.1   Abrasion or friction burn, infected, neck/face/scalp
910.2   Blister without infection, neck/face/scalp
910.3   Blister, infected, neck/face/scalp
910.4   Insect bite, nonvenomous, without infection, neck/face/scalp
910.5   Insect bite, nonvenomous, infected, neck/face/scalp
910.6   Superficial foreign body (splinter) without major open wound and without infection,
        neck/face/scalp
910.7   Superficial foreign body (splinter) without major open wound, infected, neck/face/scalp
910.8   Other and unspecified superficial injury of face, neck, and scalp without infection,
        neck/face/scalp
910.9   Other and unspecified superficial injury of face, neck, and scalp, infected, neck/face/scalp
911.0   Abrasion or friction burn without infection, trunk



                                                                                           Page 217
NATIONAL COVERAGE DETERMINATION                                         Complete Blood Count

911.1   Abrasion or friction burn, infected, trunk
911.2   Blister without mention of infection, trunk
911.3   Blister, infected, trunk
911.4   Insect bite, nonvenomous, without infection, trunk
911.5   Insect bite, nonvenomous, infected, trunk
911.6   Superficial foreign body (splinter) without major open wound and infection, trunk
911.7   Superficial foreign body (splinter) without major open wound, infected, trunk
911.8   Other and unspecified superficial injury of trunk without infection, trunk
911.9   Other and unspecified superficial injury of trunk, infected
912.0   Abrasion or friction burn without infection, shoulder and upper arm
912.1   Abrasion or friction burn, infected, shoulder and upper arm
912.2   Blister without infection, shoulder and upper arm
912.3   Blister, infected, shoulder and upper arm
912.4   Insect bite, nonvenomous, without infection, shoulder and upper arm
912.5   Insect bite, nonvenomous, infected, shoulder and upper arm
912.6   Superficial foreign body (splinter) without major open wound and infection, shoulder and
        upper arm
912.7   Superficial foreign body (splinter) without major open wound, infected, shoulder and
        upper arm
912.8   Other and unspecified superficial injury of shoulder and upper arm without infection
912.9   Other and unspecified superficial injury of shoulder and upper arm, infected
913.0   Abrasion or friction burn without infection, elbow, forearm, and wrist
913.1   Abrasion or friction burn, infected, elbow, forearm, and wrist
913.2   Blister without infection, elbow, forearm, and wrist
913.3   Blister, infected, elbow, forearm, and wrist
913.4   Insect bite, nonvenomous, without infection, elbow, forearm, and wrist
913.5   Insect bite, nonvenomous, infected, elbow, forearm, and wrist
913.6   Superficial foreign body (splinter) without major open wound and infection, elbow,
        forearm, and wrist
913.7   Superficial foreign body (splinter) without major open wound, infected, elbow, forearm,
        and wrist
913.8   Other and unspecified superficial injury of elbow, forearm, and wrist without infection
913.9   Other and unspecified superficial injury of elbow, forearm, and wrist, infected
914.0   Abrasion or friction burn without infection, hand(s) except finger(s)
914.1   Abrasion or friction burn, infected, hand(s) except finger(s)
914.2   Blister without infection, hand(s) except finger(s)
914.3   Blister, infected, hand(s) except finger(s)
914.4   Insect bite, nonvenomous, without infection, hand(s) except finger(s)
914.5   Insect bite, nonvenomous, infected, hand(s) except finger(s)
914.6   Superficial foreign body (splinter) without major open wound and infection, hand(s)
        except finger(s)
914.7   Superficial foreign body (splinter) without major open wound, infected, hand(s) except
        finger(s)
914.8   Other and unspecified superficial injury of hand without infection
914.9   Other and unspecified superficial injury of hand, infected
915.0   Abrasion or friction burn without infection, finger(s)
915.1   Abrasion or friction burn, infected, finger(s)
915.2   Blister without infection, finger(s)
915.3   Blister, infected, finger(s)
915.4   Insect bite, nonvenomous, without infection, finger(s)
915.5   Insect bite, nonvenomous, infected, finger(s)
915.6   Superficial foreign body (splinter) without major open wound and infection, finger(s)
915.7   Superficial foreign body (splinter) without major open wound, infected, finger(s)



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NATIONAL COVERAGE DETERMINATION                                          Complete Blood Count

915.8   Other and unspecified superficial injury of fingers without infection
915.9   Other and unspecified superficial injury of fingers, infected
916.0   Abrasion or friction burn without infection, hip, thigh, leg, and ankle
916.1   Abrasion or friction burn, infected, hip, thigh, leg, and ankle
916.2   Blister without infection, hip, thigh, leg, and ankle
916.3   Blister, infected, hip, thigh, leg, and ankle
916.4   Insect bite, nonvenomous, without infection, hip, thigh, leg, and ankle
916.5   Insect bite, nonvenomous, infected, hip, thigh, leg, and ankle
916.6   Superficial foreign body (splinter) without major open wound and infection, hip, thigh, leg,
        and ankle
916.7   Superficial foreign body (splinter) without major open wound, infected, hip, thigh, leg, and
        ankle
916.8   Other and unspecified superficial injury of hip, thigh, leg, and ankle without infection
916.9   Other and unspecified superficial injury of hip, thigh, leg, and ankle, infected
917.0   Abrasion or friction burn without infection, foot and toe(s)
917.1   Abrasion or friction burn, infected, foot and toe(s)
917.2   Blister without infection, foot and toe(s)
917.3   Blister, infected, foot and toe(s)
917.4   Insect bite, nonvenomous, without infection, foot and toe(s)
917.5   Insect bite, nonvenomous, infected, foot and toe(s)
917.6   Superficial foreign body (splinter) without major open wound and infection, foot and toe(s)
917.7   Superficial foreign body (splinter) without major open wound, infected, foot and toe(s)
917.8   Other and unspecified superficial injury of foot and toes without infection, foot and toe(s)
917.9   Other and unspecified superficial injury of foot and toes, infected
918.0   Superficial injury of eyelids and periocular area
918.1   Superficial injury of cornea
918.2   Superficial injury of conjunctiva
918.9   Other and unspecified superficial injuries of eye
919.0   Abrasion or friction burn without infection
919.1   Abrasion or friction burn, infected
919.2   Blister without infection
919.3   Blister, infected, eye
919.4   Insect bite, nonvenomous, without infection
919.5   Insect bite, nonvenomous, infected
919.6   Superficial foreign body (splinter) without major open wound and without infection
919.7   Superficial foreign body (splinter) without major open wound, infected
919.8   Other and unspecified superficial injury without infection
919.9   Other and unspecified superficial injury, infected
930.0   Corneal foreign body
930.1   Foreign body in conjunctival sac
930.2   Foreign body in lacrimal punctum
930.8   Foreign body in other and combined sites of external eye
930.9   Foreign body in unspecified site of external eye
931     Foreign body in ear
932     Foreign body in nose
955.0   Injury to peripheral nerve(s) of shoulder girdle and upper limb, axillary nerve
955.1   Injury to peripheral nerve(s) of shoulder girdle and upper limb, median nerve
955.2   Injury to peripheral nerve(s) of shoulder girdle and upper limb, ulnar nerve
955.3   Injury to peripheral nerve(s) of shoulder girdle and upper limb, radial nerve
955.4   Injury to peripheral nerve(s) of shoulder girdle and upper limb, musculocutaneous nerve
955.5   Injury to peripheral nerve(s) of shoulder girdle and upper limb, cutaneous sensory nerve,
        upper limb
955.6   Injury to peripheral nerve(s) of shoulder girdle and upper limb, digital nerve



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NATIONAL COVERAGE DETERMINATION                                           Complete Blood Count

955.7    Injury to peripheral nerve(s) of shoulder girdle and upper limb, other specified nerve(s)
955.8    Injury to peripheral nerve(s) of shoulder girdle and upper limb, multiple nerves
955.9    Injury to peripheral nerve(s) of shoulder girdle and upper limb, unspecified nerve
956.0    Injury to peripheral nerve(s) of pelvic girdle and lower limb, sciatic nerve
956.1    Injury to peripheral nerve(s) of pelvic girdle and lower limb, femoral nerve
956.2    Injury to peripheral nerve(s) of pelvic girdle and lower limb, posterior tibial nerve
956.3    Injury to peripheral nerve(s) of pelvic girdle and lower limb, peroneal nerve
956.4    Injury to peripheral nerve(s) of pelvic girdle and lower limb, cutaneous sensory nerve
956.5    Injury to peripheral nerve(s) of pelvic girdle and lower limb, other specified nerve(s)
956.8    Injury to peripheral nerve(s) of pelvic girdle and lower limb, multiple nerves
956.9    Injury to peripheral nerve(s) of pelvic girdle and lower limb, unspecified nerve
957.0    Injury to superficial nerves of head and neck
957.1    Injury to other specified nerve(s)
957.8    Injury to multiple nerves in several parts
957.9    Injury to other and unspecified nerves, unspecified site
V03.0    Need for prophylactic vaccination, cholera alone
V03.1    Need for prophylactic vaccination, typhoid-paratyphoid alone
V03.2    Need for prophylactic vaccination, tuberculosis [BCG]
V03.3    Need for prophylactic vaccination, plague
V03.4    Need for prophylactic vaccination, tularemia
V03.5    Need for prophylactic vaccination, diphtheria alone
V03.6    Need for prophylactic vaccination, pertussis alone
V03.7    Need for prophylactic vaccination, tetanus toxoid alone
V03.81   Need for prophylactic vaccination, Hemophilus influenza, type B [Hib]
V03.82   Need for prophylactic vaccination, Streptococcus pneumoniae [pneumococcus]
V03.89   Need for prophylactic vaccination, other specified vaccination
V03.9    Need for prophylactic vaccination, unspecified single bacterial disease
V04.0    Need for prophylactic vaccination, poliomyelitis
V04.1    Need for prophylactic vaccination, smallpox
V04.2    Need for prophylactic vaccination, measles alone
V04.3    Need for prophylactic vaccination, rubella alone
V04.4    Need for prophylactic vaccination, yellow fever
V04.5    Need for prophylactic vaccination, rabies
V04.6    Need for prophylactic vaccination, mumps alone
V04.7    Need for prophylactic vaccination, common cold
V04.81   Need for prophylactic vaccination and inoculation, Influenza
V04.82   Need for prophylactic vaccination and inoculation, respiratory synctial virus (RSV)
V04.89   Need for prophylactic vaccination and inoculation, other viral diseases
V05.0    Need for prophylactic vaccination, arthropod-borne viral encephalitis
V05.1    Need for prophylactic vaccination, other arthropod-borne viral diseases
V05.2    Need for prophylactic vaccination, leishmaniasis
V05.3    Need for prophylactic vaccination, viral hepatitis
V05.4    Need for prophylactic vaccination, varicella
V05.8    Need for prophylactic vaccination, other specified single disease
V05.9    Need for prophylactic vaccination, unspecified single disease
V06.0    Need for prophylactic vaccination, cholera with typhoid-paratyphoid [cholera TAB]
V06.1    Need for prophylactic vaccination, Diphtheria-tetanus-pertussis, combined [DTP] [DtaP]
V06.2    Need for prophylactic vaccination, diphtheria-tetanus-pertussis with typhoid-paratyphoid
V06.3    Need for prophylactic vaccination, diphtheria-tetanus-pertussis with poliomyelitis
V06.4    Need for prophylactic vaccination, measles-mumps-rubella [MMR]
V06.5    Need for prophylactic vaccination, tetanus-diphtheria [Td] [DT]
V06.6    Need for prophylactic vaccination, streptococcus pneumoniae and influenza
V06.8    Need for prophylactic vaccination, other combinations



                                                                                           Page 220
NATIONAL COVERAGE DETERMINATION                                       Complete Blood Count

V06.9    Need for prophylactic vaccination, unspecified combined vaccine
V11.0    Personal history of schizophrenia
V11.1    Personal history of affective disorders
V11.2    Personal history of neurosis
V11.3    Personal history of alcoholism
V11.8    Personal history of other mental disorders
V11.9    Personal history of unspecified mental disorder
V14.0    Personal history of allergy to penicillin
V14.1    Personal history of allergy to other antibiotic agent
V14.2    Personal history of allergy to sulfonamides
V14.3    Personal history of allergy to other anti-infective agent
V14.4    Personal history of allergy to anesthetic agent
V14.5    Personal history of allergy to narcotic agent
V14.6    Personal history of allergy to analgesic agent
V14.7    Personal history of allergy to serum or vaccine
V14.8    Personal history of allergy to other specified medicinal agents
V15.85   Exposure to potentially hazardous body fluids
V16.0    Family history of malignant neoplasm of gastointestinal tract
V16.1    Family history of malignat neoplasm, trachea, bronchus, and lung
V16.2    Family history of malignat neoplasm, other respiratory and intrathoracic organs
V16.3    Family history of malignat neoplasm, breast
V16.40   Family history of malignat neoplasm, genital organs, unspecified
V16.51   Family history of malignant neoplasm, kidney
V16.52   Family history of malignant neoplasm, bladder
V16.59   Family history of malignant neoplasm, other
V16.6    Family history of malignat neoplasm, leukemia
V16.7    Family history of malignat neoplasm, other lymphatic and hematopoietic neoplasms
V16.8    Family history of malignat neoplasm, other specified malignant neoplasm
V16.9    Family history of malignat neoplasm, unspecified
V17.0    Family history of psychiatric condition
V17.1    Family history of stroke (cerebrovascular)
V17.2    Family history of other neurological diseases
V17.3    Family history of ischemic heart disease
V17.41   Family history of sudden cardiac death (SCD)
V17.49   Family history of other cardiovascular diseases
V17.5    Family history of asthma
V17.6    Family history of other chronic respiratory conditions
V17.7    Family history of arthritis
V17.81   Family history, Osteoporosis
V17.89   Family history, Other musculoskeletal diseases
V18.0    Family history of diabetes mellitus
V18.11   Family history of multiple endocrine neoplasia [MEN] syndrome
V18.19   Family history of other endocrine and metabolic diseases
V18.2    Family history of anemia
V18.3    Family history of other blood disorders
V18.4    Family history of mental retardation
V18.51   Family history of colonic polyps
V18.59   Family history of other digestive disorders
V18.61   Family history of polycystic kidney disease
V18.69   Family history of other kidney disease
V18.7    Family history of other genitourinary diseases
V18.8    Family history of infectious and parasitic diseases
V18.9    Family history, Genetic disease carrier



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NATIONAL COVERAGE DETERMINATION                                          Complete Blood Count

V19.0    Blindness or visual loss
V19.1    Family history of other eye disorders
V19.2    Family history of deafness or hearing loss
V19.3    Family history of other ear disorders
V19.4    Family history of skin conditions
V19.5    Family history of congenital anomalies
V19.6    Family history of allergic disorders
V19.7    Family history of consanguinity
V19.8    Family history of other condition
V20.0    Foundling
V20.1    Other healthy infant or child receiving care
V20.2    Routine infant or child health check
V21.0    Period of rapid growth in childhood
V21.1    Puberty
V21.2    Other adolescence
V21.30   Low birth weight, unspecified
V21.31   Low birth weight, < 500 gms
V21.32   Low birth weight, 500-999 gms
V21.33   Low birth weight, 1000-1499 gms
V21.34   Low birth weight, 1500-1999 gms
V21.35   Low birth weight, 2000-2500 gms
V21.8    Other specified constitutional states in development
V21.9    Unspecified constitutional state in development
V25.01   Prescription of oral contraceptives
V25.02   Initiation of other contraceptive measures
V25.03   Encounter for emergency contraceptive counseling and prescription
V25.04   Counseling and instruction in natural family planning to avoid pregnancy
V25.09   Other family planning advice
V25.1    Insertion of intrauterine contraceptive device
V25.2    Sterilization
V25.3    Menstrual extraction
V25.40   Contraceptive surveillance, unspecified
V25.41   Contraceptive pill
V25.42   Intrauterine contraceptive device
V25.43   Implantable subdermal contraceptive
V25.49   Other contraceptive method
V25.5    Insertion of implantable subdermal contraceptive
V25.8    Other specified contraceptive management
V25.9    Unspecified contraceptive management
V26.0    Tuboplasty or vasoplasty after previous sterilization
V26.1    Artificial insemination
V26.21   Fertility testing
V26.22   Aftercare following sterilization reversal
V26.29   Other investigation and testing
V26.31   Testing of female for genetic disease carrier status
V26.32   Other genetic testing of female
V26.33   Genetic counseling
V26.34   Testing of male for genetic disease carrier status
V26.35   Encounter for testing of male partner of habitual aborter
V26.39   Other genetic testing of male
V26.41   Procreative counseling and advice using natural family planning
V26.49   Other procreative management counseling and advice
V26.51   Tubal ligation status



                                                                                     Page 222
NATIONAL COVERAGE DETERMINATION                                                Complete Blood Count

V26.52   Vasectomy status
V26.81   Encounter for assisted reproductive fertility procedure cycle
V26.89   Other specified procreative management
V26.9    Unspecified procreative management
V28.0    Amniocentesis
V28.1    Antenatal screening, AFP levels in amniotic fluid
V28.2    Other screening based on amniocentesis
V28.3    Screening for malformation using ultrasonics
V28.4    Screening for fetal growth retardation using ultrasonics
V28.5    Screening for isoimmunization
V28.6    Screening for Strep B
V28.8    Other specified antenatal screening
V28.9    Unspecified antenatal screening
V40.0    Problems with learning
V40.1    Problems with communication [including speech]
V40.2    Other mental problems
V40.3    Other behavioral problems
V40.9    Unspecified mental or behavioral problem
V41.0    Problems with sight
V41.1    Other eye problems
V41.2    Problems with hearing
V41.3    Other ear problems
V41.4    Problems with voice production
V41.5    Problems with smell and taste
V41.6    Problems with swallowing and mastication
V41.7    Problems with sexual function
V41.8    Other problems with special functions
V41.9    Unspecified problem with special functions
V43.0    Organ or tissue replaced by other means, eye globe
V43.1    Organ or tissue replaced by other means, lens
V44.0    Artificial opening status, tracheostomy
V44.1    Artificial opening status, gastrostomy
V44.2    Artificial opening statusg ileostomy
V44.3    Artificial opening status, colostomy
V44.4    Artificial opening status, other artificial opening of gastrointestinal tract
V44.50   Artificial opening status, cystostomy, unspecified
V44.51   Artificial opening status, cutaneous cystostomy, vesicostomy
V44.52   Artificial opening status, appendico- cystostomy
V44.59   Artificial opening status, other cystostomy
V44.6    Artificial opening status, other artificial opening of urinary tract
V44.7    Artificial vagina
V44.8    Other artificial opening status
V44.9    Unspecified artificial opening status
V45.00   Unspecified cardiac device
V45.01   Cardiac pacemaker
V45.02   Automatic implantable cardiac defibrillator
V45.09   Other specified cardiac device
V45.1    Renal dialysis status
V45.2    Presence of cerebrospinal fluid drainage device
V45.3    Intestinal bypass or anastomosis status
V45.4    Arthrodesis status
V45.51   Intrauterine contraceptive device
V45.52   Subdermal contraceptive implant



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NATIONAL COVERAGE DETERMINATION                                              Complete Blood Count

V45.59   Other contraceptive implant
V45.61   Cataract extraction status
V45.69   Other states following eye surgery
V45.71   Acquuired absence of breast
V45.72   Acquuired absence of intestine
V45.73   Acquuired absence of kidney
V45.74   Acquuired absence of other parts of urinary tract
V45.75   Acquired absence of stomach
V45.76   Acquuired absence of lung
V45.77   Acquuired absence of genital organs
V45.78   Acquuired absence of eye
V45.79   Acquuired absence of other organ
V45.81   Aortocoronary bypass status
V45.82   Percutaneous transluminal coronary angioplasty status
V45.83   Breast implant removal status
V45.84   Dental restoration status
V45.85   Insulin pump status
V45.86   Bariatric surgery status
V45.89   Other postsurgical status
V48.0    Deficiencies of head
V48.1    Deficiencies of neck and trunk
V48.2    Mechanical and motor problems with head
V48.3    Mechanical and motor problems with neck and trunk
V48.4    Sensory problem with head
V48.5    Sensory problem with neck and trunk
V48.6    Disfigurements of head
V48.7    Disfigurements of neck and trunk
V48.8    Other problems with head, neck, and trunk
V48.9    Unspecified problem with head, neck, or trunk
V49.0    Deficiencies of limbs
V49.1    Mechanical problems with limbs
V49.2    Motor problems with limbs
V49.3    Sensory problems with limbs
V49.4    Disfigurements of limbs
V49.5    Other problems of limbs
V49.60   Upper limb amputation status, unspecified level
V49.61   Upper limb amputation status, thumb
V49.62   Upper limb amputation status, other finger(s)
V49.63   Upper limb amputation status, hand
V49.64   Upper limb amputation status, wrist
V49.65   Upper limb amputation status, below elbow
V49.66   Upper limb amputation status, above elbow
V49.67   Upper limb amputation status, shoulder
V49.70   Lower limb amputation status, unspecified level
V49.71   Lower limb amputation status, great toe
V49.72   Lower limb amputation status, other toe(s)
V49.73   Lower limb amputation status, foot
V49.74   Lower limb amputation status, ankle
V49.75   Lower limb amputation status, below knee
V49.76   Lower limb amputation status, above knee
V49.77   Lower limb amputation status, hip
V49.81   Asymptomatic postmenopausal status (age-related) (natural)
V49.82   Other conditions influencing health status, dental sealant status



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NATIONAL COVERAGE DETERMINATION                                           Complete Blood Count

V49.84   Bed confinement status
V49.89   Other conditions influencing health status, other specified conditions
V49.9    Unspecified problems influencing health status
V50.0    Hair transplant
V50.1    Other plastic surgery for unacceptable cosmetic appearance
V50.2    Routine or ritual circumcision
V50.3    Ear piercing
V50.41   Prophylactic organ removal, breast
V50.42   Prophylactic organ removal, ovary
V50.49   Prophylactic organ removal, other
V50.8    Other elective surgery
V50.9    Unspecified elective surgery
V51      Aftercare involving the use of plastic surgery
V52.0    Fitting and adjustment of artificial arm (complete) (partial)
V52.1    Fitting and adjustment of artificial leg (complete) (partial)
V52.2    Fitting and adjustment of artificial eye
V52.3    Fitting and adjustment of dental prosthetic device
V52.4    Fitting and adjustment of breast prosthesis and implant
V52.8    Fitting and adjustment of other specified prosthetic device
V52.9    Fitting and adjustment of unspecified prosthetic device
V53.01   Fitting and adjustment of cerebral ventricular shunt
V53.02   Fitting and adjustment of neuropacemaker
V53.09   Fitting and adjustment of other devices related to nervous system
V53.1    Fitting and adjustment of Spectacles and contact lenses
V53.2    Fitting and adjustment of Hearing aid
V53.31   Fitting and adjustment of Cardiac pacemaker
V53.32   Fitting and adjustment of Automatic implantable cardiac defibrillator
V53.39   Fitting and adjustment of Other cardiac device
V53.4    Fitting and adjustment of Orthodontic devices
V53.5    Fitting and adjustment of Other intestinal appliance
V53.6    Fitting and adjustment of Urinary devices
V53.7    Fitting and adjustment of Orthopedic devices
V53.8    Fitting and adjustment of Wheelchair
V53.90   Fitting and adjustment, unspecified device
V53.91   Fitting and adjustment of insulin pump
V53.99   Fitting and adjustment, other device
V54.01   Encounter for removal of internal fixation device
V54.02   Encounter for lengthening/adjustment of growth rod
V54.09   Other aftercare involving internal fixation device
V54.10   Aftercare for healing traumatic fracture of arm, unspecified
V54.11   Aftercare for healing traumatic fracture of upper arm
V54.12   Aftercare for healing traumatic fracture of lower arm
V54.13   Aftercare for healing traumatic fracture of hip
V54.14   Aftercare for healing traumatic fracture of leg, unspecified
V54.15   Aftercare for healing traumatic fracture of upper leg
V54.16   Aftercare for healing traumatic fracture of lower leg
V54.17   Aftercare for healing traumatic fracture of vertebrae
V54.19   Aftercare for healing traumatic fracture of other bone
V54.20   After care for healing pathologic fracture of arm, unspecified
V54.21   Aftercare for healing pathologic fracture of upper arm
V54.22   Aftercare for healing pathologic fracture of lower arm
V54.23   Aftercare for healing pathologic fracture of hip
V54.24   Aftercare for healing pathologic fracture of leg, unspecified



                                                                                      Page 225
NATIONAL COVERAGE DETERMINATION                                       Complete Blood Count

V54.25   Aftercare for healing pathologic fracture of upper leg
V54.26   Aftercare for healing pathologic fracture of lower leg
V54.27   Aftercare for healing pathologic fracture of vertebrae
V54.29   Aftercare for healing pathologic fracture of other bone
V54.81   Aftercare following joint replacement
V54.89   Other orthopedic aftercare
V54.9    Unspecified orthopedic aftercare
V55.0    Attention to artificial openings, tracheostomy
V55.1    Attention to artificial openings, gastrostomy
V55.2    Attention to artificial openings, ileostomy
V55.3    Attention to artificial openings, colostomy
V55.4    Attention to other artificial opening of digestive tract
V55.5    Attention to artificial openings, cystostomy
V55.6    Attention to other artificial opening of urinary tract
V55.7    Artificial vagina
V55.8    Other specified artificial opening
V55.9    Unspecified artificial opening
V57.0    Breathing exercises
V57.1    Other physical therapy
V57.21   Encounter for occupational therapy
V57.22   Encounter for vocational therapy
V57.3    Speech therapy
V57.4    Orthoptic training
V57.81   Orthotic training
V57.89   Other specified rehabilitation procedure
V57.9    Unspecified rehabilitation procedure
V58.5    Orthodontics
V59.01   Donors, whole blood
V59.02   Donors, stem cells
V59.09   Donors, other
V59.1    Donors, skin
V59.2    Donors, bone
V59.3    Donors, bone marrow
V59.4    Donors, kidney
V59.5    Donors, cornea
V59.6    Donors, liver
V59.70   Egg (oocyte) (ovum) donor, unspecified
V59.71   Egg (oocyte) (ovum) donor, under age 35,anonymous recipient
V59.72   Egg (oocyte) (ovum) donor, under age 35,designated recipient
V59.73   Egg (oocyte) (ovum) donor, age 35 and over,anonymous recipient
V59.74   Egg (oocyte) (ovum) donor, age 35 and over,designated recipient
V59.8    Donors, other specified organ or tissue
V59.9    Donors, unspecified organ or tissue
V60.0    Lack of housing
V60.1    Inadequate housing
V60.2    Inadequate material resources
V60.3    Person living alone
V60.4    No other household member able to render care
V60.5    Holiday relief care
V60.6    Person living in residential institution
V60.8    Other specified housing or economic circumstances
V60.9    Unspecified housing or economic circumstance
V61.0    Family disruption



