CMS Limitations Guide - Cardiovascular Services
Starting July 1, 2008, CMS has placed numerous medical necessity limits on tests and procedures. This reference guide provides you with all of the latest changes.
This guide is not an all-inclusive list of National Coverage
Documents (NCD) and Local Coverage Documents (LCD).
Please consult the CMS website for additional information
at cms.hhs.gov/mcd/search.asp?clickon=search. You can
search by LCD or NCD or keyword and region.
CMS will deny payment if the correct diagnosis codes are
not entered on the order form, and your patient’s test or
procedure will not be covered. We compiled this information in one location to make it easier for you to find the
proper codes for medically necessary diagnoses.
It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g. to the fourth or
fifth digit). The correct use of an ICD-9-CM code listed
below does not assure coverage of a service. The service
must be reasonable and necessary in the specific case and
must meet the criteria specified in this determination.
We will continue to update this list as new CMS limitations
are announced. You can always find the most current list
on mymunson.org.
If you have any questions, please contact Kari Smith,
Office Coordinator, at (231) 935-2296, or Karen Popa,
Director, Patient Access Services, at (231) 935-7493.
CMS Limitations
Cardiolite Stress Testing
LCD # L2611, Effective date: 09/30/2008
CPT/HCPCS Codes: CPT 78460, CPT 78461, CPT 78464, CPT 78465, CPT 78472, CPT 78478, CPT 78481, CPT 78483,
CPT 93015, CPT 93016, CPT 93017, CPT 93018
ICD-9 codes that SUPPORT medical necessity for perfusion with or without functional studies (CPT codes 78460,
78461, 78464, 78465, 78472, 78473, 78478, 78480, 78481, 78483, 93015, 93016, 93017, and 93018):
410.00
410.01
410.02
410.10
410.11
410.12
410.20
410.21
410.22
410.30
410.31
410.32
410.40
410.41
410.42
410.50
410.51
410.52
410.60
410.61
410.62
410.70
410.71
410.72
410.80
410.81
410.82
410.90
410.91
410.92
411.0
411.1
411.81
411.89
412
413.0
413.1
413.9
414.00
414.01
414.02
414.03
acute myocardial infarction of anterolateral wall episode of care unspecified
acute myocardial infarction of anterolateral wall initial episode of care
acute myocardial infarction of anterolateral wall subsequent episode of care
acute myocardial infarction of other anterior wall episode of care unspecified
acute myocardial infarction of other anterior wall initial episode of care
acute myocardial infarction of other anterior wall subsequent episode of care
acute myocardial infarction of inferolateral wall episode of care unspecified
acute myocardial infarction of inferolateral wall initial episode of care
acute myocardial infarction of inferolateral wall subsequent episode of care
acute myocardial infarction of inferoposterior wall episode of care unspecified
acute myocardial infarction of inferoposterior wall initial episode of care
acute myocardial infarction of inferoposterior wall subsequent episode of care
acute myocardial infarction of other inferior wall episode of care unspecified
acute myocardial infarction of other inferior wall initial episode of care
acute myocardial infarction of other inferior wall subsequent episode of care
acute myocardial infarction of other lateral wall episode of care unspecified
acute myocardial infarction of other lateral wall initial episode of care
acute myocardial infarction of other lateral wall subsequent episode of care
true posterior wall infarction episode of care unspecified
true posterior wall infarction initial episode of care
true posterior wall infarction subsequent episode of care
subendocardial infarction episode of care unspecified
subendocardial infarction initial episode of care
subendocardial infarction subsequent episode of care
acute myocardial infarction of other specified sites episode of care unspecified
acute myocardial infarction of other specified sites initial episode of care
acute myocardial infarction of other specified sites subsequent episode of care
acute myocardial infarction of unspecified site episode of care unspecified
acute myocardial infarction of unspecified site initial episode of care
acute myocardial infarction of unspecified site subsequent episode of care
postmyocardial infarction syndrome
intermediate coronary syndrome
acute coronary occlusion without myocardial infarction
other acute and subacute forms of ischemic heart disease other
old myocardial infarction
angina decubitus
prinzmetal angina
other and unspecified angina pectoris
coronary atherosclerosis of unspecified type of vessel native or graft
coronary atherosclerosis of native coronary artery
coronary atherosclerosis of autologous vein bypass graft
coronary atherosclerosis of nonautologous biological bypass graft
CMS Limitations
Cardiolite Stress Testing (con’t)
414.04
414.06
414.07
414.10
414.11
414.12
414.19
414.2
414.8
414.9
427.41
427.42
427.5
428.0
428.1
428.20
428.21
428.22
428.23
428.40
428.41
428.42
428.43
429.79
429.83
429.89
746.85
786.05
786.50
786.51
786.59
794.31
996.72
996.83
V42.1
V45.81
V45.82
coronary atherosclerosis of artery bypass graft
coronary atherosclerosis of native coronary artery of transplanted heart
coronary atherosclerosis of bypass graft (artery) (vein) of transplanted heart
aneurysm of heart (wall)
aneurysm of coronary vessels
dissection of coronary artery
other aneurysm of heart
chronic total occlusion of coronary artery
other specified forms of chronic ischemic heart disease
chronic ischemic heart disease unspecified
ventricular fibrillation
ventricular flutter
cardiac arrest
congestive heart failure unspecified
left heart failure
unspecified systolic heart failure
acute systolic heart failure
chronic systolic heart failure
acute on chronic systolic heart failure
unspecified combined systolic and diastolic heart failure
acute combined systolic and diastolic heart failure
chronic combined systolic and diastolic heart failure
acute on chronic combined systolic and diastolic heart failure
certain sequelae of myocardial infarction not elsewhere classified other
takotsubo syndrome
other ill-defined heart diseases
coronary artery anomaly congenital
shortness of breath
unspecified chest pain
precordial pain
other chest pain
nonspecific abnormal electrocardiogram (ecg) (ekg)
other complications due to other cardiac device implant and graft
complications of transplanted heart
heart replaced by transplant
postsurgical aortocoronary bypass status
percutaneous transluminal coronary angioplasty status
CMS Limitations
Dobutamine Stress Echocardiograms
LCD # L14293, L23620, L26409, Effective date: 01/01/2009
ICD-9 Codes that SUPPORT medical necessity for Dobutamine Stress Echocardiograms:
410.02
410.12
410.22
410.32
410.42
410.52
410.62
410.72
411.0
411.1
411.81
411.89
413.0
413.1
413.9
414.00
414.01
414.02
414.03
414.04
414.05
414.06
414.07
414.2
414.8
424.