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NATIONAL COVERAGE DETERMINATION                                         Complete Blood Count

V61.10   Counseling for marital problems, unspecified
V61.11   Counseling for marital problems, victim of spousal abuse
V61.12   Counseling for perpetrator of spousal and partner abuse
V61.20   Parent-child problem, unspecified
V61.21   Child abuse
V61.22   Counseling for perpetrator of parent child abuse
V61.29   Other parent-child problem
V61.3    Problems with aged parents or in-laws
V61.41   Alcoholism in family
V61.49   Other family problems
V61.5    Multiparity
V61.6    Illegitimacy or illegitimate pregnancy
V61.7    Other unwanted pregnancy
V61.8    Other specified family circumstances
V61.9    Unspecified family circumstance
V62.0    Unemployment
V62.1    Adverse effects of work environment
V62.2    Other occupational circumstances or maladjustment
V62.3    Educational circumstances
V62.4    Social maladjustment
V62.5    Legal circumstances
V62.6    Refusal of treatment for reasons of religion or conscience
V62.81   Interpersonal problems, not elsewhere classified
V62.82   Bereavement, uncomplicated
V62.83   Counseling for perpetrator of physical/sexual abuse
V62.84   Suicidal ideation
V62.89   Other interpersonal problems
V62.9    Unspecified psychosocial circumstance
V65.0    Healthy person accompanying sick person
V65.11   Pediatric pre-birth visit for expectant mother
V65.19   Other person consulting on behalf of another person
V65.2    Person feigning illness
V65.3    Dietary surveillance and counseling
V65.40   Counseling, not elsewhere classified
V65.41   Exercise counseling
V65.42   Counseling on substance use and abuse
V65.43   Counseling on injury prevention
V65.44   Human immunodeficiency virus [HIV] counseling
V65.45   Counseling on other sexually transmitted diseases
V65.46   Encounter for insulin pump training
V65.49   Other specified counseling
V65.5    Person with feared complaint in whom no diagnosis was made
V65.8    Other reasons for seeking consultation
V65.9    Unspecified reason for consultation
V66.0    Consultation following surgery
V66.1    Consultation following radiotherapy
V66.2    Consultation following chemotherapy
V66.3    Consultation following psychotherapy and other treatment for mental disorder
V66.4    Consultation following treatment of fracture
V66.5    Consultation following other treatment
V66.6    Consultation following combined treatment
V66.7    Encounter for palliative care
V66.9    Consultation unspecified convalescence



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NATIONAL COVERAGE DETERMINATION                                         Complete Blood Count

V67.3    Follow-up examination following psychotherapy and other
V67.4    Follow-up examination following treatment of fracture
V68.01   Disability examination
V68.09   Other issue of medical certificates
V68.1    Issue of repeat prescriptions
V68.2    Request for expert evidence
V68.81   Referral of patient without examination or treatment
V68.89   Encounter for other specified administrative purpose
V68.9    Encounter for unspecified administrative purpose
V69.3    Gambling and betting
V70.0    Routine general medical examination at a health care facility
V70.1    General psychiatric examination, requested by the authority
V70.2    General psychiatric examination, other and unspecified
V70.3    Other medical examination for administrative purposes
V70.4    Examination for medicolegal reasons
V70.5    Health examination of defined subpopulations
V70.6    Health examination in population surveys
V70.7    Examination for normal comparison or control in clinical research
V70.8    Other specified general medical examinations
V70.9    Unspecified general medical examination
V71.01   Observation for suspected mental condition, adult antisocial behavior
V71.02   Observation for suspected mental condition, childhood or adolescent antisocial behavior
V71.09   Observation for suspected mental condition, other suspected mental condition
V72.0    Examination of eyes and vision
V72.11   Encounter for hearing examination following failed hearing screening
V72.19   Other examination of ears and hearing
V72.2    Dental examination
V72.40   Pregnancy examination or test, pregnancy unconfirmed
V72.41   Pregnancy examination or test, negative result
V72.5    Radiological examination, not elsewhere classified
V72.6    Laboratory examination
V72.7    Diagnostic skin and sensitization tests
V72.9    Unspecified examination
V73.0    Special screening examination for poliomyelitis
V73.1    Special screening examination for smallpox
V73.2    Special screening examination for measles
V73.3    Special screening examination for rubella
V73.4    Special screening examination for yellow fever
V73.5    Special screening examination for other arthropod-borne viral diseases
V73.6    Special screening examination for trachoma
V73.81   Special screening examination, Human papillomavirus (HPV)
V73.88   Special screening examination for other specified chlamydial diseases
V73.89   Special screening examination for other specified viral diseases
V73.98   Special screening examination for unspecified chlamydial disease
V73.99   Special screening examination for unspecified viral disease
V74.0    Special screening examination for cholera
V74.1    Special screening examination for pulmonary tuberculosis
V74.2    Special screening examination for leprosy
V74.3    Special screening examination for diphtheria
V74.4    Special screening examination for bacterial conjunctivitis
V74.5    Special screening examination for venereal disease
V74.6    Special screening examination for yaws
V74.8    Special screening examination for other specified bacterial and spirochetal diseases



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NATIONAL COVERAGE DETERMINATION                                        Complete Blood Count

V74.9    Special screening examination for unspecified bacterial and spirochetal disease
V75.0    Special screening examination for rickettsial diseases
V75.1    Special screening examination for malaria
V75.2    Special screening examination for leishmaniasis
V75.3    Special screening examination for trypanosomiasis
V75.4    Special screening examination for mycotic infections
V75.5    Special screening examination for schistosomiasis
V75.6    Special screening examination for filariasis
V75.7    Special screening examination for intestinal helminthiasis
V75.8    Special screening examination for other specified parasitic infections
V75.9    Special screening examination for unspecified infectious disease
V76.0    Special screening for malignant neoplasms, respiratory organs
V76.10   Breast screening, unspecified
V76.11   Screening mammogram for high risk patient
V76.12   Other screening mammogram
V76.19   Other screening breast exam
V76.2    Special screening for malignant neoplasms, cervix
V76.3    Special screening for malignant neoplasms, bladder
V76.42   Special screening for malignant neoplasms, oral cavity
V76.43   Special screening for malignant neoplasms, skin
V76.44   Special screening for malignant neoplasms, prostate
V76.45   Special screening for malignant neoplasms, testis
V76.46   Special screening for malignant neoplasms, ovary
V76.47   Special screening for malignant neoplasms, vagina
V76.49   Special screening for malignant neoplasms, other
V76.50   Special screening for malignant neoplasms, intestine, unspecified
V76.51   Special screening for malignant neoplasms, colon
V76.52   Special screening for malignant neoplasms, small intestine
V76.81   Special screening for malignant neoplasms, nervous system
V76.89   Special screening for malignant neoplasms, other neoplasm
V76.9    Special screening for malignant neoplasms, unspecified
V77.0    Special screening for thyroid disorders
V77.1    Special screening for diabetes mellitus
V77.2    Special screening for malnutrition
V77.3    Special screening for phenylketonuria [PKU]
V77.4    Special screening for galactosemia
V77.5    Special screening for gout
V77.6    Special screening for cystic fibrosis
V77.7    Special screening for other inborn errors of metabolism
V77.8    Special screening for obesity
V77.91   Special screening for lipoid disorders
V77.99   Special screening for other disorders
V78.0    Special screening for iron deficiency anemia
V78.1    Special screening for other and unspecified deficiency anemia
V78.2    Special screening for sickle-cell disease or trait
V78.3    Special screening for other hemoglobinopathies
V78.8    Special screening for other disorders of blood and blood-forming organs
V78.9    Special screening for unspecified disorder of blood and blood-forming organs
V79.0    Special screening for depression
V79.1    Special screening for alcoholism
V79.2    Special screening for mental retardation
V79.3    Special screening for developmental handicaps in early childhood
V79.8    Special screening for other specified mental disorders and developmental handicaps



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NATIONAL COVERAGE DETERMINATION                                       Complete Blood Count

V79.9    Special screening for unspecified mental disorder and developmental handicaps
V80.0    Special screening for neurological conditions
V80.1    Special screening for glaucoma
V80.2    Special screening for other eye conditions
V80.3    Special screening for ear diseases
V81.0    Special screening for ischemic heart disease
V81.1    Special screening for hypertension
V81.2    Special screening for other and unspecified cardiovascular conditions
V81.3    Special screening for chronic bronchitis and emphysema
V81.4    Special screening for other and unspecified respiratory conditions
V81.5    Special screening for nephropathy
V81.6    Special screening for other and unspecified genitourinary conditions
V82.0    Special screening for skin conditions
V82.1    Special screening for rheumatoid arthritis
V82.2    Special screening for other rheumatic disorders
V82.3    Special screening for congenital dislocation of hip
V82.4    Special screening for postnatal screening for chromosomal anomalies
V82.5    Special screening for chemical poisoning and other contamination
V82.6    Multiphasic screening
V82.71   Screening for genetic disease carrier status
V82.79   Other genetic screening
V82.81   Special screening for osterporosis
V82.89   Special screening for other specified conditions
V82.9    Special screening for unspecified condition




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NATIONAL COVERAGE DETERMINATION                                                                             85610


NATIONAL COVERAGE DETERMINATION
85610
85610-Prothrombin time;




CPT CODE: 85610



CPT CODE DESCRIPTOR: Prothrombin time;



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS:

                          When an ESRD patient is tested for PT, testing more frequently than weekly
                          requires documentation of medical necessity [e.g. other than Chronic Renal Failure
                          (ICD-9-CM 585) or Renal Failure, Unspecified (ICD-9-CM 586)].

                          The need to repeat this test is determined by changes in the underlying medical
                          condition and/or the dosing of warfarin. In a patient on stable warfarin therapy, it is
                          ordinarily not necessary to repeat testing more than every two to three weeks.



COVERED ICD-9 CODES:
002.0 Typhoid fever
002.1 Paratyphoid fever A
002.2 Paratyphoid fever B
002.3 Paratyphoid fever C
002.9 Paratyphoid fever, unspecified
003.0 Salmonella gastroenteritis
003.1 Salmonella septicemia
003.20 Localized salmonella infection, unspecified
003.21 Salmonella meningitis
003.22 Salmonella pneumonia
003.23 Salmonella arthritis
003.24 Salmonella osteomyelitis
003.29 Other localized salmonella infection
003.8 Other specified salmonella infections
003.9 Salmonella infection, unspecified
038.9 Unspecified septicemia
042    Human immunodeficiency virus [HIV] disease
060.0 Sylvatic yellow fever
060.1 Urban yellow fever
060.9 Yellow fever, unspecified
065.0 Crimean hemorrhagic fever
065.1 Omsk hemorrhagic fever
065.2 Kyasanur Forest disease
065.3 Other tick-borne hemorrhagic fever
065.4 Mosquito-borne hemorrhagic fever
065.8 Other specified arthropod-borne hemorrhagic fever
065.9 Arthropod-borne hemorrhagic fever, unspecified
070.0 Viral hepatitis A with hepatic coma
070.1 Viral hepatitis A without hepatic coma
070.20 Viral hepatitis B with hepatic coma, acute or unspecified, without hepatitis delta
070.21 Viral hepatitis B with hepatic coma, acute or unspecified, with hepatitis delta
070.22 Viral hepatitis B with hepatic coma, chronic, without hepatitis delta


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NATIONAL COVERAGE DETERMINATION                                                                  85610

070.23   Viral hepatitis B with hepatic coma, chronic, with hepatitis delta
070.30   Viral hepatitis B without hepatic coma, acute or unspecified, without hepatitis delta
070.31   Viral hepatitis B without hepatic coma, acute or unspecified, with hepatitis delta
070.32   Viral hepatitis B without hepatic coma, chronic, without hepatitis delta
070.33   Viral hepatitis B without hepatic coma, chronic, with hepatitis delta
070.41   Acute hepatitis C with hepatic coma
070.42   Hepatitis delta without active hepatitis B disease with hepatic coma
070.43   Hepatitis E with hepatic coma
070.44   Chronic hepatitis C with hepatic coma
070.49   Other specified viral hepatitis with hepatic coma
070.51   Acute hepatitis C without mention of hepatic coma
070.52   Hepatitis delta without active hepatitis B disease or hepatic coma
070.53   Hepatitis E without hepatic coma
070.54   Chronic hepatitis C without hepatic coma
070.59   Other specified viral hepatitis without hepatic coma
070.6    Unspecified viral hepatitis with hepatic coma
070.70   Unspecified viral hepatitis C without hepatic coma
070.71   Unspecified viral hepatitis C with hepatic coma
070.9    Unspecified viral hepatitis without hepatic coma
075      Infectious mononucleosis
078.6    Hemorrhagic nephrosonephritis
078.7    Arenaviral hemorrhagic fever
084.8    Blackwater fever
120.0    Schistosoma haematobium
121.1    Clonorchiasis
121.3    Fascioliasis
124      Trichinosis
134.2    Hirudiniasis
135      Sarcoidosis
152.0    Malignant neoplasm of duodenum
152.1    Malignant neoplasm of jejunum
152.2    Malignant neoplasm of ileum
152.3    Malignant neoplasm of meckel's diverticulum
152.8    Malignant neoplasm of other specified sites of small intestine
152.9    Malignant neoplasm of small intestine, unspecified
155.0    Malignant neoplasm, liver, primary
155.1    Malignant neoplasm, intrahepatic bile ducts
155.2    Malignant neoplasm, liver, not specified as primary or
156.0    Malignant neoplasm, gallbladder
156.1    Malignant neoplasm, extrahepatic bile ducts
156.2    Malignant neoplasm, ampulla of Vater
156.8    Malignant neoplasm, other specified sites of gallbladder
156.9    Malignant neoplasm, biliary tract, part unspecified
157.0    Malignant neoplasm, head of pancreas
157.1    Malignant neoplasm, body of pancreas
157.2    Malignant neoplasm, tail of pancreas
157.3    Malignant neoplasm, pancreatic duct
157.4    Malignant neoplasm, islets of Langerhans
157.8    Malignant neoplasm, other specified sites of pancreas
157.9    Malignant neoplasm, pancreas, part unspecified
188.0    Malignant neoplasm of trigone of urinary bladder
188.1    Malignant neoplasm of dome of urinary bladder
188.2    Malignant neoplasm of lateral wall of urinary bladder



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NATIONAL COVERAGE DETERMINATION                                                              85610

188.3    Malignant neoplasm, anterior wall of urinary bladder
188.4    Malignant neoplasm, posterior wall of urinary bladder
188.5    Malignant neoplasm of bladder neck
188.6    Malignant neoplasm of ureteric orifice
188.7    Malignant neoplasm of urachus
188.8    Malignant neoplasm of other specified sites of bladder
188.9    Malignant neoplasm of bladder, part unspecified
189.0    Malignant neoplasm of kidney, except pelvis
189.1    Malignant neoplasm of renal pelvis
189.2    Malignant neoplasm of ureter
189.3    Malignant neoplasm of urethra
189.4    Malignant neoplasm of paraurethral glands
189.8    Malignant neoplasm of other specified sites of urinary organs
189.9    Malignant neoplasm of urinary organ, site unspecified
198.0    Secondary malignant neoplasm of kidney
198.1    Secondary malignant neoplasm of other urinary organs
200.00   Reticulosarcoma, unspecified site, extranodal and solid organ sites
200.01   Reticulosarcoma of lymph nodes of head, face, and neck
200.02   Reticulosarcoma of intrathoracic lymph nodes
200.03   Reticulosarcoma of intra-abdominal lymph nodes
200.04   Reticulosarcoma of lymph nodes of axilla and upper limb
200.05   Reticulosarcoma of lymph nodes of inguinal region and lower limb
200.06   Reticulosarcoma of intrapelvic lymph nodes
200.07   Reticulosarcoma of spleen
200.08   Reticulosarcoma, lymph nodes of multiple sites
200.10   Lymphosarcoma, unspecified site, extranodal and solid organ sites
200.11   Lymphosarcoma of lymph nodes of head, face, and neck
200.12   Lymphosarcoma of intrathoracic lymph nodes
200.13   Lymphosarcoma of intra-abdominal lymph nodes
200.14   Lymphosarcoma of lymph nodes of axilla and upper limb
200.15   Lymphosarcoma of lymph nodes of inguinal region and lower limb
200.16   Lymphosarcoma of intrapelvic lymph nodes
200.17   Lymphosarcoma of spleen
200.18   Lymphosarcoma, lymph nodes of multiple sites
200.20   Burkitt's tumor or lymphoma, unspecified site, extranodal and solid organ sites
200.21   Burkitt's tumor or lymphoma of lymph nodes of head, face, and neck
200.22   Burkitt's tumor or lymphoma of intrathoracic lymph nodes
200.23   Burkitt's tumor or lymphoma of intra-abdominal lymph nodes
200.24   Burkitt's tumor or lymphoma of lymph nodes of axilla and upper limb
200.25   Burkitt's tumor or lymphoma of lymph nodes of inguinal region and lower limb
200.26   Burkitt's tumor or lymphoma of intrapelvic lymph nodes
200.27   Burkitt's tumor or lymphoma of spleen
200.28   Burkitt's tumor or lymphoma, lymph nodes of multiple sites
200.30   Marginal zone lymphoma, unspecified site, extranodal and solid organ sites
200.31   Marginal zone lymphoma, lymph nodes of head, face, and neck
200.32   Marginal zone lymphoma, intrathoracic lymph nodes
200.33   Marginal zone lymphoma, intraabdominal lymph nodes
200.34   Marginal zone lymphoma, lymph nodes of axilla and upper limb
200.35   Marginal zone lymphoma, lymph nodes of inguinal region and lower limb
200.36   Marginal zone lymphoma, intrapelvic lymph nodes
200.37   Marginal zone lymphoma, spleen
200.38   Marginal zone lymphoma, lymph nodes of multiple sites
200.40   Mantle cell lymphoma, unspecified site, extranodal and solid organ sites



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NATIONAL COVERAGE DETERMINATION                                                          85610

200.41   Mantle cell lymphoma, lymph nodes of head, face, and neck
200.42   Mantle cell lymphoma, intrathoracic lymph nodes
200.43   Mantle cell lymphoma, intra-abdominal lymph nodes
200.44   Mantle cell lymphoma, lymph nodes of axilla and upper limb
200.45   Mantle cell lymphoma, lymph nodes of inguinal region and lower limb
200.46   Mantle cell lymphoma, intrapelvic lymph nodes
200.47   Mantle cell lymphoma, spleen
200.48   Mantle cell lymphoma, lymph nodes of multiple sites
200.50   Primary central nervous system lymphoma, unspecified site, extranodal and solid organ
         sites
200.51   Primary central nervous system lymphoma, lymph nodes of head, face, and neck
200.52   Primary central nervous system lymphoma, intrathoracic lymph nodes
200.53   Primary central nervous system lymphoma, intra-abdominal lymph nodes
200.54   Primary central nervous system lymphoma, lymph nodes of axilla and upper limb
200.55   Primary central nervous system lymphoma, lymph nodes of inguinal region and lower
         limb
200.56   Primary central nervous system lymphoma, intrapelvic lymph nodes
200.57   Primary central nervous system lymphoma, spleen
200.58   Primary central nervous system lymphoma, lymph nodes of multiple sites
200.60   Anaplastic large cell lymphoma, unspecified site, extranodal and solid organ sites
200.61   Anaplastic large cell lymphoma, lymph nodes of head, face, and neck
200.62   Anaplastic large cell lymphoma, intrathoracic lymph nodes
200.63   Anaplastic large cell lymphoma, intra-abdominal lymph nodes
200.64   Anaplastic large cell lymphoma, lymph nodes of axilla and upper limb
200.65   Anaplastic large cell lymphoma, lymph nodes of inguinal region and lower limb
200.66   Anaplastic large cell lymphoma, intrapelvic lymph nodes
200.67   Anaplastic large cell lymphoma, spleen
200.68   Anaplastic large cell lymphoma, lymph nodes of multiple sites
200.70   Large cell lymphoma, unspecified site, extranodal and solid organ sites
200.71   Large cell lymphoma, lymph nodes of head, face, and neck
200.72   Large cell lymphoma, intrathoracic lymph nodes
200.73   Large cell lymphoma, intra-abdominal lymph nodes
200.74   Large cell lymphoma, lymph nodes of axilla and upper limb
200.75   Large cell lymphoma, lymph nodes of inguinal region and lower limb
200.76   Large cell lymphoma, intrapelvic lymph nodes
200.77   Large cell lymphoma, spleen
200.78   Large cell lymphoma, lymph nodes of multiple sites
200.80   Other named variants of lymphosarcoma and reticulosarcoma, unspecified site,
         extranodal and solid organ sites
200.81   Other named variants of lymphosarcoma and reticulosarcoma of lymph nodes of head,
         face, and neck
200.82   Other named variants of lymphosarcoma and reticulosarcoma of intrathoracic lymph
         nodes
200.83   Other named variants of lymphosarcoma and reticulosarcoma of intra-abdominal lymph
         nodes
200.84   Other named variants of lymphosarcoma and reticulosarcoma of lymph nodes of axilla
         and upper limb
200.85   Other named variants of lymphosarcoma and reticulosarcoma of lymph nodes of inguinal
         region and lower limb
200.86   Other named variants of lymphosarcoma and reticulosarcoma of intrapelvic lymph nodes
200.87   Other named variants of lymphosarcoma and reticulosarcoma of spleen
200.88   Other named variants of lymphosarcoma and reticulosarcoma of lymph nodes, multiple
         sites



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NATIONAL COVERAGE DETERMINATION                                                               85610

202.00   Nodular lymphoma, unspecified site, extranodal and solid organ sites
202.01   Nodular lymphoma, lymph nodes of head, face, and neck
202.02   Nodular lymphoma, intrathoracic lymph nodes
202.03   Nodular lymphoma, intra-abdominal lymph nodes
202.04   Nodular lymphoma, lymph nodes of axilla and upper limb
202.05   Nodular lymphoma, lymph nodes of inguinal region and lower limb
202.06   Nodular lymphoma, intrapelvic lymph nodes
202.07   Nodular lymphoma, spleen
202.08   Nodular lymphoma, lymph nodes of multiple sites
202.10   Mycosis fungoides, unspecified site, extranodal and solid organ sites
202.11   Mycosis fungoides, lymph nodes of head, face, and neck
202.12   Mycosis fungoides, intrathoracic lymph nodes
202.13   Mycosis fungoides, intra-abdominal lymph nodes
202.14   Mycosis fungoides, lymph nodes of axilla and upper limb
202.15   Mycosis fungoides, lymph nodes of inguinal region and lower limb
202.16   Mycosis fungoides, intrapelvic lymph nodes
202.17   Mycosis fungoides, spleen
202.18   Mycosis fungoides, lymph nodes of multiple sites
202.20   Sézary's disease, unspecified site, extranodal and solid organ sites
202.21   Sézary's disease, lymph nodes of head, face, and neck
202.22   Sézary's disease, intrathoracic lymph nodes
202.23   Sézary's disease, intra-abdominal lymph nodes
202.24   Sézary's disease, lymph nodes of axilla and upper limb
202.25   Sézary's disease, lymph nodes of inguinal region and lower limb
202.26   Sézary's disease, intrapelvic lymph nodes
202.27   Sézary's disease, spleen
202.28   Sézary's disease, lymph nodes of multiple sites
202.30   Malignant histiocytosis, unspecified site, extranodal and solid organ sites
202.31   Malignant histiocytosis, lymph nodes of head, face, and neck
202.32   Malignant histiocytosis, intrathoracic lymph nodes
202.33   Malignant histiocytosis, intra-abdominal lymph nodes
202.34   Malignant histiocytosis, lymph nodes of axilla and upper limb
202.35   Malignant histiocytosis, lymph nodes of inguinal region and lower limb
202.36   Malignant histiocytosis, intrapelvic lymph nodes
202.37   Malignant histiocytosis, spleen
202.38   Malignant histiocytosis, lymph nodes of multiple sites
202.40   Leukemic reticuloendotheliosis, unspecified site, extranodal and solid organ sites
202.41   Leukemic reticuloendotheliosis, lymph nodes of head, face, and neck
202.42   Leukemic reticuloendotheliosis, intrathoracic lymph nodes
202.43   Leukemic reticuloendotheliosis, intra-abdominal lymph nodes
202.44   Leukemic reticuloendotheliosis, lymph nodes of axilla and upper limb
202.45   Leukemic reticuloendotheliosis, lymph nodes of inguinal region and lower limb
202.46   Leukemic reticuloendotheliosis, intrapelvic lymph nodes
202.47   Leukemic reticuloendotheliosis, spleen
202.48   Leukemic reticuloendotheliosis, lymph nodes of multiple sites
202.50   Letterer-Siwe disease, unspecified site, extranodal and solid organ sites
202.51   Letterer-Siwe disease, lymph nodes of head, face, and neck
202.52   Letterer-Siwe disease, intrathoracic lymph nodes
202.53   Letterer-Siwe disease, intra-abdominal lymph nodes
202.54   Letterer-Siwe disease, lymph nodes of axilla and upper limb
202.55   Letterer-Siwe disease, lymph nodes of inguinal region and lower limb
202.56   Letterer-Siwe disease, intrapelvic lymph nodes
202.57   Letterer-Siwe disease, spleen