424.1
424.2
424.3
425.1
425.2
425.3
425.4
425.5
425.7
425.8
425.9
426.2
426.3
426.4
426.82
428.0
428.1
428.20
428.21
428.22
acute myocardial infarction of anterolateral wall subsequent episode of care
acute myocardial infarction of other anterior wall subsequent episode of care
acute myocardial infarction of inferolateral wall subsequent episode of care
acute myocardial infarction of inferoposterior wall subsequent episode of care
acute myocardial infarction of other inferior wall subsequent episode of care
acute myocardial infarction of other lateral wall subsequent episode of care
true posterior wall infarction subsequent episode of care
subendocardial infarction subsequent episode of care
postmyocardial infarction syndrome
intermediate coronary syndrome
acute coronary occlusion without myocardial infarction
other acute and subacute forms of ischemic heart disease other
angina decubitus
prinzmetal angina
other and unspecified angina pectoris
coronary atherosclerosis of unspecified type of vessel native or graft
coronary atherosclerosis of native coronary artery
coronary atherosclerosis of autologous vein bypass graft
coronary atherosclerosis of nonautologous biological bypass graft
coronary atherosclerosis of artery bypass graft
coronary atherosclerosis of unspecified bypass graft
coronary atherosclerosis of native coronary artery of transplanted heart
coronary atherosclerosis of bypass graft (artery) (vein) of transplanted heart
chronic total occlusion of coronary artery
other specified forms of chronic ischemic heart disease
mitral valve disorders
aortic valve disorders
tricuspid valve disorders specified as nonrheumatic
pulmonary valve disorders
hypertrophic obstructive cardiomyopathy
obscure cardiomyopathy of africa
endocardial fibroelastosis
other primary cardiomyopathies
alcoholic cardiomyopathy
nutritional and metabolic cardiomyopathy
cardiomyopathy in other diseases classified elsewhere
secondary cardiomyopathy unspecified
left bundle branch hemiblock
other left bundle branch block
right bundle branch block
long qt syndrome
congestive heart failure unspecified
left heart failure
unspecified systolic heart failure
acute systolic heart failure
chronic systolic heart failure
CMS Limitations
Dobutamine Stress Echocardiograms (con’t)
428.23
428.30
428.31
428.32
428.33
428.40
428.41
428.42
428.43
428.9
429.0
429.1
429.2
429.3
429.4
780.2
786.02
786.05
786.09
786.50
786.51
794.31
996.1
996.72
996.83
v58.69
acute on chronic systolic heart failure
unspecified diastolic heart failure
acute diastolic heart failure
chronic diastolic heart failure
acute on chronic diastolic heart failure
unspecified combined systolic and diastolic heart failure
acute combined systolic and diastolic heart failure
chronic combined systolic and diastolic heart failure
acute on chronic combined systolic and diastolic heart failure
heart failure unspecified
myocarditis unspecified
myocardial degeneration
cardiovascular disease unspecified
cardiomegaly
functional disturbances following cardiac surgery
syncope and collapse
orthopnea
shortness of breath
respiratory abnormality other
unspecified chest pain
precordial pain
nonspecific abnormal electrocardiogram (ecg) (ekg)
mechanical complication of other vascular device implant and graft
other complications due to other cardiac device implant and graft
complications of transplanted heart
long-term (current) use of other medications
CMS Limitations
Electrocardiography (ECG or EKG)
LCD # L27427; Effective Date: 06/05/2009
CPT/HCPCS Codes: CPT 93005, CPT 93010
ICD-9 codes that SUPPORT medical necessity for electrocardiogram, routine ecg with at least 12 leads; tracing only,
without interpretation and report (CPT 93005); and electrocardiogram, routine ecg with at least 12 leads; interpretation
and report only (CPT 93010):
002.0
002.1
002.2
002.3
005.1
017.90
017.91
017.92
017.93
017.94
017.95
017.96
018.00
018.01
018.02
018.03
018.04
018.05
018.06
018.80
018.81
018.82
018.83
018.84
018.85
018.86
020.2
022.3
032.0
032.82
034.1
typhoid fever
paratyphoid fever a
paratyphoid fever b
paratyphoid fever c
botulism food poisoning
tuberculosis of other specified organs unspecified examination
tuberculosis of other specified organs bacteriological or histological examination not done
tuberculosis of other specified organs bacteriological or histological examination results unknown (at
present)
tuberculosis of other specified organs tubercle bacilli found (in sputum) by microscopy
tuberculosis of other specified organs tubercle bacilli not found (in sputum) by microscopy but found
by bacterial culture
tuberculosis of other specified organs tubercle bacilli not found by bacteriological examination but
tuberculosis confirmed histologically
tuberculosis of other specified organs tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
acute miliary tuberculosis unspecified examination
acute miliary tuberculosis bacteriological or histological examination not done
acute miliary tuberculosis bacteriological or histological examination results unknown (at present)
acute miliary tuberculosis tubercle bacilli found (in sputum) by microscopy
acute miliary tuberculosis tubercle bacilli not found (in sputum) by microscopy but found by bacterial
culture
acute miliary tuberculosis tubercle bacilli not found by bacteriological examination but tuberculosis
confirmed histologically
acute miliary tuberculosis tubercle bacilli not found by bacteriological or histological examination but
tuberculosis confirmed by other methods (inoculation of animals)
other specified miliary tuberculosis unspecified examination
other specified miliary tuberculosis bacteriological or histological examination not done
other specified miliary tuberculosis bacteriological or histological examination results unknown (at
present)
other specified miliary tuberculosis tubercle bacilli found (in sputum) by microscopy
other specified miliary tuberculosis tubercle bacilli not found (in sputum) by microscopy but found by
bacterial culture
other specified miliary tuberculosis tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
other specified miliary tuberculosis tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
septicemic plague
anthrax septicemia
faucial diphtheria
diphtheritic myocarditis
scarlet fever
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
036.2
036.40
036.41
036.42
036.43
038.0
038.10
038.11
038.12
038.19
038.2
038.3
038.40
038.41
038.42
038.43
038.44
038.49
038.8
038.9
040.0
040.82
042
054.5
066.40
066.41
066.42
066.49
074.1
074.20
074.21
074.22
074.23
075
086.0
088.81
093.0
093.1
093.20
093.21
093.22
093.23
093.24
093.81
093.82
093.89
093.9
098.83
098.84
098.85
meningococcemia
meningococcal carditis unspecified
meningococcal pericarditis
meningococcal endocarditis
meningococcal myocarditis
streptococcal septicemia
staphylococcal septicemia unspecified
methicillin susceptible staphylococcus aureus septicemia
methicillin resistant staphylococcus aureus septicemia
other staphylococcal septicemia
pneumococcal septicemia
septicemia due to anaerobes
septicemia due to gram-negative organism unspecified
septicemia due to hemophilus influenzae (h. influenzae)
septicemia due to escherichia coli (e. coli)
septicemia due to pseudomonas
septicemia due to serratia
other septicemia due to gram-negative organisms
other specified septicemias
unspecified septicemia
gas gangrene
toxic shock syndrome
human immunodeficiency virus (hiv) disease
herpetic septicemia
west nile fever, unspecified
west nile fever with encephalitis
west nile fever with other neurologic manifestation
west nile fever with other complications
epidemic pleurodynia
coxsackie carditis unspecified
coxsackie pericarditis
coxsackie endocarditis
coxsackie myocarditis
infectious mononucleosis
chagas’ disease with heart involvement
lyme disease
aneurysm of aorta specified as syphilitic
syphilitic aortitis
syphilitic endocarditis of valve unspecified
syphilitic endocarditis of mitral valve