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NATIONAL COVERAGE DETERMINATION                                                          85610

202.58   Letterer-Siwe disease, lymph nodes of multiple sites
202.60   Malignant mast cell tumors, unspecified site, extranodal and solid organ sites
202.61   Malignant mast cell tumors, lymph nodes of head, face, and neck
202.62   Malignant mast cell tumors, intrathoracic lymph nodes
202.63   Malignant mast cell tumors, intra-abdominal lymph nodes
202.64   Malignant mast cell tumors, lymph nodes of axilla and upper limb
202.65   Malignant mast cell tumors, lymph nodes of inguinal region and lower limb
202.66   Malignant mast cell tumors, intrapelvic lymph nodes
202.67   Malignant mast cell tumors, spleen
202.68   Malignant mast cell tumors, lymph nodes of multiple sites
202.70   Peripheral T cell lymphoma, unspecified site, extranodal and solid organ sites
202.71   Peripheral T cell lymphoma, lymph nodes of head, face, and neck
202.72   Peripheral T cell lymphoma, intrathoracic lymph nodes
202.73   Peripheral T cell lymphoma, intra-abdominal lymph nodes
202.74   Peripheral T cell lymphoma, lymph nodes of axilla and upper limb
202.75   Peripheral T cell lymphoma, lymph nodes of inguinal region and lower limb
202.76   Peripheral T cell lymphoma, intrapelvic lymph nodes
202.77   Peripheral T cell lymphoma, spleen
202.78   Peripheral T cell lymphoma, lymph nodes of multiple sites
202.80   Other lymphomas, unspecified site, extranodal and solid organ sites
202.81   Other lymphomas, lymph nodes of head, face, and neck
202.82   Other lymphomas, intrathoracic lymph nodes
202.83   Other lymphomas, intra-abdominal lymph nodes
202.84   Other lymphomas, lymph nodes of axilla and upper limb
202.85   Other lymphomas, lymph nodes of inguinal region and lower limb
202.86   Other lymphomas, intrapelvic lymph nodes
202.87   Other lymphomas, spleen
202.88   Other lymphomas, lymph nodes of multiple sites
202.90   Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue,
         unspecified site, extranodal and solid organ sites
202.91   Other and unspecified malignant neoplasms, lymph nodes of head, face, and neck
202.92   Other and unspecified malignant neoplasms, intrathoracic lymph nodes
202.93   Other and unspecified malignant neoplasms, intra-abdominal lymph nodes
202.94   Other and unspecified malignant neoplasms, lymph nodes of axilla and upper limb
202.95   Other and unspecified malignant neoplasms, lymph nodes of inguinal region and lower
         limb
202.96   Other and unspecified malignant neoplasms, intrapelvic lymph nodes
202.97   Other and unspecified malignant neoplasms, spleen
202.98   Other and unspecified malignant neoplasms, lymph nodes of multiple sites
223.0    Benign neoplasm of kidney, except pelvis
223.1    Benign neoplasm of renal pelvis
223.2    Benign neoplasm of ureter
223.3    Benign neoplasm of bladder
223.81   Benign neoplasm of urethra
223.89   Benign neoplasm of other sites of urinary organs
223.9    Urinary organ, site unspecified
238.4    Polycythemia vera
238.5    Histiocytic and mast cells
238.6    Plasma cells
238.71   Essential thrombocythemia
238.72   Low grade myelodysplastic syndrome lesions
238.73   High grade myelodysplastic syndrome lesions
238.74   Myelodysplastic syndrome with 5q deletion



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NATIONAL COVERAGE DETERMINATION                                                                85610

238.75   Myelodysplastic syndrome, unspecified
238.76   Myelofibrosis with myeloid metaplasia
238.79   Other lymphatic and hematopoietic tissues
239.4    Neoplasms of unspecified nature of bladder
239.5    Neoplasms of unspecified nature of other genitourinary organs
239.9    Neoplasms of unspecified nature, site unspecified
246.3    Hemorrhage and infarction of thyroid
250.40   Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41   Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42   Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43   Diabetes with renal manifestations, type I, uncontrolled
263.0    Malnutrition of moderate degree
263.1    Malnutrition of mild degree
263.2    Arrested development following protein-calorie malnutrition
263.8    Other protein-calorie malnutrition
263.9    Unspecified protein-calorie malnutrition
269.0    Vitamin K deficiency
269.2    Unspecified vitamin deficiency
273.0    Polyclonal hypergammaglobulinemia
273.1    Monoclonal paraproteinemia
273.2    Other paraproteinemias
273.3    Macroglobulinemia
273.8    Other disorders of plasma protein metabolism
273.9    Unspecified disorder of plasma protein metabolism
275.0    Disorders of iron metabolism
277.1    Disorders of porphyrin metabolism
277.30   Amyloidosis, unspecified
277.31   Familial Mediterranean fever
277.39   Other amyloidosis
280.0    Iron deficiency anemia, unspecified
280.9    Iron deficiency anemia, unspecified
281.0    Pernicious anemia
281.1    Other vitamin B12 deficiency anemia
281.9    Unspecified deficiency anemia
285.0    Sideroblastic anemia
285.1    Acute posthemorrhagic anemia
286.0    Congenital factor VIII disorder
286.1    Congenital factor IX disorder
286.2    Congenital factor XI deficiency
286.3    Congenital deficiency of other clotting factors
286.4    von Willebrand's disease
286.5    Hemorrhagic disorder due to circulating anticoagulants
286.6    Defibrination syndrome
286.7    Acquired coagulation factor deficiency
286.9    Other and unspecified coagulation defects
287.0    Allergic purpura
287.1    Qualitative platelet defects
287.2    Other nonthrombocytopenic purpuras
287.30   Primary thrombocytopenia, unspecified
287.31   Immune thrombocytopenic purpura
287.32   Evans' syndrome
287.33   Congenital and hereditary thrombocytopenic purpura
287.39   Other primary thrombocytopenia



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287.4    Secondary thrombocytopenia
287.5    Thrombocytopenia, unspecified
287.8    Other specified hemorrhagic conditions
287.9    Unspecified hemorrhagic conditions
289.81   Primary hypercoagulable state
290.40   Vascular dementia,uncomplicated
290.41   Vascular dementia with delirium
290.42   Vascular dementia with delusions
290.43   Vascular dementia with depressed mood
325      Phlebitis and thrombophlebitis of intracranial venous sinuses
342.90   Hemiplegia, unspecified, affecting unspecified side
342.91   Hemiplegia, unspecified, affecting dominant side
342.92   Hemiplegia, unspecified, affecting nondominant side
360.43   Hemophthalmos, except current injury
362.18   Retinal vasculitis
362.30   Retinal vascular occlusion, unspecified
362.31   Central retinal artery occlusion
362.32   Arterial branch occlusion
362.33   Partial arterial occlusion
362.34   Transient arterial occlusion
362.35   Central retinal vein occlusion
362.36   Venous tributary (branch) occlusion
362.37   Venous engorgement
362.43   Hemorrhagic detachment of retinal pigment epithelium
362.81   Retinal hemorrhage
363.61   Choroidal hemorrhage, unspecified
363.62   Expulsive choroidal hemorrhage
363.63   Choroidal rupture
363.70   Choroidal detachment, unspecified
363.71   Serous choroidal detachment
363.72   Hemorrhagic choroidal detachment
368.9    Unspecified visual disturbance
372.72   Conjunctival hemorrhage
374.81   Hemorrhage of eyelid
376.32   Orbital hemorrhage
377.42   Hemorrhage in optic nerve sheaths
377.53   Disorders of optic chiasm, associated with vascular disorders
377.62   Disorders of other visual pathways, associated with vascular disorders
377.72   Disorders of visual cortex, associated with vascular disorders
379.23   Vitreous hemorrhage
380.31   Hematoma of auricle or pinna
386.2    Vertigo of central origin
386.50   Labyrinthine dysfunction, unspecified
394.0    Mitral stenosis
394.1    Rheumatic mitral insufficiency
394.2    Mitral stenosis with insufficiency
394.9    Other and unspecified mitral valve diseases
395.0    Rheumatic aortic stenosis
395.2    Rheumatic aortic stenosis with insufficiency
396.0    Mitral valve stenosis and aortic valve stenosis
396.1    Mitral valve stenosis and aortic valve insufficiency
396.2    Mitral valve insufficiency and aortic valve stenosis
396.3    Mitral valve insufficiency and aortic valve insufficiency



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396.8    Multiple involvement of mitral and aortic valves
396.9    Mitral and aortic valve diseases, unspecified
397.0    Diseases of tricuspid valve
397.1    Rheumatic diseases of pulmonary valve
397.9    Rheumatic diseases of endocardium, valve unspecified
398.0    Rheumatic myocarditis
398.90   Rheumatic heart disease, unspecified
398.91   Rheumatic heart failure (congestive)
398.99   Other Rheumatic heart disease
403.01   Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or
         end stage renal disease
403.11   Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end
         stage renal disease
403.91   Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or
         end stage renal disease
404.02   Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.12   Hypertensive heart and chronic kidney disease, benign, without heart failure and with
         chronic kidney disease stage V or end stage renal disease
404.92   Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
         with chronic kidney disease stage V or end stage renal disease
410.00   Infarction of anterolateral wall, episode of care unspecified
410.01   Infarction of anterolateral wall, initial episode of care
410.02   Infarction of anterolateral wall, subsequent episode of care
410.10   Infarction of other anterior wall, episode of care unspecified
410.11   Infarction of other anterior wall, initial episode of care
410.12   Infarction of other anterior wall, subsequent episode of care
410.20   Infarction of inferolateral wall, episode of care unspecified
410.21   Infarction of inferolateral wall, initial episode of care
410.22   Infarction of inferolateral wall, subsequent episode of care
410.30   Infarction of inferoposterior wall, episode of care unspecified
410.31   Infarction of inferoposterior wall, initial episode of care
410.32   Infarction of inferoposterior wall,subsequent episode of care
410.40   Infarction of other inferior wall, episode of care unspecified
410.41   Infarction of other inferior wal, initial episode of care
410.42   Infarction of other inferior wall, subsequent episode of care
410.50   Infarction of other lateral wall, episode of care unspecified
410.51   Infarction of other lateral wall, initial episode of care
410.52   Infarction of other lateral wall, subsequent episode of care
410.60   True posterior wall infarction, episode of care unspecified
410.61   True posterior wall infarction, initial episode of care
410.62   True posterior wall infarction, subsequent episode of care
410.70   Subendocardial infarction, episode of care unspecified
410.71   Subendocardial infarction, initial episode of care
410.72   Subendocardial infarction, subsequent episode of care
410.80   Infarction of other specified sites, episode of care unspecified
410.81   Infarction of other specified sites, initial episode of care
410.82   Infarction of other specified sites, subsequent episode of care
410.90   Infarction, unspecified site, episode of care unspecified
410.91   Infarction, unspecified site, initial episode of care
410.92   Infarction, unspecified site, subsequent episode of care
411.1    Intermediate coronary syndrome
411.81   Coronary occlusion without myocardial infarction



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411.89   Other ischemic heart disease
413.0    Angina decubitus
413.1    Prinzmetal angina
413.9    Other and unspecified angina pectoris
414.00   Coronary atherosclerosis of unspecified vessel
414.01   Coronary atherosclerosis of native coronary artery
414.02   Coronary atherosclerosis of autologous biological bypass graft
414.03   Coronary atherosclerosis of nonautologous biological bypass graft
414.04   Coronary atherosclerosis of artery bypass graft
414.05   Coronary atherosclerosis of unspecified bypass graft
414.06   Coronary atherosclerosis of native coronary artery of transplanted heart
414.07   Coronary atherosclerosis, of bypass graft of transplanted heart
414.8    Other specified forms of chronic ischemic heart disease
414.9    Chronic ischemic heart disease, unspecified
415.0    Acute cor pulmonale
415.11   Iatrogenic pulmonary embolism and infarction
415.12   Septic pulmonary embolism
415.19   Other pulmonary embolism and infarction
416.9    Chronic pulmonary heart disease, unspecified
423.0    Hemopericardium
424.0    Mitral valve disorders
424.1    Aortic valve disorders
424.90   Endocarditis, valve unspecified, unspecified cause
425.0    Endomyocardial fibrosis
425.1    Hypertrophic obstructive cardiomyopathy
425.2    Obscure cardiomyopathy of Africa
425.3    Endocardial fibroelastosis
425.4    Other primary cardiomyopathies
425.5    Alcoholic cardiomyopathy
425.7    Nutritional and metabolic cardiomyopathy
425.8    Cardiomyopathy in other diseases classified elsewhere
425.9    Secondary cardiomyopathy, unspecified
427.0    Paroxysmal supraventricular tachycardia
427.1    Paroxysmal ventricular tachycardia
427.2    Paroxysmal tachycardia, unspecified
427.31   Atrial fibrillation
427.32   Atrial flutter
427.41   Ventricular fibrillation
427.42   Ventricular flutter
427.5    Cardiac arrest
427.60   Premature beats, unspecified
427.61   Supraventricular premature beats
427.69   Other Premature beats
427.81   Sinoatrial node dysfunction
427.89   Other node dysfunction
427.9    Cardiac dysrhythmia, unspecified
428.0    Congestive heart failure
428.1    Left heart failure
428.20   Systolic heart failure, unspecified
428.21   Systolic heart failure, acute
428.22   Systolic heart failure, chronic
428.23   Systolic heart failure, acute on chronic
428.30   Diastolic heart failure, unspecified



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428.31   Diastolic heart failure, acute
428.32   Diastolic heart failure, chronic
428.33   Diastolic heart failure, acute on chronic
428.40   Combined systolic and diastolic heart failure, unspecified
428.41   Combined systolic and diastolic heart failure, acute
428.42   Combined systolic and diastolic heart failure, chronic
428.43   Combined systolic and diastolic heart failure, acute on chronic
428.9    Heart failure, unspecified
429.0    Myocarditis, unspecified
429.1    Myocardial degeneration
429.2    Cardiovascular disease, unspecified
429.3    Cardiomegaly
429.4    Functional disturbances following cardiac surgery
429.79   Other cardiac defect
430      Subarachnoid hemorrhage
431      Intracerebral hemorrhage
432.0    Nontraumatic extradural hemorrhage
432.1    Subdural hemorrhage
432.9    Unspecified intracranial hemorrhage
433.00   Occlusion and stenosis, basilar artery without cerebral infarction
433.01   Occlusion and stenosis, basilar artery with cerebral infarction
433.10   Occlusion and stenosis, carotid artery without cerebral infarction
433.11   Occlusion and stenosis, carotid artery with cerebral infarction
433.20   Occlusion and stenosis, vertebral artery without cerebral infarction
433.21   Occlusion and stenosis, vertebral artery with cerebral infarction
433.30   Occlusion and stenosis, multiple and bilateral without cerebral infarction
433.31   Occlusion and stenosis, multiple and bilateral with cerebral infarction
433.80   Occlusion and stenosis, other specified precerebral artery without cerebral infarction
433.81   Occlusion and stenosis, with cerebral infarction
433.90   Occlusion and stenosis, unspecified precerebral artery without cerebral infarction
433.91   Occlusion and stenosis, unspecified precerebral artery with cerebral infarction
434.00   Cerebral thrombosis without cerebral infarction
434.01   Cerebral thrombosis with cerebral infarction
434.10   Cerebral embolism without cerebral infarction
434.11   Cerebral embolism with cerebral infarction
434.90   Cerebral artery occlusion, unspecified without cerebral infarction
434.91   Cerebral artery occlusion, unspecified with cerebral infarction
435.0    Basilar artery syndrome
435.1    Vertebral artery syndrome
435.2    Subclavian steal syndrome
435.3    Vertebrobasilar artery syndrome
435.8    Other specified transient cerebral ischemias
435.9    Unspecified transient cerebral ischemia
436      Acute, but ill-defined, cerebrovascular disease
437.0    Cerebral atherosclerosis
437.1    Other generalized ischemic cerebrovascular disease
437.6    Nonpyogenic thrombosis of intracranial venous sinus
440.0    Atherosclerosis of aorta
440.1    Atherosclerosis of renal artery
440.20   Atherosclerosis of the extremities, unspecified
440.21   Atherosclerosis of the extremities with intermittent claudication
440.22   Atherosclerosis of the extremities with rest pain
440.23   Atherosclerosis of the extremities with ulceration



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440.24   Atherosclerosis of the extremities with gangrene
440.29   Other atherosclerosis of the extremities
440.30   Atherosclerosis of unspecified graft
440.31   Atherosclerosis of autologous vein bypass graft
440.32   Atherosclerosis of nonautologous vein bypass graft
440.4    Chronic total occlusion of artery of the extremities
440.8    Atherosclerosis of other specified arteries
440.9    Generalized and unspecified atherosclerosis
441.00   Dissection of aorta, unspecified site
441.01   Dissection of aorta, thoracic
441.02   Dissection of aorta, abdominal
441.03   Dissection of aorta, thoracoabdominal
441.1    Thoracic aneurysm, ruptured
441.2    Thoracic aneurysm without rupture
441.3    Abdominal aneurysm, ruptured
441.4    Abdominal aneurysm without rupture
441.5    Aortic aneurysm of unspecified site, ruptured
441.6    Thoracoabdominal aneurysm, ruptured
441.7    Thoracoabdominal aneurysm, without rupture
441.9    Aortic aneurysm of unspecified site without rupture
443.0    Raynaud's syndrome
443.1    Thromboangiitis obliterans [Buerger's disease]
443.21   Dissection of carotid artery
443.22   Dissection of iliac artery
443.23   Dissection of renal artery
443.24   Dissection of vertebral artery
443.29   Dissection of other artery
443.81   Peripheral angiopathy in diseases classified elsewhere
443.82   Erythromelalgia
443.89   Other peripheral angiopathy
443.9    Peripheral vascular disease, unspecified
444.0    Arterial embolism and thrombosis of abdominal aorta
444.1    Arterial embolism and thrombosis of thoracic aorta
444.21   Arterial embolism and thrombosis, upper extremity
444.22   Arterial embolism and thrombosis, lower extremity
444.81   Arterial embolism and thrombosis, iliac artery
444.89   Arterial embolism and thrombosis, other
444.9    Arterial embolism and thrombosis of unspecified artery
447.1    Stricture of artery
447.2    Rupture of artery
447.6    Arteritis, unspecified
448.0    Hereditary hemorrhagic telangiectasia
448.9    Other and unspecified capillary diseases
451.0    Phlebitis and thrombophlebitis of superficial vessels of lower extremities
451.11   Phlebitis and thrombophlebitis, femoral vein
451.19   Phlebitis and thrombophlebitis, other
451.2    Phlebitis and thrombophlebitis of lower extremities, unspecified
451.81   Phlebitis and thrombophlebitis, iliac vein
451.82   Phlebitis and thrombophlebitis of superficial veins of upper extremities
451.83   Phlebitis and thrombophlebitis of deep veins of upper extremities
451.84   Phlebitis and thrombophlebitis of upper extremities, unspecified
451.89   Phlebitis and thrombophlebitis other sites
451.9    Phlebitis and thrombophlebitis of unspecified site



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452    Portal vein thrombosis
453.0  Budd-Chiari syndrome
453.1  Thrombophlebitis migrans
453.2  Embolism and thrombosis of vena cava
453.3  Embolism and thrombosis of renal vein
453.40 Venous embolism and thrombosis of unspecified deep vessels of lower extremity
453.41 Venous embolism and thrombosis of deep vessels of proximal lower extremity
453.42 Venous embolism and thrombosis of deep vessels of distal lower extremity
453.8  Embolism and thrombosis of other specified veins
453.9  Embolism and thrombosis of unspecified site
455.2  Internal hemorrhoids with other complication
455.5  External hemorrhoids with other complication
455.8  Unspecified hemorrhoids with other complication
456.0  Esophageal varices with bleeding
456.1  Esophageal varices without bleeding
456.8  Varices of other sites
459.0  Hemorrhage, unspecified
459.10 Postphlebitic syndrome without complications
459.11 Postphlebitic syndrome with ulcer
459.12 Postphlebitic syndrome with inflammation
459.13 Postphlebitic syndrome with ulcer and inflammation
459.19 Postphlebitic syndrome with other complication
459.2  Compression of vein
459.81 Venous (peripheral) insufficiency, unspecified
459.89 Other specified disorders of circulatory system
511.8  Other specified forms of effusion, except tuberculous
514    Pulmonary congestion and hypostasis
530.7  Gastroesophageal laceration-hemorrhage syndrome
530.82 Esophageal hemorrhage
530.86 Infection of esophagostomy
530.87 Mechanical complication of esophagostomy
531.00 Peptic ulcer, acute with hemorrhage without obstruction
531.01 Peptic ulcer, acute with hemorrhage with obstruction
531.10 Peptic ulcer, acute with perforation without obstruction
531.11 Peptic ulcer, acute with perforation with obstruction
531.20 Peptic ulcer, acute with hemorrhage and perforation without obstruction
531.21 Peptic ulcer, acute with hemorrhage and perforation with obstruction
531.30 Peptic ulcer, acute without hemorrhage or perforation without obstruction
531.31 Peptic ulcer, acute without hemorrhage or perforation with obstruction
531.40 Peptic ulcer, chronic or unspecified with hemorrhage without obstruction
531.41 Peptic ulcer, chronic or unspecified with hemorrhage with obstruction
531.50 Peptic ulcer, chronic or unspecified with perforation without obstruction
531.51 Peptic ulcer, chronic or unspecified with perforation with obstruction
531.60 Peptic ulcer, chronic or unspecified with hemorrhage and perforation without obstruction
531.61 Peptic ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
531.70 Peptic ulcer, chronic without hemorrhage or perforation without obstruction
531.71 Peptic ulcer, chronic without hemorrhage or perforation with obstruction
531.90 Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation without
       obstruction
531.91 Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation with
       obstruction
532.00 Peptic ulcer, acute with hemorrhage without obstruction
532.01 Peptic ulcer, acute with hemorrhage with obstruction



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532.10   Peptic ulcer, acute with perforation without obstruction
532.11   Peptic ulcer, acute with perforation with obstruction
532.20   Peptic ulcer, acute with hemorrhage and perforation without obstruction
532.21   Peptic ulcer, acute with hemorrhage and perforation with obstruction
532.30   Peptic ulcer, acute without hemorrhage or perforation without obstruction
532.31   Peptic ulcer, acute without hemorrhage or perforation with obstruction
532.40   Peptic ulcer, chronic or unspecified with hemorrhage without obstruction
532.41   Peptic ulcer, chronic or unspecified with hemorrhage with obstruction
532.50   Peptic ulcer, chronic or unspecified with perforation without obstruction
532.51   Peptic ulcer, chronic or unspecified with perforation with obstruction
532.60   Peptic ulcer, chronic or unspecified with hemorrhage and perforation without obstruction
532.61   Peptic ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
532.70   Peptic ulcer, chronic without hemorrhage or perforation without obstruction
532.71   Peptic ulcer, chronic without hemorrhage or perforation with obstruction
532.90   Peptic ulcer, unspecified as acute or chronic without obstruction
532.91   Peptic ulcer, unspecified as acute or chronic with obstruction hemorrhage or perforation
533.00   Peptic ulcer, acute with hemorrhage without obstruction
533.01   Peptic ulcer, acute with hemorrhage with obstruction
533.10   Peptic ulcer, acute with perforation without obstruction
533.11   Peptic ulcer, acute with perforation with obstruction
533.20   Peptic ulcer, acute with hemorrhage and perforation without obstruction
533.21   Peptic ulcer, acute with hemorrhage and perforation with obstruction
533.30   Peptic ulcer, acute without hemorrhage and perforation without obstruction
533.31   Peptic ulcer, acute without hemorrhage and perforation with obstruction
533.40   Peptic ulcer, chronic or unspecified with hemorrhage without obstruction
533.41   Peptic ulcer, chronic or unspecified with hemorrhage with obstruction
533.50   Peptic ulcer, chronic or unspecified with perforation without obstruction
533.51   Peptic ulcer, chronic or unspecified with perforation with obstruction
533.60   Peptic ulcer, chronic or unspecified with hemorrhage and perforation without obstruction
533.61   Peptic ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
533.70   Peptic ulcer, chronic without hemorrhage or perforation without obstruction
533.71   Peptic ulcer, chronic without hemorrhage or perforation with obstruction
533.90   Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation without
         obstruction
533.91   Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation with
         obstruction
534.00   Gastrojejunal ulcer, acute with hemorrhage without obstruction
534.01   Gastrojejunal ulcer, acute with hemorrhage with obstruction
534.10   Gastrojejunal ulcer, acute with perforation without obstruction
534.11   Gastrojejunal ulcer, acute with perforation with obstruction
534.20   Gastrojejunal ulcer, acute with hemorrhage and perforation without obstruction
534.21   Gastrojejunal ulcer, acute with hemorrhage and perforation with obstruction
534.30   Gastrojejunal ulcer, acute without hemorrhage or perforation without obstruction
534.31   Gastrojejunal ulcer, acute without hemorrhage or perforation with obstruction
534.40   Gastrojejunal ulcer, chronic or unspecified with hemorrhage without obstruction
534.41   Gastrojejunal ulcer, chronic or unspecified with hemorrhage with obstruction
534.50   Gastrojejunal ulcer, chronic or unspecified with perforation without obstruction
534.51   Gastrojejunal ulcer, chronic or unspecified with perforation with obstruction
534.60   Gastrojejunal ulcer, chronic or unspecified with hemorrhage and perforation without
         obstruction
534.61   Gastrojejunal ulcer, chronic or unspecified with hemorrhage and perforation with
         obstruction




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534.70 Gastrojejunal ulcer, chronic without hemorrhage or perforation without mention of
       obstruction
534.71 Gastrojejunal ulcer, chronic without hemorrhage or perforation with obstruction
534.90 Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
       without obstruction
534.91 Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
       with obstruction
535.00 Acute gastritis without hemorrhage
535.01 Acute gastritis with hemorrhage
535.10 Atrophic gastritis without hemorrhage
535.11 Atrophic gastritis with hemorrhage
535.20 Gastric mucosal hypertrophy without hemorrhage
535.21 Gastric mucosal hypertrophy with hemorrhage
535.30 Alcoholic gastritis without hemorrhage
535.31 Alcoholic gastritis with hemorrhage
535.40 Other specified gastritis without hemorrhage
535.41 Other specified gastritis with hemorrhage
535.50 Unspecified gastritis and gastroduodenitis without hemorrhage
535.51 Unspecified gastritis and gastroduodenitis with hemorrhage
535.60 Duodenitis without hemorrhage
535.61 Duodenitis with hemorrhage
555.0 Regional enteritis, small intestine
555.1 Regional enteritis, large intestine
555.2 Regional enteritis, small intestine with large intestine
555.9 Regional enteritis, unspecified site
556.0 Ulcerative (chronic) enterocolitis
556.1 Ulcerative (chronic) ileocolitis
556.2 Ulcerative (chronic) proctitis
556.3 Ulcerative (chronic) proctosigmoiditis
556.4 Pseudopolyposis of colon
556.5 Left-sided ulcerative (chronic) colitis
556.6 Universal ulcerative (chronic) colitis
556.8 Other ulcerative colitis
556.9 Ulcerative colitis, unspecified
557.0 Acute vascular insufficiency of intestine
557.1 Chronic vascular insufficiency of intestine
557.9 Unspecified vascular insufficiency of intestine
562.02 Diverticulosis of small intestine with hemorrhage
562.03 Diverticulitis of small intestine with hemorrhage
562.10 Diverticulosis of colon without hemorrhage
562.11 Diverticulitis of colon without hemorrhage
562.12 Diverticulosis of colon with hemorrhage
562.13 Diverticulitis of colon with hemorrhage
568.81 Hemoperitoneum (nontraumatic)
569.3 Hemorrhage of rectum and anus
571.0 Alcoholic fatty liver
571.1 Acute alcoholic hepatitis
571.2 Alcoholic cirrhosis of liver
571.3 Alcoholic liver damage, unspecified
571.40 Chronic hepatitis, unspecified
571.41 Chronic persistent hepatitis
571.49 Other chronic hepatitis
571.5 Cirrhosis of liver without mention of alcohol



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571.6    Biliary cirrhosis
571.8    Other chronic nonalcoholic liver disease
571.9    Unspecified chronic liver disease without mention of
572.2    Hepatic coma
572.4    Hepatorenal syndrome
572.8    Other sequelae of chronic liver disease
573.1    Hepatitis in viral diseases classified elsewhere
573.2    Hepatitis in other infectious diseases classified elsewhere
573.3    Hepatitis, unspecified
573.4    Hepatic infarction
573.8    Other specified disorders of liver
573.9    Unspecified disorder of liver
576.0    Postcholecystectomy syndrome
576.1    Cholangitis
576.2    Obstruction of bile duct
576.3    Perforation of bile duct
576.4    Fistula of bile duct
576.5    Spasm of sphincter of Oddi
576.8    Other specified disorders of biliary tract
576.9    Unspecified disorder of biliary tract
577.0    Acute pancreatitis
578.0    Hematemesis
578.1    Blood in stool
578.9    Hemorrhage of gastrointestinal tract, unspecified
579.0    Celiac disease
579.1    Tropical sprue
579.2    Blind loop syndrome
579.3    Other and unspecified postsurgical nonabsorption
579.4    Pancreatic steatorrhea
579.8    Other specified intestinal malabsorption
579.9    Unspecified intestinal malabsorption
581.0    Nephrotic syndrome with lesion of proliferative glomerulonephritis
581.1    Nephrotic syndrome with lesion of membranous glomerulonephritis
581.2    Nephrotic syndrome with lesion of membranoproliferative glomerulonephritis
581.3    Nephrotic syndrome with lesion of minimal change glomerulonephritis
581.81   Nephrotic syndrome in diseases classified elsewhere
581.89   Other nephrotic syndrome
581.9    Nephrotic syndrome with unspecified pathological lesion in
583.9    Nephritis and nephropathy with unspecified pathological lesion in kidney
584.5    Acute renal failure with lesion of tubular necrosis
584.6    Acute renal failure with lesion of renal cortical necrosis
584.7    Acute renal failure with lesion of renal medullary [papillary] necrosis
584.8    Acute renal failure with other specified pathological lesion in kidney
584.9    Acute renal failure, unspecified
585.4    Chronic kidney disease, Stage IV (severe)
585.5    Chronic kidney disease, Stage V
585.6    End stage renal disease
585.9    Chronic kidney disease, unspecified
586      Renal failure, unspecified
593.81   Vascular disorders of kidney
593.82   Ureteral fistula
593.89   Other disorders of kidney and ureter
596.7    Hemorrhage into bladder wall



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596.8    Other specified disorders of bladder
599.7    Hematuria
607.82   Vascular disorders of penis
608.83   Vascular disorders of male genital organs
611.8    Other specified disorders of breast
620.7    Hematoma of broad ligament
621.4    Hematometra
622.8    Other specified noninflammatory disorders of cervix
623.6    Vaginal hematoma
623.8    Other specified noninflammatory disorders of vagina
624.5    Hematoma of vulva
626.2    Excessive or frequent menstruation
626.3    Puberty bleeding
626.4    Irregular menstrual cycle
626.5    Ovulation bleeding
626.6    Metrorrhagia
626.7    Postcoital bleeding
626.8    Other disorders of menstruation
626.9    Unspecified disorders of menstruation
627.0    Premenopausal menorrhagia
627.1    Postmenopausal bleeding
629.0    Hematocele, female, not elsewhere classified
632      Missed abortion
634.10   Spontaneous abortion complicated by delayed or excessive hemorrhage, unspecified
634.11   Spontaneous abortion complicated by delayed or excessive hemorrhage, incomplete
634.12   Spontaneous abortion complicated by delayed or excessive hemorrhage, complete
635.10   Legally induced abortion complicated by delayed or excessive hemorrhage, unspecified
635.11   Legally induced abortion complicated by delayed or excessive hemorrhage, incomplete
635.12   Legally induced abortion complicated by delayed or excessive hemorrhage, complete
636.10   Illegally induced abortion complicated by delayed or excessive hemorrhage, unspecified
636.11   Illegally induced abortion complicated by delayed or excessive hemorrhage, incomplete
636.12   Illegally induced abortion complicated by delayed or excessive hemorrhage, complete
637.10   Unspecified abortion complicated by delayed or excessive hemorrhage, unspecified
637.11   Unspecified abortion complicated by delayed or excessive hemorrhage, incomplete
637.12   Unspecified abortion complicated by delayed or excessive hemorrhage, complete
638.1    Failed attempted abortion complicated by delayed or excessive hemorrhage
639.1    Complications following abortion and ectopic and molar pregnancies, delayed or
         excessive hemorrhage
639.6    Complications following abortion and ectopic pregnancy, embolism
640.00   Threatened abortion, unspecified
640.01   Threatened abortion, delivered, with or without antepartum condition
640.03   Threatened abortion, antepartum condition or complication
640.80   Other specified hemorrhage in early pregnancy, unspecified as to episode of care or not
         applicable
640.81   Other specified hemorrhage in early pregnancy, delivered, with or without antepartum
         condition
640.83   Other specified hemorrhage in early pregnancy, antepartum condition or complication
640.90   Unspecified hemorrhage in early pregnancy, unspecified as to episode of care or not
         applicable
640.91   Unspecified hemorrhage in early pregnancy delivered, with or without antepartum
         condition
640.93   Unspecified hemorrhage in early pregnancy, antepartum condition or complication
641.00   Placenta previa without hemorrhage, unspecified as to episode of care or not applicable



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641.01 Placenta previa without hemorrhage, delivered, with or without mention of antepartum
       condition
641.03 Placenta previa without hemorrhage, antepartum condition or complication
641.10 Hemorrhage from placenta previa, unspecified as to episode of care or not applicable
641.11 Hemorrhage from placenta previa, delivered, with or without antepartum condition
641.13 Hemorrhage from placenta previa, antepartum condition or complication
641.20 Premature separation of placenta, unspecified as to episode of care or not applicable
641.21 Premature separation of placenta delivered, with or without antepartum condition
641.23 Premature separation of placenta, antepartum condition or complication
641.30 Antepartum hemorrhage associated with coagulation, unspecified as to episode of care
       or not applicable
641.31 Antepartum hemorrhage associated with coagulation, delivered, with or without
       antepartum condition
641.33 Antepartum hemorrhage associated with coagulation, antepartum condition or
       complication defects
641.80 Other antepartum hemorrhage, unspecified as to episode of care or not applicable
641.81 Other antepartum hemorrhage, delivered, with or without antepartum condition
641.83 Other antepartum hemorrhage, antepartum condition or complication
641.90 Unspecified antepartum hemorrhage, unspecified as to episode of care or not applicable
641.91 Unspecified antepartum hemorrhage, delivered, with or without antepartum condition
641.93 Unspecified antepartum hemorrhage, antepartum condition or complication
642.00 Benign essential hypertension complicating pregnancy, childbirth, and the puerperium,
       unspecified as to episode of care or not applicable
642.01 Benign essential hypertension complicating pregnancy, childbirth, and the puerperium,
       delivered, with or without antepartum condition
642.02 Benign essential hypertension complicating pregnancy, childbirth, and the puerperium,
       delivered, with postpartum complication
642.03 Benign essential hypertension complicating pregnancy, childbirth, and the puerperium,
       antepartum condition or complication
642.04 Benign essential hypertension complicating pregnancy, childbirth, and the puerperium,
       postpartum condition or complication
642.10 Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the
       puerperium, unspecified as to episode of care or not applicable
642.11 Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the
       puerperium, delivered, with or without antepartum condition
642.12 Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the
       puerperium, delivered, with postpartum complication
642.13 Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the
       puerperium, antepartum condition or complication
642.14 Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the
       puerperium, postpartum condition or complication
642.20 Other pre-existing hypertension complicating pregnancy, childbirth, and the puerperium,
       unspecified as to episode of care or not applicable
642.21 Other pre-existing hypertension complicating pregnancy, childbirth, and the puerperium,
       delivered, with or without antepartum condition
642.22 Other pre-existing hypertension complicating pregnancy, childbirth, and the puerperium,
       delivered, with postpartum complication
642.23 Other pre-existing hypertension complicating pregnancy, childbirth, and the puerperium,
       antepartum condition or complication
642.24 Other pre-existing hypertension complicating pregnancy, childbirth, and the puerperium,
       postpartum condition or complication
642.30 Transient hypertension of pregnancy, unspecified as to episode of care or not applicable




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NATIONAL COVERAGE DETERMINATION                                                            85610

642.31 Transient hypertension of pregnancy, delivered, with or without mention of antepartum
       condition
642.32 Transient hypertension of pregnancy, delivered, with mention of postpartum complication
642.33 Transient hypertension of pregnancy, antepartum condition or complication
642.34 Transient hypertension of pregnancy, postpartum condition or complication
642.40 Mild or unspecified pre-eclampsia, unspecified as to episode of care or not applicable
642.41 Mild or unspecified pre-eclampsia, delivered, with or without antepartum condition
642.42 Mild or unspecified pre-eclampsia, delivered, with postpartum complication
642.43 Mild or unspecified pre-eclampsia, antepartum condition or complication
642.44 Mild or unspecified pre-eclampsia, postpartum condition or complication
642.50 Severe pre-eclampsia, unspecified as to episode of care or not applicable
642.51 Severe pre-eclampsia, delivered, with or without antepartum condition
642.52 Severe pre-eclampsia, delivered, with postpartum complication
642.53 Severe pre-eclampsia, antepartum condition or complication
642.54 Severe pre-eclampsia, postpartum condition or complication
642.60 Eclampsia, unspecified as to episode of care or not applicable
642.61 Eclampsia, delivered, with or without antepartum condition
642.62 Eclampsia, delivered, with postpartum complication
642.63 Eclampsia, antepartum condition or complication
642.64 Eclampsia, postpartum condition or complication
642.70 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, unspecified as
       to episode of care or not applicable
642.71 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, delivered, with
       or without antepartum condition
642.72 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, delivered, with
       postpartum complication
642.73 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, antepartum
       condition or complication
642.74 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, postpartum
       condition or complication
642.90 Unspecified hypertension complicating pregnancy, childbirth, or the puerperium,
       unspecified as to episode of care or not applicable
642.91 Unspecified hypertension complicating pregnancy, childbirth, or the puerperium,
       delivered, with or without antepartum condition
642.92 Unspecified hypertension complicating pregnancy, childbirth, or the puerperium,
       delivered, with postpartum complication
642.93 Unspecified hypertension complicating pregnancy, childbirth, or the puerperium,
       antepartum condition or complication
642.94 Unspecified hypertension complicating pregnancy, childbirth, or the puerperium,
       postpartum condition or complication
646.70 Liver disorders in pregnancy, unspecified episode of care
646.71 Liver disorders in pregnancy, delivered, with or without antepartum condition
646.73 Liver disorders in pregnancy, antepartum condition or complication defects
649.30 Coagulation defects complicating pregnancy, childbirth, or the puerperium, unspecified as
       to episode of care or not applicable
649.31 Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with
       or without mention of antepartum condition
649.32 Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with
       mention of postpartum complication
649.33 Coagulation defects complicating pregnancy, childbirth, or the puerperium, antepartum
       condition or complication
649.34 Coagulation defects complicating pregnancy, childbirth, or the puerperium, postpartum
       condition or complication



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NATIONAL COVERAGE DETERMINATION                                                           85610

649.50 Spotting complicating pregnancy, unspecified as to episode of care or not applicable
649.51 Spotting complicating pregnancy, delivered, with or without mention of antepartum
       condition
649.53 Spotting complicating pregnancy, antepartum condition or complication
656.00 Fetal-maternal hemorrhage, unspecified episode of care
656.01 Fetal-maternal hemorrhage delivered, with or without antepartum condition
656.03 Fetal-maternal hemorrhage, antepartum condition or complication
658.40 Infection of amniotic cavity, unspecified episode of care
658.41 Infection of amniotic cavity, delivered, with or without antepartum condition
658.43 Infection of amniotic cavity, antepartum condition or complication
666.00 Third-stage hemorrhage, unspecified episode of care
666.02 Third-stage hemorrhage, delivered, with postpartum complication
666.04 Third-stage hemorrhage, postpartum condition or complication
666.10 Other immediate postpartum hemorrhage, unspecified episode of care
666.12 Other immediate postpartum hemorrhage, delivered, with postpartum complication
666.14 Other immediate postpartum hemorrhage, postpartum condition or complication
666.20 Delayed and secondary postpartum hemorrhage, unspecified episode of care
666.22 Delayed and secondary postpartum hemorrhage, delivered, with postpartum complication
666.24 Delayed and secondary postpartum hemorrhage, postpartum condition or complication
666.30 Postpartum coagulation defects, unspecified episode of care
666.32 Postpartum coagulation defects delivered, with postpartum complication
666.34 Postpartum coagulation defects, postpartum condition or complication
671.20 Superficial thrombophlebitis in pregnancy or the puerperium, unspecified episode of care
671.21 Superficial thrombophlebitis in pregnancy or the puerperium, delivered, with or without
       antepartum condition
671.22 Superficial thrombophlebitis in pregnancy or the puerperium, delivered, with postpartum
       complication
671.23 Superficial thrombophlebitis in pregnancy or the puerperium, antepartum condition or
       complication
671.24 Superficial thrombophlebitis in pregnancy or the puerperium, postpartum condition or
       complication
671.30 Deep phlebothrombosis, antepartum, unspecified episode of care
671.31 Deep phlebothrombosis, antepartum, delivered, with or without antepartum condition
671.33 Deep phlebothrombosis, antepartum, antepartum condition or complication
671.40 Deep phlebothrombosis, postpartum, unspecified episode of care
671.42 Deep phlebothrombosis, postpartum, delivered, with postpartum complication
671.44 Deep phlebothrombosis, postpartum, postpartum condition or complication
671.50 Other phlebitis and thrombosis in pregnancy or the puerperium, unspecified episode of
       care
671.51 Other phlebitis and thrombosis in pregnancy or the puerperium, delivered, with or without
       antepartum condition
671.52 Other phlebitis and thrombosis in pregnancy or the puerperium, delivered, with
       postpartum complication
671.53 Other phlebitis and thrombosis in pregnancy or the puerperium, antepartum condition or
       complication
671.54 Other phlebitis and thrombosis in pregnancy or the puerperium, postpartum condition or
       complication
671.80 Other venous complications in pregnancy or the puerperium, unspecified episode of care
671.81 Other venous complications in pregnancy or the puerperium, delivered, with or without
       antepartum condition
671.82 Other venous complications in pregnancy or the puerperium, delivered, with postpartum
       complication




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NATIONAL COVERAGE DETERMINATION                                                           85610

671.83 Other venous complications in pregnancy or the puerperium, antepartum condition or
       complication
671.84 Other venous complications in pregnancy or the puerperium, postpartum condition or
       complication
671.90 Unspecified venous complication in pregnancy or the puerperium, unspecified episode of
       care
671.91 Unspecified venous complication in pregnancy or the puerperium, delivered, with or
       without antepartum condition
671.92 Unspecified venous complication in pregnancy or the puerperium, delivered, with
       postpartum complication
671.93 Unspecified venous complication in pregnancy or the puerperium, antepartum condition
       or complication
671.94 Unspecified venous complication in pregnancy or the puerperium, postpartum condition
       or complication
673.00 Obstetrical air embolism, unspecified episode of care
673.01 Obstetrical air embolism, delivered, with or without antepartum condition
673.02 Obstetrical air embolism, delivered, with postpartum complication
673.03 Obstetrical air embolism, antepartum condition or complication
673.04 Obstetrical air embolism, postpartum condition or complication
673.10 Amniotic fluid embolism, unspecified episode of care
673.11 Amniotic fluid embolism, delivered, with or without antepartum condition
673.12 Amniotic fluid embolism, delivered, with postpartum complication
673.13 Amniotic fluid embolism, antepartum condition or complication
673.14 Amniotic fluid embolism, postpartum condition or complication
673.20 Obstetrical blood-clot embolism, unspecified episode of care
673.21 Obstetrical blood-clot embolism, delivered, with or without of antepartum condition
673.22 Obstetrical blood-clot embolism, delivered, with postpartum complication
673.23 Obstetrical blood-clot embolism, antepartum condition or complication
673.24 Obstetrical blood-clot embolism, postpartum condition or complication
673.30 Obstetrical pyemic and septic embolism, unspecified episode of care
673.31 Obstetrical pyemic and septic embolism, delivered, with or without antepartum condition
673.32 Obstetrical pyemic and septic embolism, delivered, with postpartum complication
673.33 Obstetrical pyemic and septic embolism, antepartum condition or complication
673.34 Obstetrical pyemic and septic embolism, postpartum condition or complication
673.80 Other obstretrical pulmonary embolism, unspecified episode of care
673.81 Other obstretrical pulmonary embolism, delivered, with or without antepartum condition
673.82 Other obstretrical pulmonary embolism, delivered, with postpartum complication
673.83 Other obstretrical pulmonary embolism, antepartum condition or complication
673.84 Other obstretrical pulmonary embolism, postpartum condition or complication
674.30 Other complications of obstetrical surgical wounds, unspecified episode of care
674.32 Other complications of obstetrical surgical wounds, delivered, with postpartum
       complication
674.34 Other complications of obstetrical surgical wounds, postpartum condition or complication
713.2 Arthropathy associated with hematological disorders
713.6 Arthropathy associated with hypersensitivity reaction
719.15 Hemarthrosis, pelvic region and thigh
719.16 Hemarthrosis, lower leg
719.19 Hemarthrosis, multiple sites
729.5 Pain in limb
729.81 Swelling of limb
733.10 Pathologic fracture, unspecified site
746.00 Pulmonary valve anomaly, unspecified
746.01 Atresia, congenital



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NATIONAL COVERAGE DETERMINATION                                                     85610

746.02   Stenosis, congenital
746.09   Other Pulmonary valve anomaly
746.1    Tricuspid atresia and stenosis, congenital
746.2    Ebstein's anomaly
746.3    Congenital stenosis of aortic valve
746.4    Congenital insufficiency of aortic valve
746.5    Congenital mitral stenosis
746.6    Congenital mitral insufficiency
746.7    Hypoplastic left heart syndrome
746.81   Subaortic stenosis
746.82   Cor triatriatum
746.83   Infundibular pulmonic stenosis
746.84   Obstructive anomalies of heart, not elsewhere classified
746.85   Coronary artery anomaly
746.86   Congenital heart block
746.87   Malposition of heart and cardiac apex
746.89   Other heart anomalies
746.9    Unspecified anomaly of heart
762.1    Other forms of placental separation and hemorrhage
767.0    Birth trauma, subdural and cerebral hemorrhage
767.11   Epicranial subaponeurotic hemorrage (massive)
767.8    Other specified birth trauma
770.3    Pulmonary hemorrhage of fetus and newborn
772.0    Fetal blood loss
772.10   Fetal and neonatal intraventricular hemorrhage, unspecified grade
772.11   Fetal and neonatal intraventricular hemorrhage, grade I
772.12   Fetal and neonatal intraventricular hemorrhage, grade II
772.13   Fetal and neonatal intraventricular hemorrhage, grade III
772.14   Fetal and neonatal intraventricular hemorrhage, grade IV
772.2    Fetal and neonatal subarachnoid hemorrhage
772.3    Umbilical hemorrhage after birth
772.4    Gastrointestinal hemorrhage of fetus and newborn
772.5    Adrenal hemorrhage of fetus and newborn
772.6    Cutaneous hemorrhage of fetus and newborn
772.8    Other specified hemorrhage of fetus or newborn
772.9    Unspecified hemorrhage of newborn
774.6    Unspecified fetal and neonatal jaundice
776.0    Hemorrhagic disease of newborn
776.1    Transient neonatal thrombocytopenia
776.2    Disseminated intravascular coagulation in newborn
776.3    Other transient neonatal disorders of coagulation
776.4    Polycythemia neonatorum
776.5    Congenital anemia
776.6    Anemia of prematurity
776.7    Transient neonatal neutropenia
776.8    Other specified transient hematological disorders of fetus and newborn
776.9    Unspecified hematological disorder specific to fetus or newborn
780.2    Syncope and collapse
782.3    Edema
782.4    Jaundice, unspecified, not of newborn
782.7    Spontaneous ecchymoses
784.7    Epistaxis
784.8    Hemorrhage from throat



                                                                                  Page 252
NATIONAL COVERAGE DETERMINATION                                                                  85610

785.4    Gangrene
785.50   Shock, unspecified
786.05   Shortness of breath
786.3    Hemoptysis
786.59   Other chest pain
789.00   Abdominal pain, unspecified site
789.01   Abdominal pain, right upper quadrant
789.02   Abdominal pain, left upper quadrant
789.03   Abdominal pain, right lower quadrant
789.04   Abdominal pain, left lower quadrant
789.05   Abdominal pain, periumbilic
789.06   Abdominal pain, epigastric
789.07   Abdominal pain, generalized
789.09   Abdominal pain, other specified site
789.1    Hepatomegaly
789.51   Malignant ascites
789.59   Other ascites
790.92   Abnormal coagulation profile
790.94   Euthyroid sick syndrome
791.2    Hemoglobinuria
794.8    Abnormal results of function studies, liver
800.00   Fracture of vault of skull, closed, without intracranial injury, unspecified state of
         consciousness
800.01   Fracture of vault of skull, closed, without intracranial injury, no loss of consciousness
800.02   Fracture of vault of skull, closed, without intracranial injury with brief loss of
         consciousness
800.03   Fracture of vault of skull, closed, without intracranial injury with moderate loss of
         consciousness
800.04   Fracture of vault of skull, closed, without intracranial injury with prolonged loss of
         consciousness, with return to pre-existing level
800.05   Fracture of vault of skull, closed, without intracranial injury with prolonged loss of
         consciousness, without return to pre-existing level
800.06   Fracture of vault of skull, closed, without intracranial injury with loss of consciousness of
         unspecified duration
800.09   Fracture of vault of skull, closed, without intracranial injury, with concussion, unspecified
800.10   Fracture of vault of skull, closed with cerebral laceration and contusion, unspecified state
         of consciousness
800.11   Fracture of vault of skull, closed, with cerebral laceration and contusion with no loss of
         consciousness
800.12   Fracture of vault of skull, closed, with cerebral laceration and contusion with brief loss of
         consciousness
800.13   Fracture of vault of skull, closed, with cerebral laceration and contusion with moderate
         loss of consciousness
800.14   Fracture of vault of skull, closed, with cerebral laceration and contusion with prolonged
         loss of consciousness and return to pre-existing level
800.15   Fracture of vault of skull, closed, with cerebral laceration and contusion with prolonged
         loss of consciousness, without return to pre-existing level
800.16   Fracture of vault of skull, closed, with cerebral laceration and contusion with loss of
         consciousness of unspecified duration
800.19   Fracture of vault of skull, closed, with cerebral laceration and contusion, with concussion,
         unspecified
800.20   Fracture of vault of skull, closed with subarachnoid, subdural, and extradural
         hemorrhage, unspecified state of consciousness