syphilitic endocarditis of aortic valve
syphilitic endocarditis of tricuspid valve
syphilitic endocarditis of pulmonary valve
syphilitic pericarditis
syphilitic myocarditis
other specified cardiovascular syphilis
cardiovascular syphilis unspecified
gonococcal pericarditis
gonococcal endocarditis
other gonococcal heart disease
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
112.5
112.81
115.03
115.04
115.13
115.14
115.93
115.94
130.3
130.8
135
153.0
153.1
153.2
153.3
153.4
153.5
153.6
153.7
153.8
153.9
162.9
163.0
163.1
163.8
163.9
164.0
164.1
164.2
164.3
164.8
164.9
174.0
174.1
174.2
174.3
174.4
174.5
174.6
174.8
174.9
197.1
212.4
212.5
212.7
238.4
240.0
240.9
241.0
241.1
disseminated candidiasis
candidal endocarditis
histoplasma capsulatum pericarditis
histoplasma capsulatum endocarditis
histoplasma duboisii pericarditis
histoplasma duboisii endocarditis
histoplasmosis pericarditis unspecified
histoplasmosis endocarditis
myocarditis due to toxoplasmosis
multisystemic disseminated toxoplasmosis
sarcoidosis
malignant neoplasm of hepatic flexure
malignant neoplasm of transverse colon
malignant neoplasm of descending colon
malignant neoplasm of sigmoid colon
malignant neoplasm of cecum
malignant neoplasm of appendix vermiformis
malignant neoplasm of ascending colon
malignant neoplasm of splenic flexure
malignant neoplasm of other specified sites of large intestine
malignant neoplasm of colon unspecified site
malignant neoplasm of bronchus and lung unspecified
malignant neoplasm of parietal pleura
malignant neoplasm of visceral pleura
malignant neoplasm of other specified sites of pleura
malignant neoplasm of pleura unspecified
malignant neoplasm of thymus
malignant neoplasm of heart
malignant neoplasm of anterior mediastinum
malignant neoplasm of posterior mediastinum
malignant neoplasm of other parts of mediastinum
malignant neoplasm of mediastinum part unspecified
malignant neoplasm of nipple and areola of female breast
malignant neoplasm of central portion of female breast
malignant neoplasm of upper-inner quadrant of female breast
malignant neoplasm of lower-inner quadrant of female breast
malignant neoplasm of upper-outer quadrant of female breast
malignant neoplasm of lower-outer quadrant of female breast
malignant neoplasm of axillary tail of female breast
malignant neoplasm of other specified sites of female breast
malignant neoplasm of breast (female) unspecified site
secondary malignant neoplasm of mediastinum
benign neoplasm of pleura
benign neoplasm of mediastinum
benign neoplasm of heart
polycythemia vera
goiter specified as simple
goiter unspecified
nontoxic uninodular goiter
nontoxic multinodular goiter
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
241.9
242.00
242.01
242.10
242.11
242.20
242.21
242.30
242.31
242.40
242.41
242.80
242.81
242.90
242.91
243
244.0
244.1
244.2
244.3
244.8
244.9
245.0
245.1
245.2
249.00
249.01
249.10
249.11
249.20
249.21
249.30
249.31
249.80
249.81
250.00
250.01
250.02
250.03
250.10
250.11
250.12
250.13
250.20
250.21
250.22
250.23
unspecified nontoxic nodular goiter
toxic diffuse goiter without thyrotoxic crisis or storm
toxic diffuse goiter with thyrotoxic crisis or storm
toxic uninodular goiter without thyrotoxic crisis or storm
toxic uninodular goiter with thyrotoxic crisis or storm
toxic multinodular goiter without thyrotoxic crisis or storm
toxic multinodular goiter with thyrotoxic crisis or storm
toxic nodular goiter unspecified type without thyrotoxic crisis or storm
toxic nodular goiter unspecified type with thyrotoxic crisis or storm
thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
thyrotoxicosis of other specified origin without thyrotoxic crisis or storm
thyrotoxicosis of other specified origin with thyrotoxic crisis or storm
thyrotoxicosis without goiter or other cause and without thyrotoxic crisis or storm
thyrotoxicosis without goiter or other cause with thyrotoxic crisis or storm
congenital hypothyroidism
postsurgical hypothyroidism
other postablative hypothyroidism
iodine hypothyroidism
other iatrogenic hypothyroidism
other specified acquired hypothyroidism
unspecified acquired hypothyroidism
acute thyroiditis
subacute thyroiditis
chronic lymphocytic thyroiditis
secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified
secondary diabetes mellitus without mention of complication, uncontrolled
secondary diabetes mellitus with ketoacidosis, not stated as uncontrolled, or unspecified
secondary diabetes mellitus with ketoacidosis, uncontrolled
secondary diabetes mellitus with hyperosmolarity, not stated as uncontrolled, or unspecified
secondary diabetes mellitus with hyperosmolarity, uncontrolled
secondary diabetes mellitus with other coma, not stated as uncontrolled, or unspecified
secondary diabetes mellitus with other coma, uncontrolled
secondary diabetes mellitus with other specified manifestations, not stated as uncontrolled, or unspecified
secondary diabetes mellitus with other specified manifestations, uncontrolled
diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled
diabetes mellitus without mention of complication, type i [juvenile type], not stated as uncontrolled
diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled
diabetes mellitus without mention of complication, type i [juvenile type], uncontrolled
diabetes with ketoacidosis, type ii or unspecified type, not stated as uncontrolled
diabetes with ketoacidosis, type i [juvenile type], not stated as uncontrolled
diabetes with ketoacidosis, type ii or unspecified type, uncontrolled
diabetes with ketoacidosis, type i [juvenile type], uncontrolled
diabetes with hyperosmolarity, type ii or unspecified type, not stated as uncontrolled
diabetes with hyperosmolarity, type i [juvenile type], not stated as uncontrolled
diabetes with hyperosmolarity, type ii or unspecified type, uncontrolled
diabetes with hyperosmolarity, type i [juvenile type], uncontrolled
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
250.30
250.31
250.32
250.33
250.40
250.41
250.42
250.43
250.50
250.51
250.52
250.53
250.60
250.61
250.62
250.63
250.70
250.71
250.72
250.73
250.80
250.81
250.82
250.83
250.90
250.91
250.92
250.93
251.0
251.1
251.2
251.3
252.00
252.01
252.02
252.08
252.1
252.8
252.9
253.0
253.2
253.5
255.0
255.10
255.11
255.12
255.13
255.14
255.2
255.3
diabetes with other coma, type ii or unspecified type, not stated as uncontrolled
diabetes with other coma, type i [juvenile type], not stated as uncontrolled
diabetes with other coma, type ii or unspecified type, uncontrolled
diabetes with other coma, type i [juvenile type], uncontrolled
diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled
diabetes with renal manifestations, type i [juvenile type], not stated as uncontrolled
diabetes with renal manifestations, type ii or unspecified type, uncontrolled
diabetes with renal manifestations, type i [juvenile type], uncontrolled
diabetes with ophthalmic manifestations, type ii or unspecified type, not stated as uncontrolled
diabetes with ophthalmic manifestations, type i [juvenile type], not stated as uncontrolled
diabetes with ophthalmic manifestations, type ii or unspecified type, uncontrolled
diabetes with ophthalmic manifestations, type i [juvenile type], uncontrolled
diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled
diabetes with neurological manifestations, type i [juvenile type], not stated as uncontrolled
diabetes with neurological manifestations, type ii or unspecified type, uncontrolled
diabetes with neurological manifestations, type i [juvenile type], uncontrolled
diabetes with peripheral circulatory disorders, type ii or unspecified type, not stated as uncontrolled
diabetes with peripheral circulatory disorders, type i [juvenile type], not stated as uncontrolled
diabetes with peripheral circulatory disorders, type ii or unspecified type, uncontrolled
diabetes with peripheral circulatory disorders, type i [juvenile type], uncontrolled
diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled
diabetes with other specified manifestations, type i [juvenile type], not stated as uncontrolled
diabetes with other specified manifestations, type ii or unspecified type, uncontrolled
diabetes with other specified manifestations, type i [juvenile type], uncontrolled
diabetes with unspecified complication, type ii or unspecified type, not stated as uncontrolled
diabetes with unspecified complication, type i [juvenile type], not stated as uncontrolled
diabetes with unspecified complication, type ii or unspecified type, uncontrolled
diabetes with unspecified complication, type i [juvenile type], uncontrolled
hypoglycemic coma
other specified hypoglycemia
hypoglycemia unspecified
postsurgical hypoinsulinemia
hyperparathyroidism, unspecified
primary hyperparathyroidism
secondary hyperparathyroidism, non-renal
other hyperparathyroidism
hypoparathyroidism
other specified disorders of parathyroid gland
unspecified disorder of parathyroid gland
acromegaly and gigantism
panhypopituitarism
diabetes insipidus
cushing’s syndrome
hyperaldosteronism, unspecified
glucocorticoid-remediable aldosteronism
conn’s syndrome
bartter’s syndrome
other secondary aldosteronism
adrenogenital disorders
other corticoadrenal overactivity
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
255.41
255.42
255.5
255.6
255.8
265.0
265.1
265.2
272.0
272.1
272.2
272.3
272.4
272.5
272.6
272.7
272.8
272.9
275.0
275.1
275.2
275.3
275.40
275.41
275.42
275.49
275.9
276.0
276.1
276.2
276.3
276.4
276.50
276.51
276.52
276.6
276.7
276.8
276.9
277.30
277.31
277.39
277.5
282.41
282.42
282.49
282.5
282.60
282.61
282.62
glucocorticoid deficiency
mineralocorticoid deficiency
other adrenal hypofunction
medulloadrenal hyperfunction
other specified disorders of adrenal glands
beriberi
other and unspecified manifestations of thiamine deficiency
pellagra
pure hypercholesterolemia
pure hyperglyceridemia
mixed hyperlipidemia
hyperchylomicronemia
other and unspecified hyperlipidemia
lipoprotein deficiencies
lipodystrophy
lipidoses
other disorders of lipoid metabolism
unspecified disorder of lipoid metabolism
disorders of iron metabolism
disorders of copper metabolism
disorders of magnesium metabolism
disorders of phosphorus metabolism
unspecified disorder of calcium metabolism
hypocalcemia
hypercalcemia
other disorders of calcium metabolism
unspecified disorder of mineral metabolism
hyperosmolality and/or hypernatremia
hyposmolality and/or hyponatremia
acidosis
alkalosis
mixed acid-base balance disorder
volume depletion, unspecified
dehydration
hypovolemia
fluid overload disorder
hyperpotassemia
hypopotassemia
electrolyte and fluid disorders not elsewhere classified
amyloidosis, unspecified
familial mediterranean fever
other amyloidosis
mucopolysaccharidosis
sickle-cell thalassemia without crisis
sickle-cell thalassemia with crisis
other thalassemia
sickle-cell trait
sickle-cell disease unspecified
hb-ss disease without crisis
hb-ss disease with crisis
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
282.63
282.64
282.68
282.69
285.9
289.0
289.7
304.01
304.02
304.21
304.22
304.41
304.51
304.71
304.72
306.2
327.20
327.21
327.22
327.23
327.24
327.25
327.26
327.27
327.29
333.4
334.0
337.00
337.01
337.09
359.21
390
391.0
391.1
391.2
391.8
391.9
392.0
392.9
393
394.0
394.1
394.2
394.9
395.0
395.1
395.2
395.9
396.0
396.1
sickle-cell/hb-c disease without crisis
sickle-cell/hb c disease with crisis
other sickle-cell disease without crisis
other sickle-cell disease with crisis
anemia unspecified
polycythemia secondary
methemoglobinemia
opioid type dependence continuous use
opioid type dependence episodic use
cocaine dependence continuous use
cocaine dependence episodic use
amphetamine and other psychostimulant dependence continuous use
hallucinogen dependence continuous use
combinations of opioid type drug with any other drug dependence continuous use
combinations of opioid type drug with any other drug dependence episodic use
cardiovascular malfunction arising from mental factors
organic sleep apnea, unspecified
primary central sleep apnea
high altitude periodic breathing
obstructive sleep apnea (adult) (pediatric)
idiopathic sleep related non obstructive alveolar hypoventilation
congenital central alveolar hypoventilation syndrome
sleep related hypoventilation/hypoxemia in conditions classifiable elsewhere
central sleep apnea in conditions classified elsewhere
other organic sleep apnea
huntington’s chorea
friedreich’s ataxia
idiopathic peripheral autonomic neuropathy, unspecified
carotid sinus syndrome
other idiopathic peripheral autonomic neuropathy
myotonic muscular dystrophy
rheumatic fever without heart involvement
acute rheumatic pericarditis
acute rheumatic endocarditis
acute rheumatic myocarditis
other acute rheumatic heart disease
acute rheumatic heart disease unspecified
rheumatic chorea with heart involvement
rheumatic chorea without heart involvement
chronic rheumatic pericarditis
mitral stenosis
rheumatic mitral insufficiency
mitral stenosis with insufficiency
other and unspecified mitral valve diseases
rheumatic aortic stenosis
rheumatic aortic insufficiency
rheumatic aortic stenosis with insufficiency
other and unspecified rheumatic aortic diseases
mitral valve stenosis and aortic valve stenosis
mitral valve stenosis and aortic valve insufficiency
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
396.2
396.3
396.8
396.9
397.0
397.1
397.9
398.0
398.90
398.91
398.99
401.0
401.1
401.9
402.00
402.01
402.10
402.11
402.90
402.91
403.00
403.01
403.10
403.11
403.90
403.91
404.00
404.01
404.02
404.03
404.10
404.11
404.12
404.13
404.90
mitral valve insufficiency and aortic valve stenosis
mitral valve insufficiency and aortic valve insufficiency
multiple involvement of mitral and aortic valves
mitral and aortic valve diseases unspecified
diseases of tricuspid valve
rheumatic diseases of pulmonary valve
rheumatic diseases of endocardium valve unspecified
rheumatic myocarditis
rheumatic heart disease unspecified
rheumatic heart failure (congestive)
other rheumatic heart diseases
malignant essential hypertension
benign essential hypertension
unspecified essential hypertension
malignant hypertensive heart disease without heart failure
malignant hypertensive heart disease with heart failure
benign hypertensive heart disease without heart failure
benign hypertensive heart disease with heart failure
unspecified hypertensive heart disease without heart failure
unspecified hypertensive heart disease with heart failure
hypertensive chronic kidney disease, malignant, with chronic kidney disease stage i through stage iv,
or unspecified
hypertensive chronic kidney disease, malignant, with chronic kidney disease stage v or end stage renal
disease
hypertensive chronic kidney disease, benign, with chronic kidney disease stage i through stage iv, or
unspecified
hypertensive chronic kidney disease, benign, with chronic kidney disease stage v or end stage renal
disease
hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv,
or unspecified
hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage
renal disease
hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney
disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney
disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, benign, without heart failure and with chronic kidney
disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, benign, without heart failure and with chronic kidney
disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease
stage v or end stage renal disease
hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage i through stage iv, or unspecified
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
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
malignant renovascular hypertension
405.09
other malignant secondary hypertension
405.11
benign renovascular hypertension
405.19
other benign secondary hypertension
405.91
unspecified renovascular hypertension
405.99