                                                                                             Page 253
NATIONAL COVERAGE DETERMINATION                                                               85610

800.21 Fracture of vault of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage with no loss of consciousness
800.22 Fracture of vault of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage with brief loss of consciousness
800.23 Fracture of vault of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage with moderate loss of consciousness
800.24 Fracture of vault of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage with prolonged loss of consciousness and return to pre-existing level
800.25 Fracture of vault of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage with prolonged loss of consciousness, without return to pre-existing level
800.26 Fracture of vault of skull, closed with subarachnoid, subdural, and extradural hemorrhage
       with loss of consciousness of unspecified duration
800.29 Fracture of vault of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage, with concussion, unspecified
800.30 Fracture of vault of skull, closed with other and unspecified intracranial hemorrhage,
       unspecified state of consciousness
800.31 Fracture of vault of skull, closed, with other and unspecified intracranial hemorrhage with
       no loss of consciousness
800.32 Fracture of vault of skull, closed, with other and unspecified intracranial hemorrhage with
       brief loss of consciousness
800.33 Fracture of vault of skull, closed, with other and unspecified intracranial hemorrhage with
       moderate loss of consciousness
800.34 Fracture of vault of skull, closed, with other and unspecified intracranial hemorrhage with
       prolonged loss of consciousness and return to pre-existing level
800.35 Fracture of vault of skull, closed, with other and unspecified intracranial hemorrhage with
       prolonged loss of consciousness, without return to pre-existing level
800.36 Fracture of vault of skull, closed, with other and unspecified intracranial hemorrhage with
       loss of consciousness of unspecified duration
800.39 Fracture of vault of skull, closed, with other and unspecified intracranial hemorrhage, with
       concussion, unspecified
800.40 Fracture of vault of skull, closed, with intracranialinjury of other and unspecified nature,
       unspecified state of consciousness
800.41 Fracture of vault of skull, closed, with intracranialinjury of other and unspecified nature
       with no loss of consciousness
800.42 Fracture of vault of skull, closed, with intracranialinjury of other and unspecified nature
       with brief loss of consciousness
800.43 Fracture of vault of skull, closed, with intracranialinjury of other and unspecified nature
       with moderate loss of consciousness
800.44 Fracture of vault of skull, closed, with intracranialinjury of other and unspecified nature
       with prolonged loss of consciousness and return to pre-existing level
800.45 Fracture of vault of skull, closed, with intracranialinjury of other and unspecified nature
       with prolonged loss of consciousness, without return to pre-existing level
800.46 Fracture of vault of skull, closed, with intracranialinjury of other and unspecified nature
       with loss of consciousness of unspecified duration
800.49 Fracture of vault of skull, closed, with intracranialinjury of other and unspecified nature,
       with concussion, unspecified
800.50 Fracture of vault of skull, open, without mention of intracranial injury unspecified state of
       consciousness
800.51 Fracture of vault of skull, open, without mention of intracranial injury with no loss of
       consciousness
800.52 Fracture of vault of skull, open, without mention of intracranial injury with brief loss of
       consciousness




                                                                                           Page 254
NATIONAL COVERAGE DETERMINATION                                                              85610

800.53 Fracture of vault of skull, open, without mention of intracranial injury with moderate loss
       of consciousness
800.54 Fracture of vault of skull, open, without mention of intracranial injury with prolonged loss
       of consciousness and return to pre-existing level
800.55 Fracture of vault of skull, open, without mention of intracranial injury with prolonged loss
       of consciousness, without return to pre-existing level
800.56 Fracture of vault of skull, open, without mention of intracranial injury with loss of
       consciousness of unspecified duration
800.59 Fracture of vault of skull, open, without mention of intracranial injury, with concussion,
       unspecified
800.60 Fracture of vault of skull, open, with cerebral laceration and contusion, unspecified state
       of consciousness
800.61 Fracture of vault of skull, open, with cerebral laceration and contusion with no loss of
       consciousness
800.62 Fracture of vault of skull, open, with cerebral laceration and contusion with brief loss of
       consciousness
800.63 Fracture of vault of skull, open, with cerebral laceration and contusion with moderate loss
       of consciousness
800.64 Fracture of vault of skull, open, with cerebral laceration and contusion with prolonged loss
       of consciousness and return to pre-existing level
800.65 Fracture of vault of skull, open, with cerebral laceration and contusion with prolonged loss
       of consciousness, without return to pre-existing level
800.66 Fracture of vault of skull, open, with cerebral laceration and contusion with loss of
       consciousness of unspecified duration
800.69 Fracture of vault of skull, open, with cerebral laceration and contusion, with concussion,
       unspecified
800.70 Fracture of vault of skull, open, with subarachnoid, subdural, and extradural hemorrhage,
       unspecified state of consciousness
800.71 Fracture of vault of skull, open, with subarachnoid, subdural, and extradural hemorrhage
       with no loss of consciousness
800.72 Fracture of vault of skull, open, with subarachnoid, subdural, and extradural hemorrhage
       with brief loss of consciousness
800.73 Fracture of vault of skull, open, with subarachnoid, subdural, and extradural hemorrhage
       with moderate loss of consciousness
800.74 Fracture of vault of skull, open, with subarachnoid, subdural, and extradural hemorrhage
       with prolonged loss of consciousness and return to pre-existing conscious level
800.75 Fracture of vault of skull, open, with subarachnoid, subdural, and extradural hemorrhage
       with prolonged loss of consciousness, without return to pre-existing level
800.76 Fracture of vault of skull, open, with subarachnoid, subdural, and extradural hemorrhage
       with loss of consciousness of unspecified duration
800.79 Fracture of vault of skull, open, with subarachnoid, subdural, and extradural hemorrhage,
       with concussion, unspecified
800.80 Fracture of vault of skull, open, with other and unspecified intracranial hemorrhage,
       unspecified state of consciousness
800.81 Fracture of vault of skull, open, with other and unspecified intracranial hemorrhage with
       no loss of consciousness
800.82 Fracture of vault of skull, open, with other and unspecified intracranial hemorrhage with
       brief loss of consciousness
800.83 Fracture of vault of skull, Open with other and unspecified intracranial hemorrhage with
       moderate loss of consciousness
800.84 Fracture of vault of skull, open, with other and unspecified intracranial hemorrhage with
       prolonged loss of consciousness and return to pre-existing level




                                                                                          Page 255
NATIONAL COVERAGE DETERMINATION                                                               85610

800.85 Fracture of vault of skull, open, with other and unspecified intracranial hemorrhage with
       prolonged loss of consciousness, without return to pre-existing level
800.86 Fracture of vault of skull, open, with other and unspecified intracranial hemorrhage with
       loss of consciousness of unspecified duration
800.89 Fracture of vault of skull, open, with other and unspecified intracranial hemorrhage, with
       concussion, unspecified
800.90 Fracture of vault of skull, open, with intracranial injury of other and unspecified nature,
       unspecified state of consciousness
800.91 Fracture of vault of skull, open, with intracranial injury of other and unspecified nature
       with no loss of consciousness
800.92 Fracture of vault of skull, open, with intracranial injury of other and unspecified nature
       with brief loss of consciousness
800.93 Fracture of vault of skull, open, with intracranial injury of other and unspecified nature
       with moderate loss of consciousness
800.94 Fracture of vault of skull, open, with intracranial injury of other and unspecified nature
       with prolonged loss of consciousness and return to pre-existing level
800.95 Fracture of vault of skull, open, with intracranial injury of other and unspecified nature
       with prolonged loss of consciousness, without return to pre-existing level
800.96 Fracture of vault of skull, open, with intracranial injury of other and unspecified nature
       with loss of consciousness of unspecified duration
800.99 Fracture of vault of skull, open, with intracranial injury of other and unspecified nature,
       with concussion, unspecified
801.00 Fracture of base of skull, closed, without intracranial injury, unspecified state of
       consciousness
801.01 Fracture of base of skull, closed, without intracranial injury with no loss of consciousness
801.02 Fracture of base of skull, closed, without intracranial injury with brief loss of
       consciousness
801.03 Fracture of base of skull, closed, without intracranial injury with moderate loss of
       consciousness
801.04 Fracture of base of skull, closed, without intracranial injury with prolonged loss of
       consciousness and return to pre-existing level
801.05 Fracture of base of skull, closed, without intracranial injury with prolonged loss of
       consciousness, without return to pre-existing level
801.06 Fracture of base of skull, closed, without mention of intracranial injury with loss of
       consciousness of unspecified duration
801.09 Fracture of base of skull, closed, without intracranial injury, with concussion, unspecified
801.10 Fracture of base of skull, closed with cerebral laceration and contusion, unspecified state
       of consciousness
801.11 Fracture of base of skull, closed, with cerebral laceration and contusion with no loss of
       consciousness
801.12 Fracture of base of skull, closed, with cerebral laceration and contusion with brief loss of
       consciousness
801.13 Fracture of base of skull, closed, with cerebral laceration and contusion with moderate
       loss of consciousness
801.14 Fracture of base of skull ,closed, with cerebral laceration and contusion with prolonged
       loss of consciousness and return to pre-existing level
801.15 Fracture of base of skull, closed, with cerebral laceration and contusion with prolonged
       loss of consciousness, without return to pre-existing level
801.16 Fracture of base of skull, closed, with cerebral laceration and contusion with loss of
       consciousness of unspecified duration
801.19 Fracture of base of skull, closed, with cerebral laceration and contusion, with concussion,
       unspecified




                                                                                          Page 256
NATIONAL COVERAGE DETERMINATION                                                               85610

801.20 Fracture of base of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage, unspecified state of consciousness
801.21 Fracture of base of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage with no loss of consciousness
801.22 Fracture of base of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage with brief loss of consciousness
801.23 Fracture of base of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage with moderate loss of consciousness
801.24 Fracture of base of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage with prolonged loss of consciousness and return to pre-existing level
801.25 Fracture of base of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage with prolonged loss of consciousness, without return to pre-existing level
801.26 Fracture of base of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage with loss of consciousness of unspecified duration
801.29 Fracture of base of skull, closed, with subarachnoid, subdural, and extradural
       hemorrhage, with concussion, unspecified
801.30 Fracture of base of skull, closed, with other and unspecified intracranial hemorrhage,
       unspecified state of consciousness
801.31 Fracture of base of skull, closed, with other and unspecified intracranial hemorrhage with
       no loss of consciousness
801.32 Fracture of base of skull, closed, with other and unspecified intracranial hemorrhage with
       brief loss of consciousness
801.33 Fracture of base of skull, closed, with other and unspecified intracranial hemorrhage with
       moderate loss of consciousness
801.34 Fracture of base of skull, closed, with other and unspecified intracranial hemorrhage with
       prolonged loss of consciousness and return to pre-existing level
801.35 Fracture of base of skull, closed, with other and unspecified intracranial hemorrhage with
       prolonged loss of consciousness, without return to pre-existing level
801.36 Fracture of base of skull, closed, with other and unspecified intracranial hemorrhage with
       loss of consciousness of unspecified duration
801.39 Fracture of base of skull, closed, with other and unspecified intracranial hemorrhage, with
       concussion, unspecified
801.40 Fracture of base of skull, closed, with intracranial injury of other and unspecified nature,
       unspecified state of consciousness
801.41 Fracture of base of skull, closed, with intracranial injury of other and unspecified nature
       with no loss of consciousness
801.42 Fracture of base of skull, closed, with intracranial injury of other and unspecified nature
       with brief loss of consciousness
801.43 Fracture of base of skull, closed, with intracranial injury of other and unspecified nature
       with moderate loss of consciousness
801.44 Fracture of base of skull, closed, with intracranial injury of other and unspecified nature
       with prolonged loss of consciousness and return to pre-existing level
801.45 Fracture of base of skull, closed, with intracranial injury of other and unspecified nature
       with prolonged loss of consciousness, without return to pre-existing level
801.46 Fracture of base of skull, closed, with intracranial injury of other and unspecified nature
       with loss of consciousness of unspecified duration
801.49 Fracture of base of skull, closed, with intracranial injury of other and unspecified nature,
       with concussion, unspecified
801.50 Fracture of base of skull, open, without intracranial injury, unspecified state of
       consciousness
801.51 Fracture of base of skull, open, without intracranial injury with no loss of consciousness
801.52 Fracture of base of skull, open, without intracranial injury with brief loss of consciousness




                                                                                           Page 257
NATIONAL COVERAGE DETERMINATION                                                             85610

801.53 Fracture of base of skull, open, without intracranial injury with moderate loss of
       consciousness
801.54 Fracture of base of skull, open, without intracranial injury with prolonged loss of
       consciousness and return to pre-existing level
801.55 Fracture of base of skull, open, without intracranial injury with prolonged loss of
       consciousness, without return to pre-existing level
801.56 Fracture of base of skull, open, without intracranial injury with loss of consciousness of
       unspecified duration
801.59 Fracture of base of skull, open, without mention of intracranial injury, with concussion,
       unspecified
801.60 Fracture of base of skull, open, with cerebral laceration and contusion, unspecified state
       of consciousness
801.61 Fracture of base of skull, open, with cerebral laceration and contusion with no loss of
       consciousness
801.62 Fracture of base of skull, open, with cerebral laceration and contusion with brief loss of
       consciousness
801.63 Fracture of base of skull, 0pen, with cerebral laceration and contusion with moderate loss
       of consciousness
801.64 Fracture of base of skull, open, with cerebral laceration and contusion with prolonged
       loss of consciousness and return to pre-existing level
801.65 Fracture of base of skull, open, with cerebral laceration and contusion with prolonged
       loss of consciousness, without return to pre-existing level
801.66 Fracture of base of skull, open, with cerebral laceration and contusion with loss of
       consciousness of unspecified duration
801.69 Fracture of base of skull, open, with cerebral laceration and contusion with concussion,
       unspecified
801.70 Fracture of base of skull, open, with subarachnoid, subdural, and extradural hemorrhage,
       unspecified state of consciousness
801.71 Fracture of base of skull, open, with subarachnoid, subdural, and extradural hemorrhage
       with no loss of consciousness
801.72 Fracture of base of skull, open, with subarachnoid, subdural, and extradural hemorrhage
       with brief loss of consciousness
801.73 Fracture of base of skull, open, with subarachnoid, subdural, and extradural hemorrhage
       with moderate loss of consciousness
801.74 Fracture of base of skull, open, with subarachnoid, subdural, and extradural hemorrhage
       with prolonged loss of consciousness and return to pre-existing level
801.75 Fracture of base of skull, open, with subarachnoid, subdural, and extradural hemorrhage
       with prolonged loss of consciousness, without return to pre-existing level
801.76 Fracture of base of skull, open, with subarachnoid, subdural, and extradural hemorrhage
       with loss of consciousness of unspecified duration
801.79 Fracture of base of skull, open, with subarachnoid, subdural, and extradural hemorrhage
       with concussion, unspecified
801.80 Fracture of base of skull, open, with other and unspecified intracranial hemorrhage,
       unspecified state of consciousness
801.81 Fracture of base of skull, open, with other and unspecified intracranial hemorrhage with
       no loss of consciousness
801.82 Fracture of base of skull, open, with other and unspecified intracranial hemorrhage with
       brief loss of consciousness
801.83 Fracture of base of skull, open, with other and unspecified intracranial hemorrhage with
       moderate loss of consciousness
801.84 Fracture of base of skull, open, with other and unspecified intracranial hemorrhage with
       prolonged loss of consciousness and return to pre-existing level




                                                                                        Page 258
NATIONAL COVERAGE DETERMINATION                                                              85610

801.85 Fracture of base of skull, open, with other and unspecified intracranial hemorrhage with
       prolonged loss of consciousness, without return to pre-existing level
801.86 Fracture of base of skull, open, with other and unspecified intracranial hemorrhage with
       loss of consciousness of unspecified duration
801.89 Fracture of base of skull, open, with other and unspecified intracranial hemorrhage with
       concussion, unspecified
801.90 Fracture of base of skull, open, with intracranial injury of other and unspecified nature,
       unspecified state of consciousness
801.91 Fracture of base of skull, open, with intracranial injury of other and unspecified nature
       with no loss of consciousness
801.92 Fracture of base of skull, open, with intracranial injury of other and unspecified nature
       with brief loss of consciousness
801.93 Fracture of base of skull, open, with intracranial injury of other and unspecified nature
       with moderate loss of consciousness
801.94 Fracture of base of skull, open, with intracranial injury of other and unspecified nature
       with prolonged loss of consciousness and return to pre-existing level
801.95 Fracture of base of skull, open, with intracranial injury of other and unspecified nature
       with prolonged loss of consciousness, without return to pre-existing level
801.96 Fracture of base of skull, open, with intracranial injury of other and unspecified nature
       with loss of consciousness of unspecified duration
801.99 Fracture of base of skull, open, with intracranial injury of other and unspecified nature
       with concussion, unspecified
802.20 Fracture of mandible, closed, unspecified site
802.21 Fracture of mandible, closed, condylar process
802.22 Fracture of mandible, closed, subcondylar
802.23 Fracture of mandible, closed, coronoid process
802.24 Fracture of mandible, closed, ramus, unspecified
802.25 Fracture of mandible, closed, angle of jaw
802.26 Fracture of mandible, closed, symphysis of body
802.27 Fracture of mandible, closed, alveolar border of body
802.28 Fracture of mandible body, closed, other and unspecified
802.29 Fracture of mandible, closed, multiple sites
802.30 Fracture of mandible, open, unspecified site
802.31 Fracture of mandible, open, condylar process
802.32 Fracture of mandible, open, subcondylar
802.33 Fracture of mandible, open, coronoid process
802.34 Fracture of mandible, open, ramus, unspecified
802.35 Fracture of mandible, open, angle of jaw
802.36 Fracture of mandible, open, symphysis of body
802.37 Fracture of mandible, open, alveolar border of body
802.38 Fracture of mandible, open, body, other and unspecified
802.39 Fracture of mandible, open, multiple sites
802.4 Fracture of malar and maxillary bones, closed
802.5 Fracture of malar and maxillary bones, open
802.6 Fracture of orbital floor (blow-out), closed
802.7 Fracture of orbital floor (blow-out), open
802.8 Fracture of other facial bones, closed
802.9 Fracture of other facial bones, open
803.00 Fracture of skull, closed, without intracranial injury, unspecified state of consciousness
803.01 Fracture of skull, closed, without intracranial injury with no loss of consciousness
803.02 Fracture of skull, closed, without intracranial injury with brief loss of consciousness
803.03 Fracture of skull, closed, without intracranial injury with moderate loss of consciousness




                                                                                          Page 259
NATIONAL COVERAGE DETERMINATION                                                               85610

803.04 Fracture of skull, closed, without intracranial injury with prolonged loss of consciousness
       and return to pre-existing level
803.05 Fracture of skull, closed, without intracranial injury with prolonged loss of consciousness,
       without return to pre-existing level
803.06 Fracture of skull, closed, without intracranial injury with loss of consciousness of
       unspecified duration
803.09 Fracture of skull, closed, without intracranial injury with concussion, unspecified
803.10 Fracture of skull, closed, with cerebral laceration and contusion, unspecified state of
       consciousness
803.11 Fracture of skull, closed, with cerebral laceration and contusion with no loss of
       consciousness
803.12 Fracture of skull, closed, with cerebral laceration and contusion with brief loss of
       consciousness
803.13 Fracture of skull, closed, with cerebral laceration and contusion with moderate loss of
       consciousness
803.14 Fracture of skull, closed, with cerebral laceration and contusion with prolonged loss of
       consciousness and return to pre-existing level
803.15 Fracture of skull, closed, with cerebral laceration and contusion with prolonged loss of
       consciousness, without return to pre-existing level
803.16 Fracture of skull, closed, with cerebral laceration and contusion with loss of
       consciousness of unspecified duration
803.19 Fracture of skull, closed, with cerebral laceration and contusion with concussion,
       unspecified
803.20 Fracture of skull, closed, with subarachnoid, subdural, and extradural hemorrhage,
       unspecified state of consciousness
803.21 Fracture of skull, closed, with subarachnoid, subdural, and extradural hemorrhage with
       no loss of consciousness
803.22 Fracture of skull, closed, with subarachnoid, subdural, and extradural hemorrhage with
       brief loss of consciousness
803.23 Fracture of skull, closed, with subarachnoid, subdural, and extradural hemorrhage with
       moderate loss of consciousness
803.24 Fracture of skull, closed, with subarachnoid, subdural, and extradural hemorrhage with
       prolonged loss of consciousness and return to pre-existing level
803.25 Fracture of skull, closed, with subarachnoid, subdural, and extradural hemorrhage with
       prolonged loss of consciousness, without return to pre-existing level
803.26 Fracture of skull, closed, with subarachnoid, subdural, and extradural hemorrhage with
       loss of consciousness of unspecified duration
803.29 Fracture of skull, closed, with subarachnoid, subdural, and extradural hemorrhage with
       concussion, unspecified
803.30 Fracture of skull, closed, with other and unspecified intracranial hemorrhage, unspecified
       state of consciousness
803.31 Fracture of skull, closed, with other and unspecified intracranial hemorrhage with no loss
       of consciousness
803.32 Fracture of skull, closed, with other and unspecified intracranial hemorrhage with brief
       loss of consciousness
803.33 Fracture of skull, closed, with other and unspecified intracranial hemorrhage with
       moderate loss of consciousness
803.34 Fracture of skull, closed, with other and unspecified intracranial hemorrhage with
       prolonged loss of consciousness and return to pre-existing level
803.35 Fracture of skull, closed, with other and unspecified intracranial hemorrhage with
       prolonged loss of consciousness, without return to pre-existing level
803.36 Fracture of skull, closed, with other and unspecified intracranial hemorrhage, with loss of
       consciousness of unspecified duration



                                                                                           Page 260
NATIONAL COVERAGE DETERMINATION                                                                 85610

803.39 Fracture of skull, closed, with other and unspecified intracranial hemorrhage with
       concussion, unspecified
803.40 Fracture of skull, closed, with intracranial injury of other and unspecified nature,
       unspecified state of consciousness
803.41 Fracture of skull, closed, with intracranial injury of other and unspecified nature with no
       loss of consciousness
803.42 Fracture of skull, closed, with intracranial injury of other and unspecified nature with brief
       loss of consciousness
803.43 Fracture of skull, closed, with intracranial injury of other and unspecified nature with
       moderate loss of consciousness
803.44 Fracture of skull, closed, with intracranial injury of other and unspecified nature with
       prolonged loss of consciousness and return to pre-existing level
803.45 Fracture of skull, closed, with intracranial injury of other and unspecified nature with
       prolonged loss of consciousness, without return to pre-existing level
803.46 Fracture of skull, closed, with intracranial injury of other and unspecified nature, with loss
       of consciousness of unspecified duration
803.49 Fracture of skull, closed, with intracranial injury of other and unspecified nature, with
       concussion, unspecified
803.50 Fracture of skull, open, without intracranial injury, unspecified state of consciousness
803.51 Fracture of skull, open, without intracranial injury with no loss of consciousness
803.52 Fracture of skull, open, without intracranial injury with brief loss of consciousness
803.53 Fracture of skull, open, without intracranial injury with moderate loss of consciousness
803.54 Fracture of skull, open, without intracranial injury with prolonged loss of consciousness
       and return to pre-existing level
803.55 Fracture of skull, open, without intracranial injury with prolonged loss of consciousness,
       without return to pre-existing level
803.56 Fracture of skull, open, without intracranial injury, with loss of consciousness of
       unspecified duration
803.59 Fracture of skull, open, without intracranial injury, with concussion, unspecified
803.60 Fracture of skull, open, with cerebral laceration and contusion, unspecified state of
       consciousness
803.61 Fracture of skull, open, with cerebral laceration and contusion with no loss of
       consciousness
803.62 Fracture of skull, open, with cerebral laceration and contusion with brief loss of
       consciousness
803.63 Fracture of skull, open, with cerebral laceration and contusion with moderate loss of
       consciousness
803.64 Fracture of skull, open, with cerebral laceration and contusion with prolonged loss of
       consciousness and return to pre-existing level
803.65 Fracture of skull, open, with cerebral laceration and contusion with prolonged loss of
       consciousness, without return to pre-existing level
803.66 Fracture of skull, open, with cerebral laceration and contusion with loss of consciousness
       of unspecified duration
803.69 Fracture of skull, open, with cerebral laceration and contusion with concussion,
       unspecified
803.70 Fracture of skull, open, with subarachnoid, subdural, and extradural hemorrhage,
       unspecified state of consciousness
803.71 Fracture of skull, open, with subarachnoid, subdural, and extradural hemorrhage with no
       loss of consciousness
803.72 Fracture of skull, open, with subarachnoid, subdural, and extradural hemorrhage with
       brief loss of consciousness
803.73 Fracture of skull, open, with subarachnoid, subdural, and extradural hemorrhage with
       moderate loss of consciousness