other unspecified secondary hypertension
410.00
acute myocardial infarction of anterolateral wall episode of care unspecified
410.01
acute myocardial infarction of anterolateral wall initial episode of care
410.02
acute myocardial infarction of anterolateral wall subsequent episode of care
410.10
acute myocardial infarction of other anterior wall episode of care unspecified
410.11
acute myocardial infarction of other anterior wall initial episode of care
410.12
acute myocardial infarction of other anterior wall subsequent episode of care
410.20
acute myocardial infarction of inferolateral wall episode of care unspecified
410.21
acute myocardial infarction of inferolateral wall initial episode of care
410.22
acute myocardial infarction of inferolateral wall subsequent episode of care
410.30
acute myocardial infarction of inferoposterior wall episode of care unspecified
410.31
acute myocardial infarction of inferoposterior wall initial episode of care
410.32
acute myocardial infarction of inferoposterior wall subsequent episode of care
410.40
acute myocardial infarction of other inferior wall episode of care unspecified
410.41
acute myocardial infarction of other inferior wall initial episode of care
410.42
acute myocardial infarction of other inferior wall subsequent episode of care
410.50
acute myocardial infarction of other lateral wall episode of care unspecified
410.51
acute myocardial infarction of other lateral wall initial episode of care
410.52
acute myocardial 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
acute myocardial infarction of other specified sites episode of care unspecified
410.81
acute myocardial infarction of other specified sites initial episode of care
410.82
acute myocardial infarction of other specified sites subsequent episode of care
410.90
acute myocardial infarction of unspecified site episode of care unspecified
410.91
acute myocardial infarction of unspecified site initial episode of care
410.92
acute myocardial infarction of unspecified site subsequent episode of care
411.0
postmyocardial infarction syndrome
411.1
intermediate coronary syndrome
411.81
acute coronary occlusion without myocardial infarction
411.89
other acute and subacute forms of ischemic heart disease other
412old myocardial infarction
413.0
angina decubitus
413.1
prinzmetal angina
413.9
other and unspecified angina pectoris
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
414.00
414.01
414.02
414.03
414.04
414.05
414.06
414.07
414.10
414.11
414.12
414.19
414.2
414.3
414.8
414.9
415.0
415.11
415.12
415.19
416.0
416.1
416.8
416.9
417.0
417.1
417.8
417.9
420.0
420.90
420.91
420.99
421.0
421.1
421.9
422.0
422.90
422.91
422.92
422.93
422.99
423.0
423.1
423.2
423.3
423.8
423.9
424.0
424.1
424.2
coronary atherosclerosis of unspecified type of vessel native or graft
coronary atherosclerosis of native coronary artery
coronary atherosclerosis of autologous vein bypass graft
coronary atherosclerosis of nonautologous biological bypass graft
coronary atherosclerosis of artery bypass graft
coronary atherosclerosis of unspecified bypass graft
coronary atherosclerosis of native coronary artery of transplanted heart
coronary atherosclerosis of bypass graft (artery) (vein) of transplanted heart
aneurysm of heart (wall)
aneurysm of coronary vessels
dissection of coronary artery
other aneurysm of heart
chronic total occlusion of coronary artery
coronary atherosclerosis due to lipid rich plaque
other specified forms of chronic ischemic heart disease
chronic ischemic heart disease unspecified
acute cor pulmonale
iatrogenic pulmonary embolism and infarction
septic pulmonary embolism
other pulmonary embolism and infarction
primary pulmonary hypertension
kyphoscoliotic heart disease
other chronic pulmonary heart diseases
chronic pulmonary heart disease unspecified
arteriovenous fistula of pulmonary vessels
aneurysm of pulmonary artery
other specified diseases of pulmonary circulation
unspecified disease of pulmonary circulation
acute pericarditis in diseases classified elsewhere
acute pericarditis unspecified
acute idiopathic pericarditis
other acute pericarditis
acute and subacute bacterial endocarditis
acute and subacute infective endocarditis in diseases classified elsewhere
acute endocarditis unspecified
acute myocarditis in diseases classified elsewhere
acute myocarditis unspecified
idiopathic myocarditis
septic myocarditis
toxic myocarditis
other acute myocarditis
hemopericardium
adhesive pericarditis
constrictive pericarditis
cardiac tamponade
other specified diseases of pericardium
unspecified disease of pericardium
mitral valve disorders
aortic valve disorders
tricuspid valve disorders specified as nonrheumatic
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
424.3
424.90
424.91
424.99
425.0
425.1
425.2
425.3
425.4
425.5
425.7
425.8
425.9
426.0
426.10
426.11
426.12
426.13
426.2
426.3
426.4
426.50
426.51
426.52
426.53
426.54
426.6
426.7
426.81
426.82
426.89
426.9
427.0
427.1
427.2
427.31
427.32
427.41
427.42
427.5
427.60
427.61
427.69
427.81
427.89
427.9
428.0
428.1
428.20
428.21
pulmonary valve disorders
endocarditis valve unspecified unspecified cause
endocarditis in diseases classified elsewhere
other endocarditis valve unspecified
endomyocardial fibrosis
hypertrophic obstructive cardiomyopathy
obscure cardiomyopathy of africa
endocardial fibroelastosis
other primary cardiomyopathies
alcoholic cardiomyopathy
nutritional and metabolic cardiomyopathy
cardiomyopathy in other diseases classified elsewhere
secondary cardiomyopathy unspecified
atrioventricular block complete
atrioventricular block unspecified
first degree atrioventricular block
mobitz (type) ii atrioventricular block
other second degree atrioventricular block
left bundle branch hemiblock
other left bundle branch block
right bundle branch block
bundle branch block unspecified
right bundle branch block and left posterior fascicular block
right bundle branch block and left anterior fascicular block
other bilateral bundle branch block
trifascicular block
other heart block
anomalous atrioventricular excitation
lown-ganong-levine syndrome
long qt syndrome
other specified conduction disorders
conduction disorder unspecified
paroxysmal supraventricular tachycardia
paroxysmal ventricular tachycardia
paroxysmal tachycardia unspecified
atrial fibrillation
atrial flutter
ventricular fibrillation
ventricular flutter
cardiac arrest
premature beats unspecified
supraventricular premature beats
other premature beats
sinoatrial node dysfunction
other specified cardiac dysrhythmias
cardiac dysrhythmia unspecified
congestive heart failure unspecified
left heart failure
unspecified systolic heart failure
acute systolic heart failure
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
428.22
428.23
428.30
428.31
428.32
428.33
428.40
428.41
428.42
428.43
428.9
429.0
429.1
429.2
429.3
429.4
429.5
429.6
429.71
429.79
429.81
429.82
429.83
429.89
429.9
430
431
432.0
432.1
432.9
433.00
433.01
433.10
433.11
433.20
433.21
433.30
433.31
433.80
433.81
434.00
434.01
434.10
434.11
434.90
434.91
435.0
435.1
435.2
435.3
chronic systolic heart failure
acute on chronic systolic heart failure
unspecified diastolic heart failure
acute diastolic heart failure
chronic diastolic heart failure
acute on chronic diastolic heart failure
unspecified combined systolic and diastolic heart failure
acute combined systolic and diastolic heart failure
chronic combined systolic and diastolic heart failure
acute on chronic combined systolic and diastolic heart failure
heart failure unspecified
myocarditis unspecified
myocardial degeneration
cardiovascular disease unspecified
cardiomegaly
functional disturbances following cardiac surgery
rupture of chordae tendineae
rupture of papillary muscle
certain sequelae of myocardial infarction not elsewhere classified acquired cardiac septal defect
certain sequelae of myocardial infarction not elsewhere classified other
other disorders of papillary muscle
hyperkinetic heart disease
takotsubo syndrome
other ill-defined heart diseases
heart disease unspecified
subarachnoid hemorrhage
intracerebral hemorrhage
nontraumatic extradural hemorrhage
subdural hemorrhage
unspecified intracranial hemorrhage
occlusion and stenosis of basilar artery without cerebral infarction
occlusion and stenosis of basilar artery with cerebral infarction
occlusion and stenosis of carotid artery without cerebral infarction
occlusion and stenosis of carotid artery with cerebral infarction
occlusion and stenosis of vertebral artery without cerebral infarction
occlusion and stenosis of vertebral artery with cerebral infarction
occlusion and stenosis of multiple and bilateral precerebral arteries without cerebral infarction
occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction
occlusion and stenosis of other specified precerebral artery without cerebral infarction
occlusion and stenosis of other specified precerebral artery with cerebral infarction
cerebral thrombosis without cerebral infarction
cerebral thrombosis with cerebral infarction
cerebral embolism without cerebral infarction
cerebral embolism with cerebral infarction
cerebral artery occlusion unspecified without cerebral infarction
cerebral artery occlusion unspecified with cerebral infarction
basilar artery syndrome
vertebral artery syndrome
subclavian steal syndrome
vertebrobasilar artery syndrome
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
435.8
435.9
436
437.0
437.1
437.2
437.3
437.4
437.5
437.6
437.7
437.8
437.9
440.0
440.1
440.20
440.21
440.22
440.23
440.24
440.29
440.4
441.00
441.01
441.02
441.03
441.1
441.2
441.3
441.4
441.5
441.6
441.7
441.9
442.0
442.1
442.2
442.3
442.81
442.82
442.83
442.84
442.89
442.9
443.0
443.1
443.21
443.22
443.23
443.24
other specified transient cerebral ischemias
unspecified transient cerebral ischemia
acute but ill-defined cerebrovascular disease
cerebral atherosclerosis
other generalized ischemic cerebrovascular disease
hypertensive encephalopathy
cerebral aneurysm nonruptured
cerebral arteritis
moyamoya disease
nonpyogenic thrombosis of intracranial venous sinus
transient global amnesia
other ill-defined cerebrovascular disease
unspecified cerebrovascular disease
atherosclerosis of aorta
atherosclerosis of renal artery
atherosclerosis of native arteries of the extremities unspecified
atherosclerosis of native arteries of the extremities with intermittent claudication
atherosclerosis of native arteries of the extremities with rest pain
atherosclerosis of native arteries of the extremities with ulceration
atherosclerosis of native arteries of the extremities with gangrene
other atherosclerosis of native arteries of the extremities
chronic total occlusion of artery of the extremities
dissection of aorta aneurysm unspecified site
dissection of aorta thoracic
dissection of aorta abdominal
dissection of aorta thoracoabdominal
thoracic aneurysm ruptured
thoracic aneurysm without rupture
abdominal aneurysm ruptured
abdominal aneurysm without rupture
aortic aneurysm of unspecified site ruptured
thoracoabdominal aneurysm ruptured
thoracoabdominal aneurysm without rupture
aortic aneurysm of unspecified site without rupture
aneurysm of artery of upper extremity
aneurysm of renal artery
aneurysm of iliac artery
aneurysm of artery of lower extremity
aneurysm of artery of neck
aneurysm of subclavian artery
aneurysm of splenic artery
aneurysm of other visceral artery
aneurysm of other specified site
other aneurysm of unspecified site
raynaud’s syndrome
thromboangiitis obliterans (buerger’s disease)
dissection of carotid artery
dissection of iliac artery
dissection of renal artery
dissection of vertebral artery
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
443.29
443.81
443.89
443.9
444.0
444.1
444.21
444.22
444.81
444.89
444.9
445.01
445.02
445.81
445.89
446.0
446.1
446.20
446.21
446.29
446.3
446.4
446.5
446.6
446.7
447.0
447.1
447.2
447.3
447.4
447.5
447.6
447.8
447.9
449
458.0
458.1
458.21
458.29
458.8
458.9
459.2
466.11
466.19
483.1
488
491.20
491.21
493.01
493.02
dissection of other artery
peripheral angiopathy in diseases classified elsewhere
other peripheral vascular disease
peripheral vascular disease unspecified
embolism and thrombosis of abdominal aorta
embolism and thrombosis of thoracic aorta
arterial embolism and thrombosis of upper extremity
arterial embolism and thrombosis of lower extremity
embolism and thrombosis of iliac artery
embolism and thrombosis of other artery
embolism and thrombosis of unspecified artery
atheroembolism of upper extremity
atheroembolism of lower extremity
atheroembolism of kidney
atheroembolism of other site
polyarteritis nodosa
acute febrile mucocutaneous lymph node syndrome (mcls)
hypersensitivity angiitis unspecified
goodpasture’s syndrome
other specified hypersensitivity angiitis
lethal midline granuloma
wegener’s granulomatosis
giant cell arteritis
thrombotic microangiopathy
takayasu’s disease
arteriovenous fistula acquired
stricture of artery
rupture of artery
hyperplasia of renal artery
celiac artery compression syndrome
necrosis of artery
arteritis unspecified
other specified disorders of arteries and arterioles
unspecified disorders of arteries and arterioles
septic arterial embolism
orthostatic hypotension
chronic hypotension
hypotension of hemodialysis
other iatrogenic hypotension
other specified hypotension
hypotension unspecified
compression of vein
acute bronchiolitis due to respiratory syncytial virus (rsv)
acute bronciolitis due to other infectious organisms
pneumonia due to chlamydia
influenza due to identified avian influenza virus
obstructive chronic bronchitis without exacerbation
obstructive chronic bronchitis with (acute) exacerbation
extrinsic asthma with status asthmaticus
extrinsic asthma with (acute) exacerbation
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
493.10
493.11
493.12
493.20
493.21
493.22
493.81
493.82
493.91
493.92
506.1
512.0
517.3
518.0
518.1
518.3
518.4
518.5
518.81
518.82
518.83
518.84
518.89
519.2
519.3
526.9
530.0
530.10
530.11
530.12
530.19
530.20
530.21
530.3
530.4
530.5
530.6
530.81
530.85
551.3
552.3
553.3
575.0
575.10
575.11
575.12
575.2
575.4
577.0
578.9
intrinsic asthma unspecified
intrinsic asthma with status asthmaticus
intrinsic asthma with (acute) exacerbation
chronic obstructive asthma unspecified
chronic obstructive asthma with status asthmaticus
chronic obstructive asthma with (acute) exacerbation
exercise-induced bronchospasm
cough variant asthma
asthma unspecified type with status asthmaticus
asthma unspecified with (acute) exacerbation
acute pulmonary edema due to fumes and vapors
spontaneous tension pneumothorax
acute chest syndrome
pulmonary collapse
interstitial emphysema
pulmonary eosinophilia
acute edema of lung unspecified
pulmonary insufficiency following trauma and surgery
acute respiratory failure
other pulmonary insufficiency not elsewhere classified
chronic respiratory failure
acute and chronic respiratory failure
other diseases of lung not elsewhere classified
mediastinitis
other diseases of mediastinum not elsewhere classified
unspecified disease of the jaws
achalasia and cardiospasm
esophagitis unspecified
reflux esophagitis
acute esophagitis
other esophagitis
ulcer of esophagus without bleeding
ulcer of esophagus with bleeding
stricture and stenosis of esophagus
perforation of esophagus
dyskinesia of esophagus
diverticulum of esophagus acquired
esophageal reflux
barrett’s esophagus
diaphragmatic hernia with gangrene
diaphragmatic hernia with obstruction
diaphragmatic hernia without obstruction or gangrene
acute cholecystitis
cholecystitis unspecified
chronic cholecystitis
acute and chronic cholecystitis
obstruction of gallbladder
perforation of gallbladder
acute pancreatitis
hemorrhage of gastrointestinal tract unspecified
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
585.3
585.4
585.5
585.6
611.71
634.50
634.51
634.52
634.60
634.61
634.62
635.50
635.51
635.52
635.60