                                                                                            Page 261
NATIONAL COVERAGE DETERMINATION                                                                  85610

803.74 Fracture of skull, open, with subarachnoid, subdural, and extradural hemorrhage with
       prolonged loss of consciousness and return to pre-existing level
803.75 Fracture of skull, open, with subarachnoid, subdural, and extradural hemorrhage with
       prolonged loss of consciousness, without return to pre-existing level
803.76 Fracture of skull, open, with subarachnoid, subdural, and extradural hemorrhage with
       loss of consciousness of unspecified duration
803.79 Fracture of skull, open, with subarachnoid, subdural, and extradural hemorrhage with
       concussion, unspecified
803.80 Fracture of skull, open, with other and unspecified intracranial hemorrhage, unspecified
       state of consciousness
803.81 Fracture of skull, open, with other and unspecified intracranial hemorrhage with no loss of
       consciousness
803.82 Fracture of skull, open, with other and unspecified intracranial hemorrhage with brief loss
       of consciousness
803.83 Fracture of skull, open, with other and unspecified intracranial hemorrhage with moderate
       loss of consciousness
803.84 Fracture of skull, open, with other and unspecified intracranial hemorrhage with
       prolonged loss of consciousness and return to pre-existing level
803.85 Fracture of skull, open, with other and unspecified intracranial hemorrhage with
       prolonged loss of consciousness, without return to pre-existing level
803.86 Fracture of skull, open, with other and unspecified intracranial hemorrhage with loss of
       consciousness of unspecified duration
803.89 Fracture of skull, open, with other and unspecified intracranial hemorrhage with
       concussion, unspecified
803.90 Fracture of skull, open, with intracranial injury of other and unspecified nature,
       unspecified state of consciousness
803.91 Fracture of skull, open, with intracranial injury of other and unspecified nature with no
       loss of consciousness
803.92 Fracture of skull, open, with intracranial injury of other and unspecified nature with brief
       loss of consciousness
803.93 Fracture of skull, open, with intracranial injury of other and unspecified nature with
       moderate loss of consciousness
803.94 Fracture of skull, open, with intracranial injury of other and unspecified nature with
       prolonged loss of consciousness and return to pre-existing level
803.95 Fracture of skull, open, with intracranial injury of other and unspecified nature with
       prolonged loss of consciousness, without return to pre-existing level
803.96 Fracture of skull, open, with intracranial injury of other and unspecified nature with loss of
       consciousness of unspecified duration
803.99 Fracture of skull, open, with intracranial injury of other and unspecified nature with
       concussion, unspecified
804.00 Multiple fractures of skull or face, closed, without intracranial injury, unspecified state of
       consciousness
804.01 Multiple fractures of skull or face, closed, without intracranial injury, with no loss of
       consciousness
804.02 Multiple fractures of skull or face, closed, without intracranial injury, with brief loss of
       consciousness
804.03 Multiple fractures of skull or face, closed, without intracranial injury, with moderate loss of
       consciousness
804.04 Multiple fractures of skull or face, closed, without intracranial injury, with prolonged loss of
       consciousness and return to pre-existing level
804.05 Multiple fractures of skull or face, closed, without intracranial injury, with prolonged loss of
       consciousness, without return to pre-existing level




                                                                                             Page 262
NATIONAL COVERAGE DETERMINATION                                                                85610

804.06 Multiple fractures of skull or face, closed, without intracranial injury, with loss of
       consciousness of unspecified duration
804.09 Multiple fractures of skull or face, closed, without intracranial injury, with concussion,
       unspecified
804.10 Multiple fractures involving skull or face, closed, with cerebral laceration and contusion,
       unspecified state of consciousness
804.11 Multiple fractures involving skull or face, closed, with cerebral laceration and contusion
       with no loss of consciousness
804.12 Multiple fractures involving skull or face, closed, with cerebral laceration and contusion
       with brief loss of consciousness
804.13 Multiple fractures involving skull or face, closed, with cerebral laceration and contusion
       with moderate loss of consciousness
804.14 Multiple fractures involving skull or face, closed, with cerebral laceration and contusion
       with prolonged loss of consciousness and return to pre-existing level
804.15 Multiple fractures involving skull or face, closed, with cerebral laceration and contusion
       with prolonged loss of consciousness, without return to pre-existing level
804.16 Multiple fractures involving skull or face, closed, with cerebral laceration and contusion
       with loss of consciousness of unspecified duration
804.19 Multiple fractures involving skull or face, closed, with cerebral laceration and contusion
       with concussion, unspecified
804.20 Multiple fractures involving skull or face, closed, with subarachnoid, subdural, and
       extradural hemorrhage unspecified state of consciousness
804.21 Multiple fractures involving skull or face, closed, with subarachnoid, subdural, and
       extradural hemorrhage with no loss of consciousness
804.22 Multiple fractures involving skull or face, closed, with subarachnoid, subdural, and
       extradural hemorrhage with brief loss of consciousness
804.23 Multiple fractures involving skull or face, closed, with subarachnoid, subdural, and
       extradural hemorrhage with moderate loss of consciousness
804.24 Multiple fractures involving skull or face, closed, with subarachnoid, subdural, and
       extradural hemorrhage with prolonged loss of consciousness and return to pre-existing
       level
804.25 Multiple fractures involving skull or face Closed with subarachnoid, subdural, and
       extradural hemorrhage with prolonged loss of consciousness, without return to pre-
       existing level
804.26 Multiple fractures involving skull or face, closed, with subarachnoid, subdural, and
       extradural hemorrhage with loss of consciousness of unspecified duration
804.29 Multiple fractures involving skull or face, closed, with subarachnoid, subdural, and
       extradural hemorrhage with concussion, unspecified
804.30 Multiple fractures involving skull or face, closed, with other and unspecified intracranial
       hemorrhage unspecified state of consciousness
804.31 Multiple fractures involving skull or face, closed, with other and unspecified intracranial
       hemorrhage with no loss of consciousness
804.32 Multiple fractures involving skull or face, closed, with other and unspecified intracranial
       hemorrhage with brief loss of consciousness
804.33 Multiple fractures involving skull or face, closed, with other and unspecified intracranial
       hemorrhage with moderate loss of consciousness
804.34 Multiple fractures involving skull or face, closed, with other and unspecified intracranial
       hemorrhage with prolonged loss of consciousness and return to pre-existing level
804.35 Multiple fractures involving skull or face, closed, with other and unspecified intracranial
       hemorrhage with prolonged loss of consciousness, without return to pre-existing level
804.36 Multiple fractures involving skull or face, closed, with other and unspecified intracranial
       hemorrhage with loss of consciousness of unspecified duration




                                                                                           Page 263
NATIONAL COVERAGE DETERMINATION                                                                   85610

804.39 Multiple fractures involving skull or face, closed, with other and unspecified intracranial
       hemorrhage with concussion, unspecified
804.40 Multiple fractures involving skull or face, closed, with intracranial injury of other and
       unspecified nature, unspecified state of consciousness
804.41 Multiple fractures involving skull or face, closed, with intracranial injury of other and
       unspecified nature with no loss of consciousness
804.42 Multiple fractures involving skull or face, closed, with intracranial injury of other and
       unspecified nature with brief loss of consciousness
804.43 Multiple fractures involving skull or face, closed, with intracranial injury of other and
       unspecified nature with moderate loss of consciousness
804.44 Multiple fractures involving skull or face, closed, with intracranialinjury of other and
       unspecified nature with prolonged loss of consciousness and return to pre-existing level
804.45 Multiple fractures involving skull or face, closed, with intracranialinjury of other and
       unspecified nature with prolonged loss of consciousness, without return to pre-existing
       conscious level
804.46 Multiple fractures involving skull or face, closed, with intracranialinjury of other and
       unspecified nature with loss of consciousness of unspecified duration
804.49 Multiple fractures involving skull or face, closed, with intracranialinjury of other and
       unspecified nature with concussion, unspecified
804.50 Multiple fractures involving skull or face, open, without intracranial injury, unspecified
       state of consciousness
804.51 Multiple fractures involving skull or face, open, without intracranial injury, with no loss of
       consciousness
804.52 Multiple fractures involving skull or face, open, without intracranial injury, with brief loss of
       consciousness
804.53 Multiple fractures involving skull or face, open, without intracranial injury, with moderate
       loss of consciousness
804.54 Multiple fractures involving skull or face, open, without intracranial injury, with prolonged
       loss of consciousness and return to pre-existing level
804.55 Multiple fractures involving skull or face, open, without intracranial injury, with prolonged
       loss of consciousness, without return to pre-existing level
804.56 Multiple fractures involving skull or face, open, without intracranial injury, with loss of
       consciousness of unspecified duration
804.59 Multiple fractures involving skull or face, open, without intracranial injury, with
       concussion, unspecified
804.60 Multiple fractures involving skull or face, open, with cerebral laceration and contusion,
       unspecified state of consciousness
804.61 Multiple fractures involving skull or face, open, with cerebral laceration and contusion with
       no loss of consciousness
804.62 Multiple fractures involving skull or face, open, with cerebral laceration and contusion with
       brief loss of consciousness
804.63 Multiple fractures involving skull or face, open, with cerebral laceration and contusion with
       moderate loss of consciousness
804.64 Multiple fractures involving skull or face, open, with cerebral laceration and contusion with
       prolonged loss of consciousness and return to pre-existing level
804.65 Multiple fractures involving skull or face, open, with cerebral laceration and contusion with
       prolonged loss of consciousness, without return to pre-existing level
804.66 Multiple fractures involving skull or face, open, with cerebral laceration and contusion with
       loss of consciousness of unspecified duration
804.69 Multiple fractures involving skull or face, open, with cerebral laceration and contusion with
       concussion, unspecified
804.70 Multiple fractures involving skull or face, open, with subarachnoid, subdural, and
       extradural hemorrhage unspecified state of consciousness



                                                                                              Page 264
NATIONAL COVERAGE DETERMINATION                                                              85610

804.71 Multiple fractures involving skull or face, open, with subarachnoid, subdural, and
       extradural hemorrhage with no loss of consciousness
804.72 Multiple fractures involving skull or face, open, with subarachnoid, subdural, and
       extradural hemorrhage with brief loss of consciousness
804.73 Multiple fractures involving skull or face, open, with subarachnoid, subdural, and
       extradural hemorrhage with moderate loss of consciousness
804.74 Multiple fractures involving skull or face, open, with subarachnoid, subdural, and
       extradural hemorrhage with prolonged loss of consciousness and return to pre-existing
       level
804.75 Multiple fractures involving skull or face, open, with subarachnoid, subdural, and
       extradural hemorrhage with prolonged loss of consciousness, without return to pre-
       existing level
804.76 Multiple fractures involving skull or face, open, with subarachnoid, subdural, and
       extradural hemorrhage with loss of consciousness of unspecified duration
804.79 Multiple fractures involving skull or face, open, with subarachnoid, subdural, and
       extradural hemorrhage with concussion, unspecified
804.80 Multiple fractures involving skull or face, open, with unspecified intracranial hemorrhage,
       unspecified state of consciousness
804.81 Multiple fractures involving skull or face, open, with unspecified intracranial hemorrhage,
       with no loss of consciousness
804.82 Multiple fractures involving skull or face, open, with unspecified intracranial hemorrhage,
       with brief loss of consciousness
804.83 Multiple fractures involving skull or face, open, with unspecified intracranial hemorrhage,
       with moderate loss of consciousness
804.84 Multiple fractures involving skull or face, open, with unspecified intracranial hemorrhage,
       with prolonged loss of consciousness and return to pre-existing level
804.85 Multiple fractures involving skull or face, open, with unspecified intracranial hemorrhage,
       with prolonged loss of consciousness, without return to pre-existing level
804.86 Multiple fractures involving skull or face, open, with unspecified intracranial hemorrhage,
       with loss of consciousness of unspecified duration
804.89 Multiple fractures involving skull or face, open, with unspecified intracranial hemorrhage,
       with concussion, unspecified
804.90 Multiple fractures involving skull or face, open, with intracranial injury of unspecified
       nature, unspecified state of consciousness
804.91 Multiple fractures involving skull or face, open, with intracranial injury of unspecified
       nature, with no loss of consciousness
804.92 Multiple fractures involving skull or face, open, with intracranial injury of unspecified
       nature, with brief loss of consciousness
804.93 Multiple fractures involving skull or face, open, with intracranial injury of unspecified
       nature, with moderate loss of consciousness
804.94 Multiple fractures involving skull or face, open, with intracranial injury of unspecified
       nature, with prolonged loss of consciousness and return to pre-existing level
804.95 Multiple fractures involving skull or face, open, with intracranial injury of unspecified
       nature, with prolonged loss of consciousness, without return to pre-existing level
804.96 Multiple fractures involving skull or face, open, with intracranial injury of unspecified
       nature, with loss of consciousness of unspecified duration
804.99 Multiple fractures involving skull or face, open, with intracranial injury of unspecified
       nature, with concussion, unspecified
805.00 Vertebral fracture without spinal cord injury, cervical, closed, unspecified level
805.01 Vertebral fracture without spinal cord injury, cervical, closed, first cervical vertebra
805.02 Vertebral fracture without spinal cord injury, cervical, closed, second cervical vertebra
805.03 Vertebral fracture without spinal cord injury, cervical, closed, third cervical vertebra
805.04 Vertebral fracture without spinal cord injury, cervical, closed, fourth cervical vertebra



                                                                                          Page 265
NATIONAL COVERAGE DETERMINATION                                                                 85610

805.05   Vertebral fracture without spinal cord injury, cervical, closed, fifth cervical vertebra
805.06   Vertebral fracture without spinal cord injury, cervical, closed, sixth cervical vertebra
805.07   Vertebral fracture without spinal cord injury, cervical, closed, seventh cervical vertebra
805.08   Vertebral fracture without spinal cord injury, cervical, closed, multiple cervical vertebrae
805.10   Vertebral fracture without spinal cord injury, cervical, closed, unspecified level
805.11   Vertebral fracture without spinal cord injury, cervical, open, first cervical vertebra
805.12   Vertebral fracture without spinal cord injury, cervical, open, second cervical vertebra
805.13   Vertebral fracture without spinal cord injury, cervical, open, third cervical vertebra
805.14   Vertebral fracture without spinal cord injury, cervical, open, fourth cervical vertebra
805.15   Vertebral fracture without spinal cord injury, cervical, open, fifth cervical vertebra
805.16   Vertebral fracture without spinal cord injury, cervical, open, sixth cervical vertebra
805.17   Vertebral fracture without spinal cord injury, cervical, open, seventh cervical vertebra
805.18   Vertebral fracture without spinal cord injury, cervical, open, multiple cervical vertebrae
805.2    Fracture of vertebral column without spinal cord injury, dorsal (thoracic), closed
805.3    Fracture of vertebral column without mention of spinal cord injury, dorsal (thoracic), open
805.4    Fracture of vertebral column without spinal cord injury, lumbar, closed
805.5    Fracture of vertebral column without spinal cord injury, lumbar, open
805.6    Fracture of vertebral column without spinal cord injury, sacrum and coccyx, closed
805.7    Fracture of vertebral column without spinal cord injury, sacrum and coccyx, open
805.8    Fracture of vertebral column without spinal cord injury, unspecified, closed
805.9    Fracture of vertebral column without spinal cord injury, unspecified, open
806.00   Fracture of vertebral column with spinal cord injury cervical, closed, C1 -C4 level with
         unspecified spinal cord injury
806.01   Fracture of vertebral column with spinal cord injury cervical, closed, C1 -C4 level with
         complete lesion of cord
806.02   Fracture of vertebral column with spinal cord injury cervical, closed, C1 -C4 level with
         anterior cord syndrome
806.03   Fracture of vertebral column with spinal cord injury cervical, closed, C1 -C4 level with
         central cord syndrome
806.04   Fracture of vertebral column with spinal cord injury cervical, closed, C1 -C4 level with
         other specified spinal cord injury
806.05   Fracture of vertebral column with spinal cord injury cervical, closed, C5 -C7 level with
         unspecified spinal cord injury
806.06   Fracture of vertebral column with spinal cord injury cervical, closed, C5 -C7 level with
         complete lesion of cord
806.07   Fracture of vertebral column with spinal cord injury cervical, closed, C5 -C7 level with
         anterior cord syndrome
806.08   Fracture of vertebral column with spinal cord injury cervical, closed, C5 -C7 level with
         central cord syndrome
806.09   Fracture of vertebral column with spinal cord injury cervical, closed, C5 -C7 level with
         other specified spinal cord injury
806.10   Fracture, cervical, open, C1 -C4 level with unspecified spinal cord injury
806.11   Fracture, cervical, open, C1 -C4 level with complete lesion of cord
806.12   Fracture, cervical, open, C1 -C4 level with anterior cord syndrome
806.13   Fracture, cervical, open, C1 -C4 level with central cord syndrome
806.14   Fracture, cervical, open, C1 -C4 level with other specified spinal cord injury
806.15   Fracture, cervical, open, C5 -C7 level with unspecified spinal cord injury
806.16   Fracture, cervical, open, C5 -C7 level with complete lesion of cord
806.17   Fracture, cervical, open, C5 -C7 level with anterior cord syndrome
806.18   Fracture, cervical, open, C5 -C7 level with central cord syndrome
806.19   Fracture, cervical, open, C5 -C7 level with other specified spinal cord injury
806.20   Fracture, dorsal [thoracic], closed, T1 -T6 level with unspecified spinal cord injury
806.21   Fracture, dorsal [thoracic], closed, T1 -T6 level with complete lesion of cord



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NATIONAL COVERAGE DETERMINATION                                                                  85610

806.22   Fracture, dorsal [thoracic], closed, T1 -T6 level with anterior cord syndrome
806.23   Fracture, dorsal [thoracic], closed, T1 -T6 level with central cord syndrome
806.24   Fracture, dorsal [thoracic], closed, T1 -T6 level with other specified spinal cord injury
806.25   Fracture, dorsal [thoracic], closed, T7 -T12 level with unspecified spinal cord injury
806.26   Fracture, dorsal [thoracic], closed, T7 -T12 level with complete lesion of cord
806.27   Fracture, dorsal [thoracic], closed, T7 -T12 level with anterior cord syndrome
806.28   Fracture, dorsal [thoracic], closed, T7 -T12 level with central cord syndrome
806.29   Fracture, dorsal [thoracic], closed, T7 -T12 level with other specified spinal cord injury
806.30   Fracture, dorsal [thoracic], open, T1 -T6 level with unspecified spinal cord injury
806.31   Fracture, dorsal [thoracic], open, T1 -T6 level with complete lesion of cord
806.32   Fracture, dorsal [thoracic], open, T1 -T6 level with anterior cord syndrome
806.33   Fracture, dorsal [thoracic], open, T1 -T6 level with central cord syndrome
806.34   Fracture, dorsal [thoracic], open, T1 -T6 level with other specified spinal cord injury
806.35   Fracture, dorsal [thoracic], open, T7 -T12 level with unspecified spinal cord injury
806.36   Fracture, dorsal [thoracic], open, T7 -T12 level with complete lesion of cord
806.37   Fracture, dorsal [thoracic], open, T7 -T12 level with anterior cord syndrome
806.38   Fracture, dorsal [thoracic], open, T7 -T12 level with central cord syndrome
806.39   Fracture, dorsal [thoracic], open, T7 -T12 level with other specified spinal cord injury
806.4    Fracture of vertebral column with spinal cord injury, lumbar, closed
806.5    Fracture of vertebral column with spinal cord injury, lumbar, open
806.60   Fracture, sacrum and coccyx, closed, with unspecified spinal cord injury
806.61   Fracture, sacrum and coccyx, closed, with complete cauda equina lesion
806.62   Fracture, sacrum and coccyx, closed, with other cauda equina injury
806.69   Fracture, sacrum and coccyx, closed, with other spinal cord injury
806.70   Fracture, sacrum and coccyx, open, with unspecified spinal cord injury
806.71   Fracture, sacrum and coccyx, open, with complete cauda equina lesion
806.72   Fracture, sacrum and coccyx, open, with other cauda equina injury
806.79   Fracture, sacrum and coccyx, open, with other spinal cord injury
806.8    Fracture, sacrum and coccyx, unspecified, closed
806.9    Fracture, sacrum and coccyx, unspecified, open
807.00   Fracture, rib(s), closed, rib(s), unspecified
807.01   Fracture, rib(s), closed, one rib
807.02   Fracture, rib(s), closed, two ribs
807.03   Fracture, rib(s), closed, three ribs
807.04   Fracture, rib(s), closed, four ribs
807.05   Fracture, rib(s), closed, five ribs
807.06   Fracture, rib(s), closed, six ribs
807.07   Fracture, rib(s), closed, seven ribs
807.08   Fracture, rib(s), closed, eight or more ribs
807.09   Fracture, rib(s), closed, multiple ribs, unspecified
807.10   Fracture, rib(s), open, rib(s), unspecified
807.11   Fracture, rib(s), open, one rib
807.12   Fracture, rib(s), open, two ribs
807.13   Fracture, rib(s), open, three ribs
807.14   Fracture, rib(s), open, four ribs
807.15   Fracture, rib(s), open, five ribs
807.16   Fracture, rib(s), open, six ribs
807.17   Fracture, rib(s), open, seven ribs
807.18   Fracture, rib(s), open, eight or more ribs
807.19   Fracture, rib(s), open, multiple ribs, unspecified
808.8    Pelvic fracture, unspecified, closed
808.9    Pelvic fracture, unspecified, open
809.0    Fracture of bones of trunk, closed



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NATIONAL COVERAGE DETERMINATION                                                      85610

809.1    Fracture of bones of trunk, open
810.00   Fracture of clavicle, closed, unspecified part
810.01   Fracture of clavicle, closed, sternal end of clavicle
810.02   Fracture of clavicle, closed, shaft of clavicle
810.03   Fracture of clavicle, closed, acromial end of clavicle
810.10   Fracture of clavicle, open, unspecified part
810.11   Fracture of clavicle, open, sternal end of clavicle
810.12   Fracture of clavicle, open, shaft of clavicle
810.13   Fracture of clavicle, open, acromial end of clavicle
811.00   Fracture of scapula, closed, unspecified part
811.01   Fracture of scapula, closed, acromial process
811.02   Fracture of scapula, closed, coracoid process
811.03   Fracture of scapula, closed, glenoid cavity and neck of scapula
811.09   Fracture of scapula, closed, other
811.10   Fracture of scapula, open, unspecified part
811.11   Fracture of scapula, open, acromial process
811.12   Fracture of scapula, open, coracoid process
811.13   Fracture of scapula, open, glenoid cavity and neck of scapula
811.19   Fracture of scapula, open, other
812.00   Fracture of humerus, upper end, closed, unspecified part
812.01   Fracture of humerus, closed, surgical neck
812.02   Fracture of humerus, closed, anatomical neck
812.03   Fracture of humerus, closed, greater tuberosity
812.09   Fracture of humerus, closed, other
812.10   Fracture of humerus, upper end, open, unspecified part
812.11   Fracture of humerus, upper end, open, surgical neck
812.12   Fracture of humerus, upper end, open, anatomical neck
812.13   Fracture of humerus, upper end, open, greater tuberosity
812.19   Fracture of humerus, upper end, open, other
812.20   Fracture of humerus, shaft or unspecified part, closed unspecified part
812.21   Fracture of humerus, closed, shaft of humerus
812.30   Fracture of humerus, shaft or unspecified part, open unspecified part
812.31   Fracture of humerus, shaft or unspecified part, open, shaft
812.40   Fracture of humerus, lower end, closed, unspecified part
812.41   Fracture of humerus, closed, supracondylar
812.42   Fracture of humerus, closed, lateral condyle
812.43   Fracture of humerus, closed, medial condyle
812.44   Fracture of humerus, closed, condyle(s), unspecified
812.49   Fracture of humerus, closed, other
812.50   Fracture of humerus, lower end, open, unspecified part
812.51   Fracture of humerus, lower end, open, supracondylar
812.52   Fracture of humerus, lower end, open, lateral condyle
812.53   Fracture of humerus, lower end, open, medial condyle
812.54   Fracture of humerus, lower end, open, condyle(s), unspecified
812.59   Fracture of humerus, lower end, open, other
813.10   Fracture, upper end of forearm, open, unspecified
813.11   Fracture, olecranon process of ulna, open
813.12   Fracture, coronoid process of ulna, open
813.13   Monteggia's fracture, open
813.14   Other and unspecified open fractures of proximal end of ulna (alone)
813.15   Fracture, head of radius, open
813.16   Fracture, neck of radius, open
813.17   Other and unspecified open fractures of proximal end of radius (alone)



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NATIONAL COVERAGE DETERMINATION                                                                85610

813.18   Fracture, radius with ulna, upper end [any part] open
813.30   Fracture, shaft, unspecified, open
813.31   Fracture, radius (alone), open
813.32   Fracture, ulna (alone), open
813.33   Fracture, radius with ulna, open
813.50   Fracture, lower end of forearm, unspecified, open
813.51   Colles' fracture, open
813.52   Other fractures of distal end of radius (alone), open
813.53   Fracture, distal end of ulna (alone), open
813.54   Fracture, radius with ulna, lower end, open
813.90   Fracture, forearm, unspecified, open
813.91   Fracture, radius (alone), unspecified, open
813.92   Fracture, ulna (alone), unspecified, open
813.93   Fracture, radius with ulna, unspecified, open
819.0    Multiple fractures involving both upper limbs, and upper limb with rib(s) and sternum,
         closed
819.1    Multiple fractures involving both upper limbs, and upper limb with rib(s) and sternum,
         open
820.00   Fracture of neck of femur, intracapsular section, unspecified
820.01   Fracture of neck of femur, transcervical fracture, epiphysis (separation) (upper)
820.02   Fracture of neck of femur, transcervical fracture, midcervical section
820.03   Fracture of neck of femur, transcervical fracture, base of neck
820.09   Fracture of neck of femur, transcervical fracture, other
820.10   Fracture of neck of femur, transcervical fracture, open, Intracapsular section, unspecified
820.11   Fracture of neck of femur, transcervical fracture, open, epiphysis (separation) (upper)
820.12   Fracture of neck of femur, transcervical fracture, open, midcervical section
820.13   Fracture of neck of femur, transcervical fracture, open, base of neck
820.19   Fracture of neck of femur, transcervical fracture, open, other
820.20   Pertrochanteric fracture, closed, trochanteric section,
820.21   Pertrochanteric fracture, closed, intertrochanteric section
820.22   Pertrochanteric fracture, closed, subtrochanteric section
820.30   Pertrochanteric fracture, open, trochanteric section, unspecified
820.31   Pertrochanteric fracture, open, intertrochanteric section
820.32   Pertrochanteric fracture, open, subtrochanteric section
820.8    Fracture, unspecified part of neck of femur, closed
820.9    Unspecified part of neck of femur, open
821.00   Fracture, unspecified part of femur, closed
821.01   Fracture of shaft of femur, closed
821.10   Fracture of unspecified part of femur, open
821.11   Fracture of shaft of femur, open
821.20   Fracture, lower end of femur, closed, unspecified part
821.21   Fracture, lower end of femur, closed, condyle
821.22   Fracture, lower end of femur, closed, epiphysis
821.23   Fracture, lower end of femur, closed, supracondylar
821.29   Fracture, lower end of femur, closed, other
821.30   Fracture, lower end of femur, open, unspecified part
821.31   Fracture, lower end of femur, open, condyle,
821.32   Fracture, lower end of femur, open, epiphysis,
821.33   Fracture, lower end of femur, open, supracondylar
821.39   Fracture, lower end of femur, open, other
823.00   Fracture of tibia and fibula upper end, closed. tibia alone
823.01   Fracture of tibia and fibula upper end, closed, fibula alone
823.02   Fracture of tibia and fibula upper end, closed, fibula with tibia