635.61
635.62
636.50
636.51
636.52
636.60
636.61
636.62
637.50
637.51
637.52
637.60
637.61
637.62
638.5
638.6
639.5
639.6
639.8
642.00
642.01
642.02
642.03
642.04
642.10
642.11
642.12
642.13
642.14
642.20
642.21
642.22
chronic kidney disease, stage iii (moderate)
chronic kidney disease, stage iv (severe)
chronic kidney disease, stage v
end stage renal disease
mastodynia
spontaneous abortion unspecified complicated by shock
spontaneous abortion incomplete complicated by shock
spontaneous abortion complete complicated by shock
spontaneous abortion unspecified complicated by embolism
spontaneous abortion incomplete complicated by embolism
spontaneous abortion complete complicated by embolism
legally induced abortion unspecified complicated by shock
legally induced abortion incomplete complicated by shock
legally induced abortion complete complicated by shock
legally induced abortion unspecified complicated by embolism
legally induced abortion incomplete complicated by embolism
legally induced abortion complete complicated by embolism
illegal abortion unspecified complicated by shock
illegal abortion incomplete complicated by shock
illegal abortion complete complicated by shock
illegal abortion unspecified complicated by embolism
illegal abortion incomplete complicated by embolism
illegal abortion complete complicated by embolism
legally unspecified type of abortion unspecified complicated by shock
legally unspecified abortion incomplete complicated by shock
legally unspecified abortion complete complicated by shock
legally unspecified type of abortion unspecified complicated by embolism
legally unspecified abortion incomplete complicated by embolism
legally unspecified abortion complete complicated by embolism
failed attempted abortion complicated by shock
failed attempted abortion complicated by embolism
shock following abortion or ectopic and molar pregnancies
embolism following abortion or ectopic and molar pregnancies
other specified complications following abortion or ectopic and molar pregnancies
benign essential hypertension complicating pregnancy childbirth and the puerperium unspecified as to
episode of care
benign essential hypertension with delivery
benign essential hypertension with delivery with postpartum complication
antepartum benign essential hypertension
postpartum benign essential hypertension
hypertension secondary to renal disease complicating pregnancy childbirth and the puerperium unspecified as to episode of care
hypertension secondary to renal disease with delivery
hypertension secondary to renal disease with delivery with postpartum complication
hypertension secondary to renal disease antepartum
hypertension secondary to renal disease postpartum
other pre-existing hypertension complicating pregnancy childbirth and the puerperium unspecified as
to episode of care
other pre-existing hypertension with delivery
other pre-existing hypertension with delivery with postpartum complication
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
642.23
642.24
642.30
642.31
642.32
642.33
642.34
642.40
642.41
642.42
642.43
642.44
642.50
642.51
642.52
642.53
642.54
642.60
642.61
642.62
642.63
642.64
642.70
642.71
642.72
642.73
642.74
642.90
642.91
642.92
642.93
642.94
648.50
648.51
648.52
648.53
648.54
648.60
648.61
648.62
648.63
648.64
668.10
668.11
other pre-existing hypertension antepartum
other pre-existing hypertension postpartum
transient hypertension of pregnancy unspecified as to episode of care
transient hypertension of pregnancy with delivery
transient hypertension of pregnancy with delivery with postpartum complication
antepartum transient hypertension
postpartum transient hypertension
mild or unspecified pre-eclampsia unspecified as to episode of care
mild or unspecified pre-eclampsia with delivery
mild or unspecified pre-eclampsia with delivery with postpartum complication
mild or unspecified pre-eclampsia antepartum
mild or unspecified pre-eclampsia postpartum
severe pre-eclampsia unspecified as to episode of care
severe pre-eclampsia with delivery
severe pre-eclampsia with delivery with postpartum complication
severe pre-eclampsia antepartum
severe pre-eclampsia postpartum
eclampsia complicating pregnancy childbirth or the puerperium unspecified as to episode of care
eclampsia with delivery
eclampsia with delivery with postpartum complication
eclampsia antepartum
eclampsia postpartum
pre-eclampsia or eclampsia superimposed on pre-existing hypertension complicating pregnancy childbirth or the puerperium unspecified as to episode of care
pre-eclampsia or eclampsia superimposed on pre-existing hypertension with delivery
pre-eclampsia or eclampsia superimposed on pre-existing hypertension with delivery with postpartum
complication
pre-eclampsia or eclampsia superimposed on pre-existing hypertension antepartum
pre-eclampsia or eclampsia superimposed on pre-existing hypertension postpartum
unspecified hypertension complicating pregnancy childbirth or the puerperium unspecified as to episode of care
unspecified hypertension with delivery
unspecified hypertension with delivery with postpartum complication
unspecified antepartum hypertension
unspecified postpartum hypertension
congenital cardiovascular disorders of mother complicating pregnancy childbirth or the puerperium
unspecified as to episode of care
congenital cardiovascular disorders of mother with delivery
congenital cardiovascular disorders of mother with delivery with postpartum complication
congenital cardiovascular disorders of mother antepartum
congenital cardiovascular disorders of mother postpartum
other cardiovascular diseases of mother complicating pregnancy childbirth or the puerperium unspecified as to episode of care
other cardiovascular diseases of mother with delivery
other cardiovascular diseases of mother with delivery with postpartum complication
other cardiovascular diseases of mother antepartum
other cardiovascular diseases of mother postpartum
cardiac complications of anesthesia or other sedation in labor and delivery unspecified as to episode
of care
cardiac complications of anesthesia or other sedation in labor and delivery delivered
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
668.12
668.13
668.14
669.10
669.11
669.12
669.13
669.14
669.20
669.21
669.22
669.23
669.24
669.40
669.41
669.42
669.43
669.44
673.00
673.01
673.02
673.03
673.04
673.10
673.11
673.12
673.13
673.14
673.20
673.21
673.22
673.23
673.24
673.30
673.31
673.32
673.33
673.34
673.80
673.81
673.82
673.83
673.84
674.50
674.51
674.52
674.53
674.54
cardiac complications of anesthesia or other sedation in labor and delivery delivered with postpartum
complication
cardiac complications of anesthesia or other sedation in labor and delivery antepartum
cardiac complications of anesthesia or other sedation in labor and delivery postpartum
obstetric shock unspecified as to episode of care
obstetric shock with delivery with or without antepartum condition
obstetric shock with delivery with postpartum complication
antepartum obstetric shock
postpartum obstetric shock
maternal hypotension syndrome complicating labor and delivery unspecified as to episode of care
maternal hypotension syndrome with delivery with or without antepartum condition
maternal hypotension syndrome with delivery with postpartum complication
maternal hypotension syndrome antepartum
maternal hypotension syndrome postpartum
other complications of obstetrical surgery and procedures unspecified as to episode of care
other complications of obstetrical surgery and procedures with delivery with or without antepartum
condition
other complications of obstetrical surgery and procedures with delivery with postpartum complication
other complications of obstetrical surgery and procedures antepartum condition or complication
other complications of obstetrical surgery and procedures postpartum condition or complication
obstetrical air embolism unspecified as to episode of care