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NATIONAL COVERAGE DETERMINATION                                                             85610

823.10   Fracture of tibia and fibula upper end, open, tibia alone
823.11   Fracture of tibia and fibula upper end, open, fibula alone
823.12   Fracture of tibia and fibula upper end, open, fibula with tibia
823.20   Fracture of tibia and fibula, shaft, closed, tibia alone
823.21   Fracture of tibia and fibula, shaft, closed, fibula alone
823.22   Fracture of tibia and fibula, shaft, closed, fibula with tibia
823.30   Fracture of tibia and fibula shaft, open, tibia alone
823.31   Fracture of tibia and fibula shaft, open, fibula alone
823.32   Fracture of tibia and fibula Shaft, open, fibula with tibia
823.40   Torus fracture, tibia alone
823.41   Torus fracture, fibula alone
823.42   Torus fracture, fibula with tibia
823.80   Fracture of tibia and fibula, unspecified part, closed, tibia alone
823.81   Fracture of tibia and fibula, unspecified part, closed, fibula alone
823.82   Fracture of tibia and fibula, unspecified part, closed, fibula with tibia
823.90   Fracture of tibia and fibula, unspecified part, open, tibia alone
823.91   Fracture of tibia and fibula, unspecified part, open, fibula alone
823.92   Fracture of tibia and fibula, unspecified part, open, fibula with tibia
827.0    Other, multiple, and ill-defined fractures of lower limb, closed
827.1    Other, multiple, and ill-defined fractures of lower limb, open
828.0    Multiple fractures, closed
828.1    Multiple fractures, open
829.0    Fracture, unspecified bone, closed
829.1    Fracture, unspecified bone, open
852.00   Subarachnoid hemorrhage following injury without open intracranial wound, unspecified
         state of consciousness
852.01   Subarachnoid hemorrhage following injury without open intracranial wound, with no loss
         of consciousness
852.02   Subarachnoid hemorrhage following injury without open intracranial wound, with brief
         loss of consciousness
852.03   Subarachnoid hemorrhage following injury without open intracranial wound, with
         moderate loss of consciousness
852.04   Subarachnoid hemorrhage following injury without open intracranial wound, with
         prolonged loss of consciousness and return to pre-existing level
852.05   Subarachnoid hemorrhage following injury without open intracranial wound, with
         prolonged loss of consciousness, without return to pre-existing level
852.06   Subarachnoid hemorrhage following injury without open intracranial wound, with loss of
         consciousness of unspecified duration
852.09   Subarachnoid hemorrhage following injury without open intracranial wound, with
         concussion, unspecified
852.10   Subarachnoid hemorrhage following injury with open intracranial wound, unspecified
         state of consciousness
852.11   Subarachnoid hemorrhage following injury with open intracranial wound with no loss of
         consciousness
852.12   Subarachnoid hemorrhage following injury with open intracranial wound with brief loss of
         consciousness
852.13   Subarachnoid hemorrhage following injury with open intracranial wound with moderate
         loss of consciousness
852.14   Subarachnoid hemorrhage following injury with open intracranial wound with prolonged
         loss of consciousness and return to pre-existing level
852.15   Subarachnoid hemorrhage following injury with open intracranial wound with prolonged
         loss of consciousness, without return to pre-existing level




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NATIONAL COVERAGE DETERMINATION                                                            85610

852.16 Subarachnoid hemorrhage following injury with open intracranial wound with loss of
       consciousness of unspecified duration
852.19 Subarachnoid hemorrhage following injury with open intracranial wound with concussion,
       unspecified
852.20 Subdural hemorrhage following injury without open intracranial wound, unspecified state
       of consciousness
852.21 Subdural hemorrhage following injury without open intracranial wound, with no loss of
       consciousness
852.22 Subdural hemorrhage following injury without open intracranial wound, with brief loss of
       consciousness
852.23 Subdural hemorrhage following injury without open intracranial wound, with moderate
       loss of consciousness
852.24 Subdural hemorrhage following injury without open intracranial wound, with prolonged
       loss of consciousness and return to pre-existing level
852.25 Subdural hemorrhage following injury without open intracranial wound, with prolonged
       loss of consciousness, without return to pre-existing level
852.26 Subdural hemorrhage following injury without open intracranial wound, with loss of
       consciousness of unspecified duration
852.29 Subdural hemorrhage following injury without open intracranial wound, with concussion,
       unspecified
852.30 Subdural hemorrhage following injury, with open intracranial wound, unspecified state of
       consciousness
852.31 Subdural hemorrhage following injury, with open intracranial wound with no loss of
       consciousness
852.32 Subdural hemorrhage following injury, with open intracranial wound with brief loss of
       consciousness
852.33 Subdural hemorrhage following injury, with open intracranial wound with moderate loss of
       consciousness
852.34 Subdural hemorrhage following injury, with open intracranial wound with prolonged loss
       of consciousness and return to pre-existing level
852.35 Subdural hemorrhage following injury, with open intracranial wound with prolonged loss
       of consciousness, without return to pre-existing level
852.36 Subdural hemorrhage following injury, with open intracranial wound, with loss of
       consciousness of unspecified duration
852.39 Subdural hemorrhage following injury, with open intracranial wound with concussion,
       unspecified
852.40 Extradural hemorrhage following injury without open intracranial wound, unspecified state
       of consciousness
852.41 Extradural hemorrhage following injury without open intracranial wound, with no loss of
       consciousness
852.42 Extradural hemorrhage following injury without open intracranial wound, with brief loss of
       consciousness
852.43 Extradural hemorrhage following injury without open intracranial wound, with moderate
       loss of consciousness
852.44 Extradural hemorrhage following injury without open intracranial wound, with prolonged
       loss of consciousness and return to pre-existing level
852.45 Extradural hemorrhage following injury without open intracranial wound, with prolonged
       loss of consciousness, without return to pre-existing level
852.46 Extradural hemorrhage following injury without open intracranial wound, with loss of
       consciousness of unspecified duration
852.49 Extradural hemorrhage following injury without open intracranial wound, with concussion,
       unspecified




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NATIONAL COVERAGE DETERMINATION                                                              85610

852.50 Extradural hemorrhage following injury, with open intracranial wound, unspecified state of
       consciousness
852.51 Extradural hemorrhage following injury, with open intracranial wound with no loss of
       consciousness
852.52 Extradural hemorrhage following injury, with open intracranial wound with brief loss of
       consciousness
852.53 Extradural hemorrhage following injury, with open intracranial wound with moderate loss
       of consciousness
852.54 Extradural hemorrhage following injury, with open intracranial wound with prolonged loss
       of consciousness and return to pre-existing level
852.55 Extradural hemorrhage following injury, with open intracranial wound with prolonged loss
       of consciousness, without return to pre-existing level
852.56 Extradural hemorrhage following injury, with open intracranial wound with loss of
       consciousness of unspecified duration
852.59 Extradural hemorrhage following injury, with open intracranial wound, with concussion,
       unspecified
853.00 Intracranial hemorrhage following injury without open intracranial wound, unspecified
       state of consciousness
853.01 Intracranial hemorrhage following injury without open intracranial wound, with no loss of
       consciousness
853.02 Intracranial hemorrhage following injury without open intracranial wound, with brief loss of
       consciousness
853.03 Intracranial hemorrhage following injury without open intracranial wound, with moderate
       loss of consciousness
853.04 Intracranial hemorrhage following injury without open intracranial wound, with prolonged
       loss of consciousness and return to pre-existing level
853.05 Intracranial hemorrhage following injury without open intracranial wound, with prolonged
       loss of consciousness, without return to pre-existing level
853.06 Intracranial hemorrhage following injury without open intracranial wound, with loss of
       consciousness of unspecified duration
853.09 Intracranial hemorrhage following injury without open intracranial wound, with
       concussion, unspecified
853.10 Intracranial hemorrhage following injury, with open intracranial wound, unspecified state
       of consciousness
853.11 Intracranial hemorrhage following injury, with open intracranial wound with no loss of
       consciousness
853.12 Intracranial hemorrhage following injury, with open intracranial wound with brief loss of
       consciousness
853.13 Intracranial hemorrhage following injury, with open intracranial wound with moderate loss
       of consciousness
853.14 Intracranial hemorrhage following injury, with open intracranial wound with prolonged loss
       of consciousness and return to pre-existing level
853.15 Intracranial hemorrhage following injury, with open intracranial wound with prolonged loss
       of consciousness, without return to pre-existing level
853.16 Intracranial hemorrhage following injury, with open intracranial wound, with loss of
       consciousness of unspecified duration
853.19 Intracranial hemorrhage following injury, with open intracranial wound, with concussion,
       unspecified
860.0 Pneumothorax without open wound into thorax
860.1 Pneumothorax with open wound into thorax
860.2 Hemothorax without open wound into thorax
860.3 Hemothorax with open wound into thorax
860.4 Pneumohemothorax without open wound into thorax



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NATIONAL COVERAGE DETERMINATION                                                                85610

860.5    Pneumohemothorax with open wound into thorax
861.00   Injury to heart, without open wound into thorax, unspecified injury
861.01   Injury to heart, without open wound into thorax, contusion
861.02   Injury to heart, without open wound into thorax, laceration without penetration of heart
         chambers
861.03   Injury to heart, without open wound into thorax, laceration with penetration of heart
         chambers
861.10   Injury to heart, with open wound into thorax, unspecified
861.11   Injury to heart, with open wound into thorax, contusion
861.12   Injury to heart, with open wound into thorax, laceration without penetration of heart
         chambers
861.13   Injury to heart, with open wound into thorax, laceration with penetration of heart
         chambers
861.20   Injury to lung, unspecified
861.21   Injury to lung, contusion
861.22   Injury to lung, laceration
861.30   Injury to lung, with open wound into thorax, unspecified
861.31   Injury to lung, with open wound into thorax, contusion
861.32   Injury to lung, with open wound into thorax, laceration
862.0    Injury to diaphragm, without open wound into cavity
862.1    Injury to diaphragm, with open wound into cavity
862.21   Injury to bronchus without open wound into cavity
862.22   Injury to esophagus without open wound into cavity
862.29   Injury to other specified intrathoracic organs, without open wound into cavity
862.31   Injury to bronchus with open wound into cavity
862.32   Injury to esophagus with open wound into cavity
862.39   Injury to other specified intrathoracic organs, with open wound into cavity
862.8    Injury to multiple and unspecified intrathoracic organs, without mention of open wound
         into cavity
862.9    Injury to multiple and unspecified intrathoracic organs, with open wound into cavity
863.0    Injury to stomach, without open wound into cavity
863.1    Injury to stomach, with open wound into cavity into cavity
863.20   Injury to small intestine, without open wound into cavity, unspecified site
863.21   Injury to duodenum without open wound into cavity
863.29   Injury to other digestive tract organ without open wound into cavity
863.30   Injury to small intestine, unspecified site, with open wound into cavity
863.31   Injury to duodenum with open wound into cavity
863.39   Injury to other digestive tract organ with open wound into cavity
863.40   Injury to colon, unspecified site, without open wound into cavity
863.41   Injury to ascending [right] colon without open wound into cavity
863.42   Injury to transverse colon without open wound into cavity
863.43   Injury to descending [left] colon without open wound into cavity
863.44   Injury to sigmoid colon without open wound into cavity
863.45   Injury to rectum without open wound into
863.46   Injury to multiple sites in colon and rectum without open wound into cavity
863.49   Injury to other colon or rectum site without open wound into cavity
863.50   Injury to colon, unspecified site, with open wound into cavity
863.51   Injury to ascending [right] colon with open wound into cavity
863.52   Injury to transverse colon with open wound into cavity
863.53   Injury to descending [left] colon with open wound into cavity
863.54   Injury to sigmoid colon with open wound into cavity
863.55   Injury to rectum with open wound into cavity
863.56   Injury to multiple sites in colon and rectum with open wound into cavity



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NATIONAL COVERAGE DETERMINATION                                                               85610

863.59   Injury to other sites in colon and rectum with open wound into cavity
863.80   Injury to gastrointestinal tract, unspecified site, without open wound into cavity
863.81   Injury to pancreas, head, without open wound into cavity
863.82   Injury to pancreas, body. without open wound into cavity
863.83   Injury to pancreas, tail, without open wound into cavity
863.84   Injury to pancreas, multiple and unspecified sites, without open wound into cavity
863.85   Injury to appendix without open wound into cavity
863.89   Injury to other gastrointestinal sites, without open wound into cavity
863.90   Injury to gastrointestinal tract, unspecified site, with open wound into cavity
863.91   Injury to pancreas, head, with open wound into cavity
863.92   Injury to pancreas, body, with open wound into cavity
863.93   Injury to pancreas, tail, with open wound into cavity
863.94   Injury to pancreas, multiple and unspecified sites, with open wound into cavity
863.95   Injury to appendix with open wound into cavity
863.99   Injury to other gastrointestinal tract sites with open wound into cavity
864.00   Injury to liver without open wound into cavity, unspecified injury
864.01   Injury to liver without open wound into cavity, hematoma and contusion
864.02   Injury to liver without open wound into cavity, laceration, minor
864.03   Injury to liver without open wound into cavity, laceration, moderate
864.04   Injury to liver without open wound into cavity, laceration, major
864.05   Injury to liver without open wound into cavity, laceration, unspecified
864.09   Injury to liver without open wound into cavity, other
864.10   Injury to liver with open wound into cavity, unspecified injury
864.11   Injury to liver with open wound into cavity, hematoma and contusion
864.12   Injury to liver with open wound into cavity, laceration, minor
864.13   Injury to liver with open wound into cavity, laceration, moderate
864.14   Injury to liver with open wound into cavity, laceration, major
864.15   Injury to liver with open wound into cavity, laceration, unspecified
864.19   Injury to liver with open wound into cavity, other
865.00   Injury to spleen without open wound into cavity, unspecified injury
865.01   Injury to spleen without open wound into cavity, hematoma without rupture of capsule
865.02   Injury to spleen without open wound into cavity, capsular tears, without major disruption
         of parenchyma
865.03   Injury to spleen without open wound into cavity, laceration extending into parenchyma
865.04   Injury to spleen without open wound into cavity, massive parenchymal disruption
865.09   Injury to spleen without mention of open wound into cavity other
865.10   Injury to spleen with open wound into cavity, unspecified injury
865.11   Injury to spleen with open wound into cavity, hematoma without rupture of capsule
865.12   Injury to spleen with open wound into cavity, capsular tears, without major disruption of
         parenchyma
865.13   Injury to spleen with open wound into cavity, laceration extending into parenchyma
865.14   Injury to spleen with open wound into cavity, massive parenchymal disruption
865.19   Injury to spleen with open wound into cavity, other
866.00   Injury to kidney without open wound into cavity, unspecified injury
866.01   Injury to kidney without open wound into cavity, hematoma without rupture of capsule
866.02   Injury to kidney without open wound into cavity, laceration
866.03   Injury to kidney without open wound into cavity, complete disruption of kidney
         parenchyma
866.10   Injury to kidney with open wound into cavity, unspecified injury
866.11   Injury to kidney with open wound into cavity, hematoma without rupture of capsule
866.12   Injury to kidney with open wound into cavity, laceration
866.13   Injury to kidney with open wound into cavity, complete disruption of kidney parenchyma
867.0    Injury to bladder and urethra, without open wound into cavity



                                                                                           Page 274
NATIONAL COVERAGE DETERMINATION                                                              85610

867.1    Injury to bladder and urethra, with open wound into cavity
867.2    Injury to ureter, without open wound into cavity
867.3    Injury to ureter, with open wound into cavity
867.4    Injury to uterus, without open wound into cavity
867.5    Injury to uterus, with open wound into cavity
867.6    Injury to other specified pelvic organs, without open wound into cavity
867.7    Injury to other specified pelvic organs, with open wound into cavity
867.8    Injury to unspecified pelvic organ, without mention of open wound into cavity
867.9    Unspecified pelvic organ, with open wound into cavity
868.00   Injury to other intra-abdominal organs without open wound into cavity, unspecified intra-
         abdominal organ
868.01   Injury to other intra-abdominal organs without open wound into cavity, adrenal gland
868.02   Injury to other intra-abdominal organs without open wound into cavity, bile duct and
         gallbladder
868.03   Injury to other intra-abdominal organs without open wound into cavity, peritoneum
868.04   Injury to other intra-abdominal organs without open wound into cavity, retroperitoneum
868.09   Injury to other intra-abdominal organs without open wound into cavity, other and multiple
         intra-abdominal organs
868.10   Injury to other intra-abdominal organs with open wound into cavity unspecified intra-
         abdominal organ
868.11   Injury to other intra-abdominal organs with open wound into cavity adrenal gland
868.12   Injury to other intra-abdominal organs with open wound into cavity bile duct and
         gallbladder
868.13   Injury to other intra-abdominal organs with open wound into cavity peritoneum
868.14   Injury to other intra-abdominal organs with open wound into cavity retroperitoneum
868.19   Injury to other intra-abdominal organs with open wound into cavity other and multiple
         intra-abdominal organs
869.0    Internal injury to unspecified or ill-defined organs without open wound into cavity
869.1    Internal injury to unspecified or ill-defined organs with open wound into cavity
900.00   Injury to carotid artery, unspecified
900.01   Injury to common carotid artery
900.02   Injury to external carotid artery
900.03   Injury to internal carotid artery
900.1    Injury to internal jugular vein
900.81   Injury to external jugular vein
900.82   Injury to multiple blood vessels of head and neck
900.89   Injury to other blood vessels of head and neck
900.9    Injury to unspecified blood vessel of head and neck
901.0    Injury to thoracic aorta
901.1    Injury to innominate and subclavian arteries
901.2    Injury to superior vena cava
901.3    Injury to innominate and subclavian veins
901.40   Injury to pulmonary vessel(s), unspecified
901.41   Injury to pulmonary artery
901.42   Injury to pulmonary vein
901.81   Injury to intercostal artery or vein
901.82   Injury to internal mammary artery or vein
901.83   Injury to multiple blood vessels of thorax
901.89   Injury to other blood vessels of thorax
901.9    Injury to unspecified blood vessel of thorax
902.0    Injury to abdominal aorta
902.10   Injury to inferior vena cava, unspecified
902.11   Injury to hepatic veins



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NATIONAL COVERAGE DETERMINATION                                            85610

902.19   Injury to other blood vessels of abdomen and pelvis
902.20   Injury to celiac and mesenteric arteries, unspecified
902.21   Injury to gastric artery
902.22   Injury to hepatic artery
902.23   Injury to splenic artery
902.24   Injury to other specified branches of celiac axis
902.25   Injury to superior mesenteric artery (trunk)
902.26   Injury to primary branches of superior mesenteric artery
902.27   Injury to inferior mesenteric artery
902.29   Injury to other celiac and mesenteric arteries
902.31   Injury to superior mesenteric vein and primary
902.32   Injury to inferior mesenteric vein
902.33   Injury to portal vein
902.34   Injury to splenic vein
902.39   Injury to other portal and splenic veins
902.40   Injury to renal vessel(s), unspecified
902.41   Injury to renal artery
902.42   Injury to renal vein
902.49   Injury to other renal blood vessels
902.50   Injury to iliac vessel(s), unspecified
902.51   Injury to hypogastric artery
902.52   Injury to hypogastric vein
902.53   Injury to iliac artery
902.54   Injury to iliac vein
902.55   Injury to uterine artery
902.56   Injury to uterine vein
902.59   Injury to other iliac blood vessels
902.81   Injury to ovarian artery
902.82   Injury to ovarian vein
902.87   Injury to multiple blood vessels of abdomen and pelvis
902.89   Injury to other specified blood vessels of abdomen and pelvis
902.9    Injury to unspecified blood vessel of abdomen and pelvis
903.00   Injury to axillary vessel(s), unspecified
903.01   Injury to axillary artery
903.02   Injury to axillary vein
903.1    Injury to brachial blood vessels
903.2    Injury to radial blood vessels
903.3    Injury to ulnar blood vessels
903.4    Injury to palmar artery
903.5    Injury to digital blood vessels
903.8    Injury to other specified blood vessels of upper extremity
903.9    Injury to unspecified blood vessel of upper extremity
904.0    Injury to common femoral artery
904.1    Injury to superficial femoral artery
904.2    Injury to femoral veins
904.3    Injury to saphenous veins
904.40   Injury to popliteal vessel(s), unspecified
904.41   Injury to popliteal artery
904.42   Injury to popliteal vein
904.50   Injury to tibial vessel(s), unspecified
904.51   Injury to anterior tibial artery
904.52   Injury to anterior tibial vein
904.53   Injury to posterior tibial artery



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NATIONAL COVERAGE DETERMINATION                                         85610

904.54   Injury to posterior tibial vein
904.6    Injury to deep plantar blood vessels
904.7    Injury to other specified blood vessels of lower extremity
904.8    Injury to unspecified blood vessel of lower extremity
904.9    Injury to blood vessels, unspecified site
920      Contusion of face, scalp, and neck except eye(s)
921.0    Black eye, not otherwise classified
921.1    Contusion of eyelids and periocular area
921.2    Contusion of orbital tissues
921.3    Contusion of eyeball
921.9    Unspecified contusion of eye
922.0    Contusion of breast
922.1    Contusion of chest wall
922.2    Contusion of abdominal wall
922.31   Contusion of back
922.32   Contusion of buttock
922.33   Contusion of interscapular region
922.4    Contusion of genital organs
922.8    Contusion of multiple sites of trunk
922.9    Contusion of unspecified part of trunk
923.00   Contusion of shoulder region
923.01   Contusion of scapular region
923.02   Contusion of axillary region
923.03   Contusion of upper arm
923.09   Contusion of multiple sites
923.10   Contusion of forearm
923.11   Contusion of elbow
923.20   Contusion of hand(s)
923.21   Contusion of wrist
923.3    Contusion of finger
923.8    Contusion of multiple sites of upper limb
923.9    Contusion of unspecified part of upper limb
924.00   Contusion of thigh
924.01   Contusion of hip
924.10   Contusion of lower leg
924.11   Contusion of knee
924.20   Contusion of foot
924.21   Contusion of ankle
924.3    Contusion of toe
924.4    Contusion of multiple sites of lower limb
924.5    Contusion of unspecified part of lower limb
924.8    Contusion of multiple sites, not elsewhere classified
924.9    Contusion of unspecified site
925.1    Crushing injury of face and scalp
925.2    Crushing injury of neck
926.0    Crushing injury of external genitalia
926.11   Crushing injury of back
926.12   Crushing injury of buttock
926.19   Crushing injury, other
926.8    Crushing injury of multiple sites of trunk
926.9    Crushing injury of unspecified site
927.00   Crushing injury of shoulder region
927.01   Crushing injury of scapular region



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NATIONAL COVERAGE DETERMINATION                                               85610

927.02   Crushing injury of axillary region
927.03   Crushing injury of upper arm
927.09   Crushing injury of multiple sites
927.10   Crushing injury of forearm
927.11   Crushing injury of elbow
927.20   Crushing injury of hand(s)
927.21   Crushing injury of wrist
927.3    Crushing injury of finger(s)
927.8    Crushing injury of multiple sites of upper limb
927.9    Crushing injury of unspecified site
928.00   Crushing injury of thigh
928.01   Crushing injury of hip
928.10   Crushing injury of lower leg
928.11   Crushing injury of knee
928.20   Crushing injury of foot
928.21   Crushing injury of ankle
928.3    Crushing injury of toe(s)
928.8    Crushing injury of multiple sites of lower limb
928.9    Crushing injury of unspecified site
929.0    Crushing injury of multiple sites, not elsewhere classified
929.9    Crushing injury of unspecified site
958.2    Secondary and recurrent hemorrhage
959.9    Injury, other and unspecified, unspecified site
964.0    Poisoning by iron and its compounds
964.1    Poisoning by liver preparations and other antianemic agents
964.2    Poisoning by anticoagulants
964.3    Poisoning by vitamin K [phytonadione]
964.4    Poisoning by fibrinolysis-affecting drugs
964.5    Poisoning by anticoagulant antagonists and other coagulants
964.6    Poisoning by gamma globulin
964.7    Poisoning by natural blood and blood products
964.8    Poisoning by other specified agents affecting blood constituents
964.9    Poisoning by unspecified agents affecting blood constituents
980.0    Toxic effect of ethyl alcohol
980.1    Toxic effect of methyl alcohol
980.2    Toxic effect of isopropyl alcohol
980.3    Toxic effect of fusel oil
980.8    Toxic effect of other specified alcohols
980.9    Toxic effect of unspecified alcohol
981      Toxic effect of petroleum products
982.0    Toxic effect of benzene and homologues
982.1    Toxic effect of carbon tetrachloride
982.2    Toxic effect of carbon disulfide
982.3    Toxic effect of other chlorinated hydrocarbon solvents
982.4    Toxic effect of nitroglycol
982.8    Toxic effect of other nonpetroleum-based solvents
987.0    Toxic effect of liquefied petroleum gases
987.1    Toxic effect of other hydrocarbon gas
987.2    Toxic effect of nitrogen oxides
987.3    Toxic effect of sulfur dioxide
987.4    Toxic effect of freon
987.5    Toxic effect of lacrimogenic gas
987.6    Toxic effect of chlorine gas



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NATIONAL COVERAGE DETERMINATION                                                                 85610

987.7    Toxic effect of hydrocyanic acid gas
987.8    Toxic effect of other specified gases, fumes, or vapors
987.9    Toxic effect of unspecified gas, fume, or vapor
989.0    Toxic effect of hydrocyanic acid and cyanides
989.1    Toxic effect of strychnine and salts
989.2    Toxic effect of chlorinated hydrocarbons
989.3    Toxic effect of organophosphate and carbamate
989.4    Toxic effect of other pesticides, not elsewhere classified
989.5    Toxic effect of venom
989.6    Toxic effect of soaps and detergents
989.7    Toxic effect of aflatoxin and other mycotoxin [food contaminants]
989.81   Toxic effect of asbestos
989.82   Toxic effect of latex
989.83   Toxic effect of silicone
989.84   Toxic effect of tobacco
989.89   Toxic effect of other substances, chiefly nonmedicinal as to source
989.9    Toxic effect of unspecified substance, chiefly nonmedicinal as to source
995.20   Unspecified adverse effect of unspecified drug, medicinal and biological substance
995.21   Arthus phenomenon
995.27   Other drug allergy
995.29   Unspecified adverse effect of other drug, medicinal and biological substance
996.82   Complications, transplanted liver
997.02   Iatrogenic cerebrovascular infarction or hemorrhage
997.4    Digestive system complications
998.11   Hemorrhage complicating a procedure
998.12   Hematoma complicating a procedure
999.2    Other vascular complications
999.8    Other transfusion reaction
V08      Asymptomatic human immunodeficiency virus [HIV] infection status
V12.1    Personal history of nutritional deficiency
V12.3    Personal history of diseases of blood and blood-forming organs
V12.50   Personal history of unspecified circulatory disease
V12.51   Personal history of venous thrombosis and embolism
V12.52   Personal history of thrombophlebitis
V12.53   Personal history of sudden cardiac arrest
V12.54   Personal history of transient ischemic attack (TIA), and cerebral infarction without
         residual deficits
V12.59   Personal history of other vein disease
V15.1    Personal history of surgery to heart and great vessels
V15.2    Personal history of surgery to other major organs
V42.0    Organ or tissue replaced by transplant, kidney
V42.1    Organ or tissue replaced by transplant, heart
V42.2    Organ or tissue replaced by transplant, heart valve
V42.6    Organ or tissue replaced by transplant, lung
V42.7    Organ or tissue replaced by transplant, liver
V42.81   Organ or tissue replaced by transplant, bone marrow
V42.82   Organ or tissue replaced by transplant, peripheral stem cells
V42.83   Organ or tissue replaced by transplant, pancreas
V42.84   Organ or tissue replaced by transplant, intestines
V42.89   Organ or tissue replaced by transplant, other organ or tissue
V43.21   Organ or tissue replaced by other means, heart assist device
V43.22   Organ or tissue replaced by other means, fully implantable artificial heart
V43.3    Organ or tissue replaced by other means, heart valve



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NATIONAL COVERAGE DETERMINATION                                    85610

V43.4    Organ or tissue replaced by other means, blood vessel
V58.2    Blood transfusion, without reported diagnosis
V58.61   Long-term (current) use of anticoagulants
V58.83   Encounter for therapeutic drug monitoring




                                                                 Page 280
NATIONAL COVERAGE DETERMINATION                                                                85730


NATIONAL COVERAGE DETERMINATION
85730
85730-Thromboplastin time, partial (PTT); plasma or whole blood




CPT CODE: 85730



CPT CODE DESCRIPTOR: Thromboplastin time, partial (PTT); plasma or whole blood



NATIONAL COVERAGE DETERMINATION FREQUENCY LIMITATIONS: None



COVERED ICD-9 CODES:
002.0 Typhoid fever
002.1 Paratyphoid fever A
002.2 Paratyphoid fever B
002.3 Paratyphoid fever C
002.9 Paratyphoid fever, unspecified
003.0 Salmonella gastroenteritis
003.1 Salmonella septicemia
003.20 Localized salmonella infection, unspecified
003.21 Salmonella meningitis
003.22 Salmonella pneumonia
003.23 Salmonella arthritis
003.24 Salmonella osteomyelitis
003.29 Other localized salmonella infection
003.8 Other specified salmonella infections
003.9 Salmonella infection, unspecified
038.9 Unspecified septicemia
042    Human immunodeficiency virus [HIV] disease
060.0 Sylvatic yellow fever
060.1 Urban yellow fever
060.9 Yellow fever, unspecified
065.0 Crimean hemorrhagic fever
065.1 Omsk hemorrhagic fever
065.2 Kyasanur Forest disease
065.3 Other tick-borne hemorrhagic fever
065.4 Mosquito-borne hemorrhagic fever
065.8 Other specified arthropod-borne hemorrhagic fever
065.9 Arthropod-borne hemorrhagic fever, unspecified
070.0 Viral hepatitis A with hepatic coma
070.1 Viral hepatitis A without hepatic coma
070.20 Viral hepatitis B with hepatic coma, acute or unspecified, without hepatitis delta
070.21 Viral hepatitis B with hepatic coma, acute or unspecified, with hepatitis delta
070.22 Viral hepatitis B with hepatic coma, chronic, without hepatitis delta
070.23 Viral hepatitis B with hepatic coma, chronic, with hepatitis delta
070.30 Viral hepatitis B without hepatic coma, acute or unspecified, without hepatitis delta
070.31 Viral hepatitis B without hepatic coma, acute or unspecified, with hepatitis delta
070.32 Viral hepatitis B without hepatic coma, chronic, without hepatitis delta
070.33 Viral hepatitis B without hepatic coma, chronic, with hepatitis delta
070.41 Acute hepatitis C with hepatic coma
070.42 Hepatitis delta without active hepatitis B disease with hepatic coma
070.43 Hepatitis E with hepatic coma


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NATIONAL COVERAGE DETERMINATION                                                                85730

070.44   Chronic hepatitis C with hepatic coma
070.49   Other specified viral hepatitis with hepatic coma
070.51   Acute hepatitis C without mention of hepatic coma
070.52   Hepatitis delta without active hepatitis B disease or hepatic coma
070.53   Hepatitis E without hepatic coma
070.54   Chronic hepatitis C without hepatic coma
070.59   Other specified viral hepatitis without hepatic coma
070.6    Unspecified viral hepatitis with hepatic coma
070.70   Unspecified viral hepatitis C without hepatic coma
070.71   Unspecified viral hepatitis C with hepatic coma
070.9    Unspecified viral hepatitis without hepatic coma
075      Infectious mononucleosis
078.6    Hemorrhagic nephrosonephritis
078.7    Arenaviral hemorrhagic fever
120.0    Schistosoma haematobium
121.1    Clonorchiasis
121.3    Fascioliasis
124      Trichinosis
135      Sarcoidosis
155.0    Malignant neoplasm, liver, primary
155.1    Malignant neoplasm, intrahepatic bile ducts
155.2    Malignant neoplasm, liver, not specified as primary or
197.7    Secondary malignant neoplasm of liver, specified as secondary
238.4    Polycythemia vera
238.71   Essential thrombocythemia
238.72   Low grade myelodysplastic syndrome lesions
238.73   High grade myelodysplastic syndrome lesions
238.74   Myelodysplastic syndrome with 5q deletion
238.75   Myelodysplastic syndrome, unspecified
238.76   Myelofibrosis with myeloid metaplasia
238.79   Other lymphatic and hematopoietic tissues
239.9    Neoplasms of unspecified nature, site unspecified
246.3    Hemorrhage and infarction of thyroid
250.40   Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.41   Diabetes with renal manifestations, type I, not stated as uncontrolled
250.42   Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43   Diabetes with renal manifestations, type I, uncontrolled
269.0    Vitamin K deficiency
273.0    Polyclonal hypergammaglobulinemia
273.1    Monoclonal paraproteinemia
273.2    Other paraproteinemias
273.3    Macroglobulinemia
273.8    Other disorders of plasma protein metabolism
273.9    Unspecified disorder of plasma protein metabolism
275.0    Disorders of iron metabolism
275.1    Disorders of copper metabolism
275.2    Disorders of magnesium metabolism
275.3    Disorders of phosphorus metabolism
275.40   Disorders of calcium metabolism, unspecified
275.41   Hypocalcemia
275.42   Hypercalcemia
275.49   Other disorders of calcium metabolism
275.8    Other specified disorders of mineral metabolism



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NATIONAL COVERAGE DETERMINATION                                            85730

275.9    Unspecified disorder of mineral metabolism
277.1    Disorders of porphyrin metabolism
277.30   Amyloidosis, unspecified
277.31   Familial Mediterranean fever
277.39   Other amyloidosis
285.1    Acute posthemorrhagic anemia
286.0    Congenital factor VIII disorder
286.1    Congenital factor IX disorder
286.2    Congenital factor XI deficiency
286.3    Congenital deficiency of other clotting factors
286.4    von Willebrand's disease
286.5    Hemorrhagic disorder due to circulating anticoagulants
286.6    Defibrination syndrome
286.7    Acquired coagulation factor deficiency
286.9    Other and unspecified coagulation defects
287.0    Allergic purpura
287.1    Qualitative platelet defects
287.2    Other nonthrombocytopenic purpuras
287.30   Primary thrombocytopenia, unspecified
287.31   Immune thrombocytopenic purpura
287.32   Evans' syndrome
287.33   Congenital and hereditary thrombocytopenic purpura
287.39   Other primary thrombocytopenia
287.4    Secondary thrombocytopenia
287.5    Thrombocytopenia, unspecified
287.8    Other specified hemorrhagic conditions
287.9    Unspecified hemorrhagic conditions
289.0    Polycythemia, secondary
289.81   Primary hypercoagulable state
325      Phlebitis and thrombophlebitis of intracranial venous sinuses
360.43   Hemophthalmos, except current injury
362.30   Retinal vascular occlusion, unspecified
362.31   Central retinal artery occlusion
362.32   Arterial branch occlusion
362.33   Partial arterial occlusion
362.34   Transient arterial occlusion
362.35   Central retinal vein occlusion
362.36   Venous tributary (branch) occlusion
362.37   Venous engorgement
362.43   Hemorrhagic detachment of retinal pigment epithelium
362.81   Retinal hemorrhage
363.61   Choroidal hemorrhage, unspecified
363.62   Expulsive choroidal hemorrhage
363.63   Choroidal rupture
363.72   Hemorrhagic choroidal detachment
368.9    Unspecified visual disturbance
372.72   Conjunctival hemorrhage
374.81   Hemorrhage of eyelid
376.32   Orbital hemorrhage
377.42   Hemorrhage in optic nerve sheaths
379.23   Vitreous hemorrhage
380.31   Hematoma of auricle or pinna




                                                                         Page 283
NATIONAL COVERAGE DETERMINATION                                                           85730

403.01 Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or
       end stage renal disease
403.11 Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end
       stage renal disease
403.91 Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or
       end stage renal disease
404.02 Hypertensive heart and chronic kidney disease, malignant, without heart failure and with
       chronic kidney disease stage V or end stage renal disease
404.12 Hypertensive heart and chronic kidney disease, benign, without heart failure and with
       chronic kidney disease stage V or end stage renal disease
404.92 Hypertensive heart and chronic kidney disease, unspecified, without heart failure and
       with chronic kidney disease stage V or end stage renal disease
410.00 Infarction of anterolateral wall, episode of care unspecified
410.01 Infarction of anterolateral wall, initial episode of care
410.02 Infarction of anterolateral wall, subsequent episode of care
410.10 Infarction of other anterior wall, episode of care unspecified
410.11 Infarction of other anterior wall, initial episode of care
410.12 Infarction of other anterior wall, subsequent episode of care
410.20 Infarction of inferolateral wall, episode of care unspecified
410.21 Infarction of inferolateral wall, initial episode of care
410.22 Infarction of inferolateral wall, subsequent episode of care
410.30 Infarction of inferoposterior wall, episode of care unspecified
410.31 Infarction of inferoposterior wall, initial episode of care
410.32 Infarction of inferoposterior wall,subsequent episode of care
410.40 Infarction of other inferior wall, episode of care unspecified
410.41 Infarction of other inferior wal, initial episode of care
410.42 Infarction of other inferior wall, subsequent episode of care
410.50 Infarction of other lateral wall, episode of care unspecified
410.51 Infarction of other lateral wall, initial episode of care
410.52 Infarction of other lateral wall, subsequent episode of care
410.60 True posterior wall infarction, episode of care unspecified
410.61 True posterior wall infarction, initial episode of care
410.62 True posterior wall infarction, subsequent episode of care
410.70 Subendocardial infarction, episode of care unspecified
410.71 Subendocardial infarction, initial episode of care
410.72 Subendocardial infarction, subsequent episode of care
410.80 Infarction of other specified sites, episode of care unspecified
410.81 Infarction of other specified sites, initial episode of care
410.82 Infarction of other specified sites, subsequent episode of care
410.90 Infarction, unspecified site, episode of care unspecified
410.91 Infarction, unspecified site, initial episode of care
410.92 Infarction, unspecified site, subsequent episode of care
423.0 Hemopericardium
427.31 Atrial fibrillation
427.9 Cardiac dysrhythmia, unspecified
428.0 Congestive heart failure
429.79 Other cardiac defect
430    Subarachnoid hemorrhage
431    Intracerebral hemorrhage
432.0 Nontraumatic extradural hemorrhage
432.1 Subdural hemorrhage
432.9 Unspecified intracranial hemorrhage
433.00 Occlusion and stenosis, basilar artery without cerebral infarction



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NATIONAL COVERAGE DETERMINATION                                                                   85730

433.01   Occlusion and stenosis, basilar artery with cerebral infarction
433.10   Occlusion and stenosis, carotid artery without cerebral infarction
433.11   Occlusion and stenosis, carotid artery with cerebral infarction
433.20   Occlusion and stenosis, vertebral artery without cerebral infarction
433.21   Occlusion and stenosis, vertebral artery with cerebral infarction
433.30   Occlusion and stenosis, multiple and bilateral without cerebral infarction
433.31   Occlusion and stenosis, multiple and bilateral with cerebral infarction
433.80   Occlusion and stenosis, other specified precerebral artery without cerebral infarction
433.81   Occlusion and stenosis, with cerebral infarction
433.90   Occlusion and stenosis, unspecified precerebral artery without cerebral infarction
433.91   Occlusion and stenosis, unspecified precerebral artery with cerebral infarction
434.00   Cerebral thrombosis without cerebral infarction
434.01   Cerebral thrombosis with cerebral infarction
434.10   Cerebral embolism without cerebral infarction
434.11   Cerebral embolism with cerebral infarction
434.90   Cerebral artery occlusion, unspecified without cerebral infarction
434.91   Cerebral artery occlusion, unspecified with cerebral infarction
435.9    Unspecified transient cerebral ischemia
444.0    Arterial embolism and thrombosis of abdominal aorta
444.1    Arterial embolism and thrombosis of thoracic aorta
444.21   Arterial embolism and thrombosis, upper extremity
444.22   Arterial embolism and thrombosis, lower extremity
444.81   Arterial embolism and thrombosis, iliac artery
444.89   Arterial embolism and thrombosis, other
444.9    Arterial embolism and thrombosis of unspecified artery
446.6    Thrombotic microangiopathy
447.2    Rupture of artery
448.0    Hereditary hemorrhagic telangiectasia
451.0    Phlebitis and thrombophlebitis of superficial vessels of lower extremities
451.11   Phlebitis and thrombophlebitis, femoral vein
451.19   Phlebitis and thrombophlebitis, other
451.2    Phlebitis and thrombophlebitis of lower extremities, unspecified
451.81   Phlebitis and thrombophlebitis, iliac vein
451.82   Phlebitis and thrombophlebitis of superficial veins of upper extremities
451.83   Phlebitis and thrombophlebitis of deep veins of upper extremities
451.84   Phlebitis and thrombophlebitis of upper extremities, unspecified
451.89   Phlebitis and thrombophlebitis other sites
451.9    Phlebitis and thrombophlebitis of unspecified site
453.0    Budd-Chiari syndrome
453.1    Thrombophlebitis migrans
453.2    Embolism and thrombosis of vena cava
453.3    Embolism and thrombosis of renal vein
453.40   Venous embolism and thrombosis of unspecified deep vessels of lower extremity
453.41   Venous embolism and thrombosis of deep vessels of proximal lower extremity
453.42   Venous embolism and thrombosis of deep vessels of distal lower extremity
453.8    Embolism and thrombosis of other specified veins
453.9    Embolism and thrombosis of unspecified site
456.0    Esophageal varices with bleeding
456.1    Esophageal varices without bleeding
456.8    Varices of other sites
459.89   Other specified disorders of circulatory system
530.7    Gastroesophageal laceration-hemorrhage syndrome
530.82   Esophageal hemorrhage



                                                                                           Page 285
NATIONAL COVERAGE DETERMINATION                                                              85730

531.00   Peptic ulcer, acute with hemorrhage without obstruction
531.01   Peptic ulcer, acute with hemorrhage with obstruction
531.10   Peptic ulcer, acute with perforation without obstruction
531.11   Peptic ulcer, acute with perforation with obstruction
531.20   Peptic ulcer, acute with hemorrhage and perforation without obstruction
531.21   Peptic ulcer, acute with hemorrhage and perforation with obstruction
531.30   Peptic ulcer, acute without hemorrhage or perforation without obstruction
531.31   Peptic ulcer, acute without hemorrhage or perforation with obstruction
531.40   Peptic ulcer, chronic or unspecified with hemorrhage without obstruction
531.41   Peptic ulcer, chronic or unspecified with hemorrhage with obstruction
531.50   Peptic ulcer, chronic or unspecified with perforation without obstruction
531.51   Peptic ulcer, chronic or unspecified with perforation with obstruction
531.60   Peptic ulcer, chronic or unspecified with hemorrhage and perforation without obstruction
531.61   Peptic ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
531.70   Peptic ulcer, chronic without hemorrhage or perforation without obstruction
531.71   Peptic ulcer, chronic without hemorrhage or perforation with obstruction
531.90   Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation without
         obstruction
531.91   Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation with
         obstruction
532.00   Peptic ulcer, acute with hemorrhage without obstruction
532.01   Peptic ulcer, acute with hemorrhage with obstruction
532.10   Peptic ulcer, acute with perforation without obstruction
532.11   Peptic ulcer, acute with perforation with obstruction
532.20   Peptic ulcer, acute with hemorrhage and perforation without obstruction
532.21   Peptic ulcer, acute with hemorrhage and perforation with obstruction
532.30   Peptic ulcer, acute without hemorrhage or perforation without obstruction
532.31   Peptic ulcer, acute without hemorrhage or perforation with obstruction
532.40   Peptic ulcer, chronic or unspecified with hemorrhage without obstruction
532.41   Peptic ulcer, chronic or unspecified with hemorrhage with obstruction
532.50   Peptic ulcer, chronic or unspecified with perforation without obstruction
532.51   Peptic ulcer, chronic or unspecified with perforation with obstruction
532.60   Peptic ulcer, chronic or unspecified with hemorrhage and perforation without obstruction
532.61   Peptic ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
532.70   Peptic ulcer, chronic without hemorrhage or perforation without obstruction
532.71   Peptic ulcer, chronic without hemorrhage or perforation with obstruction
532.90   Peptic ulcer, unspecified as acute or chronic without obstruction
532.91   Peptic ulcer, unspecified as acute or chronic with obstruction hemorrhage or perforation
533.00   Peptic ulcer, acute with hemorrhage without obstruction
533.01   Peptic ulcer, acute with hemorrhage with obstruction
533.10   Peptic ulcer, acute with perforation without obstruction
533.11   Peptic ulcer, acute with perforation with obstruction
533.20   Peptic ulcer, acute with hemorrhage and perforation without obstruction
533.21   Peptic ulcer, acute with hemorrhage and perforation with obstruction
533.30   Peptic ulcer, acute without hemorrhage and perforation without obstruction
533.31   Peptic ulcer, acute without hemorrhage and perforation with obstruction
533.40   Peptic ulcer, chronic or unspecified with hemorrhage without obstruction
533.41   Peptic ulcer, chronic or unspecified with hemorrhage with obstruction
533.50   Peptic ulcer, chronic or unspecified with perforation without obstruction
533.51   Peptic ulcer, chronic or unspecified with perforation with obstruction
533.60   Peptic ulcer, chronic or unspecified with hemorrhage and perforation without obstruction
533.61   Peptic ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
533.70   Peptic ulcer, chronic without hemorrhage or perforation without obstruction



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NATIONAL COVERAGE DETERMINATION                                                            85730

533.71 Peptic ulcer, chronic without hemorrhage or perforation with obstruction
533.90 Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation without
       obstruction
533.91 Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation with
       obstruction
534.00 Gastrojejunal ulcer, acute with hemorrhage without obstruction
534.01 Gastrojejunal ulcer, acute with hemorrhage with obstruction
534.10 Gastrojejunal ulcer, acute with perforation without obstruction
534.11 Gastrojejunal ulcer, acute with perforation with obstruction
534.20 Gastrojejunal ulcer, acute with hemorrhage and perforation without obstruction
534.21 Gastrojejunal ulcer, acute with hemorrhage and perforation with obstruction
534.30 Gastrojejunal ulcer, acute without hemorrhage or perforation without obstruction
534.31 Gastrojejunal ulcer, acute without hemorrhage or perforation with obstruction
534.40 Gastrojejunal ulcer, chronic or unspecified with hemorrhage without obstruction
534.41 Gastrojejunal ulcer, chronic or unspecified with hemorrhage with obstruction
534.50 Gastrojejunal ulcer, chronic or unspecified with perforation without obstruction
534.51 Gastrojejunal ulcer, chronic or unspecified with perforation with obstruction
534.60 Gastrojejunal ulcer, chronic or unspecified with hemorrhage and perforation without
       obstruction
534.61 Gastrojejunal ulcer, chronic or unspecified with hemorrhage and perforation with
       obstruction
534.70 Gastrojejunal ulcer, chronic without hemorrhage or perforation without mention of
       obstruction
534.71 Gastrojejunal ulcer, chronic without hemorrhage or perforation with obstruction
534.90 Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
       without obstruction
534.91 Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
       with obstruction
535.00 Acute gastritis without hemorrhage
535.01 Acute gastritis with hemorrhage
535.10 Atrophic gastritis without hemorrhage
535.11 Atrophic gastritis with hemorrhage
535.20 Gastric mucosal hypertrophy without hemorrhage
535.21 Gastric mucosal hypertrophy with hemorrhage
535.30 Alcoholic gastritis without hemorrhage
535.31 Alcoholic gastritis with hemorrhage
535.40 Other specified gastritis without hemorrhage
535.41 Other specified gastritis with hemorrhage
535.50 Unspecified gastritis and gastroduodenitis without hemorrhage
535.51 Unspecified gastritis and gastroduodenitis with hemorrhage
535.60 Duodenitis without hemorrhage
535.61 Duodenitis with hemorrhage
537.83 Angiodysplasia of stomach and duodenum with hemorrhage
537.84 Dieulafoy lesion (hemorrhagic) of stomach and duodeum
556.0 Ulcerative (chronic) enterocolitis
556.1 Ulcerative (chronic) ileocolitis
556.2 Ulcerative (chronic) proctitis
556.3 Ulcerative (chronic) proctosigmoiditis
556.4 Pseudopolyposis of colon
556.5 Left-sided ulcerative (chronic) colitis
556.6 Universal ulcerative (chronic) colitis
556.8 Other ulcerative colitis
556.9 Ulcerative colitis, unspecified



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NATIONAL COVERAGE DETERMINATION                                          85730

557.0    Acute vascular insufficiency of intestine
557.1    Chronic vascular insufficiency of intestine
557.9    Unspecified vascular insufficiency of intestine
562.02   Diverticulosis of small intestine with hemorrhage
562.03   Diverticulitis of small intestine with hemorrhage
562.12   Diverticulosis of colon with hemorrhage
562.13   Diverticulitis of colon with hemorrhage
568.81   Hemoperitoneum (nontraumatic)
569.3    Hemorrhage of rectum and anus
570      Acute and subacute necrosis of liver
571.0    Alcoholic fatty liver
571.1    Acute alcoholic hepatitis
571.2    Alcoholic cirrhosis of liver
571.3    Alcoholic liver damage, unspecified
571.40   Chronic hepatitis, unspecified
571.41   Chronic persistent hepatitis
571.49   Other chronic hepatitis
571.5    Cirrhosis of liver without mention of alcohol
571.6    Biliary cirrhosis
571.8    Other chronic nonalcoholic liver disease
571.9    Unspecified chronic liver disease without mention of
572.0    Abscess of liver
572.1    Portal pyemia
572.2    Hepatic coma
572.3    Portal hypertension
572.4    Hepatorenal syndrome
572.8    Other sequelae of chronic liver disease
573.0    Chronic passive congestion of liver
573.1    Hepatitis in viral diseases classified elsewhere
573.2    Hepatitis in other infectious diseases classified elsewhere
573.3    Hepatitis, unspecified
573.4    Hepatic infarction
573.8    Other specified disorders of liver
573.9    Unspecified disorder of liver
576.0    Postcholecystectomy syndrome
576.1    Cholangitis
576.2    Obstruction of bile duct
576.3    Perforation of bile duct
576.4    Fistula of bile duct
576.5    Spasm of sphincter of Oddi
576.8    Other specified disorders of biliary tract
576.9    Unspecified disorder of biliary tract
577.0    Acute pancreatitis
578.0    Hematemesis
578.1    Blood in stool
578.9    Hemorrhage of gastrointestinal tract, unspecified
579.0    Celiac disease
579.1    Tropical sprue
579.2    Blind loop syndrome
579.3    Other and unspecified postsurgical nonabsorption
579.4    Pancreatic steatorrhea
579.8    Other specified intestinal malabsorption
579.9    Unspecified intestinal malabsorption



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NATIONAL COVERAGE DETERMINATION                                                           85730

581.0    Nephrotic syndrome with lesion of proliferative glomerulonephritis
581.1    Nephrotic syndrome with lesion of membranous glomerulo