obstetrical air embolism with delivery with or without antepartum condition
obstetrical air embolism with delivery with postpartum complication
obstetrical air embolism antepartum condition or complication
obstetrical air embolism postpartum condition or complication
amniotic fluid embolism unspecified as to episode of care
amniotic fluid embolism with delivery with or without antepartum condition
amniotic fluid embolism with delivery with postpartum complication
amniotic fluid embolism antepartum condition or complication
amniotic fluid embolism postpartum condition or complication
obstetrical blood-clot embolism unspecified as to episode of care
obstetrical blood-clot embolism with delivery with or without antepartum condition
obstetrical blood-clot embolism with postpartum complication
obstetrical blood-clot embolism antepartum
obstetrical blood-clot embolism postpartum
obstetrical pyemic and septic embolism unspecified as to episode of care
obstetrical pyemic and septic embolism with delivery with or without antepartum condition
obstetrical pyemic and septic embolism with delivery with postpartum complicaton
obstetrical pyemic and septic embolism antepartum
obstetrical pyemic and septic embolism postpartum
other obstetrical pulmonary embolism unspecified as to episode of care
other obstetrical pulmonary embolism with delivery with or without antepartum condition
other obstetrical pulmonary embolism with delivery with postpartum complication
other obstetrical pulmonary embolism antepartum
other obstetrical pulmonary embolism postpartum
peripart cardiomyopathy unspecified
peripartum cardiomyopathy with delivery with or without antepartum condition
peripartum cardiomyopathy with delivery with postpartum complication
peripartum cardiomyopathy with antepartum condition or complication
peripartum cardiomyopathy with postpartum condition or complication
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
710.0
710.1
710.3
710.4
714.2
724.1
729.1
729.5
733.6
738.3
745.0
745.10
745.11
745.12
745.19
745.2
745.3
745.4
745.5
745.60
745.61
745.69
745.7
745.8
745.9
746.00
746.01
746.02
746.09
746.1
746.2
746.3
746.4
746.5
746.6
746.7
746.81
746.82
746.83
746.84
746.85
746.86
746.87
746.89
746.9
747.0
747.10
747.11
747.20
747.21
systemic lupus erythematosus
systemic sclerosis
dermatomyositis
polymyositis
other rheumatoid arthritis with visceral or systemic involvement
pain in thoracic spine
myalgia and myositis unspecified
pain in limb
tietze’s disease
acquired deformity of chest and rib
common truncus
complete transposition of great vessels
double outlet right ventricle
corrected transposition of great vessels
other transposition of great vessels
tetralogy of fallot
common ventricle
ventricular septal defect
ostium secundum type atrial septal defect
endocardial cushion defect unspecified type
ostium primum defect
other endocardial cushion defects
cor biloculare
other bulbus cordis anomalies and anomalies of cardiac septal closure
unspecified defect of septal closure
congenital pulmonary valve anomaly unspecified
atresia of pulmonary valve congenital
stenosis of pulmonary valve congenital
other congenital anomalies of pulmonary valve
tricuspid atresia and stenosis congenital
ebstein’s anomaly
congenital stenosis of aortic valve
congenital insufficiency of aortic valve
congenital mitral stenosis
congenital mitral insufficiency
hypoplastic left heart syndrome
subaortic stenosis congenital
cor triatriatum
infundibular pulmonic stenosis congenital
congenital obstructive anomalies of heart not elsewhere classified
coronary artery anomaly congenital
congenital heart block
malposition of heart and cardiac apex
other specified congenital anomalies of heart
unspecified congenital anomaly of heart
patent ductus arteriosus
coarctation of aorta (preductal) (postductal)
interruption of aortic arch
congenital anomaly of aorta unspecified
congenital anomalies of aortic arch
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
747.22
747.29
747.3
747.40
747.41
747.42
747.49
747.5
754.81
754.82
756.3
758.0
758.1
758.32
758.4
758.5
758.7
758.81
758.89
759.3
759.4
759.7
759.81
759.82
759.83
759.89
768.2
768.3
768.4
768.5
768.6
768.9
769
770.89
771.0
771.1
771.3
775.3
775.4
775.5
775.6
775.7
778.0
779.0
779.4
779.5
780.01
780.02
780.03
780.09
congenital atresia and stenosis of aorta
other congenital anomalies of aorta
congenital anomalies of pulmonary artery
congenital anomaly of great veins unspecified
total anomalous pulmonary venous connection
partial anomalous pulmonary venous connection
other anomalies of great veins
absence or hypoplasia of umbilical artery
pectus excavatum
pectus carinatum
other congenital anomalies of ribs and sternum
down’s syndrome
patau’s syndrome
velo-cardio-facial syndrome
balanced autosomal translocation in normal individual
other conditions due to autosomal anomalies
klinefelter’s syndrome
other conditions due to sex chromosome anomalies
other conditions due to chromosome anomalies
situs inversus
conjoined twins
multiple congenital anomalies so described
prader-willi syndrome
marfan syndrome
fragile x syndrome
other specified congenital anomalies
fetal distress before onset of labor in liveborn infant
fetal distress first noted during labor in liveborn infant
fetal distress unspecified as to time of onset in liveborn infant
severe birth asphyxia
mild or moderate birth asphyxia
unspecified severity of birth asphyxia in liveborn infant
respiratory distress syndrome in newborn
other respiratory problems after birth
congenital rubella
congenital cytomegalovirus infection
tetanus neonatorum
neonatal thyrotoxicosis
hypocalcemia and hypomagnesemia of newborn
other transitory neonatal electrolyte disturbances
neonatal hypoglycemia
late metabolic acidosis of newborn
hydrops fetalis not due to isoimmunization
convulsions in newborn
drug reactions and intoxications specific to newborn
drug withdrawal syndrome in newborn
coma
transient alteration of awareness
persistent vegetative state
alteration of consciousness other
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
780.2
780.31
780.32
780.39
780.4
780.57
780.60
780.61
780.62
780.63
780.64
780.65
780.71
780.79
781.5
781.7
782.3
782.5
782.61
782.62
784.1
785.0
785.1
785.2
785.3
785.50
785.51
785.52
785.59
786.00
786.01
786.02
786.05
786.09
786.1
786.50
786.51
786.52
786.59
786.7
787.1
789.00
789.01
789.02
789.03
789.04
789.05
789.06
789.07
789.09
syncope and collapse
febrile convulsions (simple), unspecified
complex febrile convulsions
other convulsions
dizziness and giddiness
unspecified sleep apnea
fever, unspecified
fever presenting with conditions classified elsewhere
postprocedural fever
postvaccination fever
chills (without fever)
hypothermia not associated with low environmental temperature
chronic fatigue syndrome
other malaise and fatigue
clubbing of fingers
tetany
edema
cyanosis
pallor
flushing
throat pain
tachycardia unspecified
palpitations
undiagnosed cardiac murmurs
other abnormal heart sounds
shock unspecified
cardiogenic shock
septic shock
other shock without trauma
respiratory abnormality unspecified
hyperventilation
orthopnea
shortness of breath
respiratory abnormality other
stridor
unspecified chest pain
precordial pain
painful respiration
other chest pain
abnormal chest sounds
heartburn
abdominal pain unspecified site
abdominal pain right upper quadrant
abdominal pain left upper quadrant
abdominal pain right lower quadrant
abdominal pain left lower quadrant
abdominal pain periumbilic
abdominal pain epigastric
abdominal pain generalized
abdominal pain other specified site
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
790.4
790.91
794.30
794.31
794.39
794.4
794.5
796.3
799.01
799.02
799.1
799.2
799.3
799.4
807.00
807.01
807.02
807.03
807.04
807.05
807.06
807.07
807.08
807.10
807.11
807.12
807.13
807.14
807.15
807.16
807.17
807.18
807.2
807.3
807.4
853.00
853.01
853.02
853.03
853.04
853.05
853.06
nonspecific elevation of levels of transaminase or lactic acid dehydrogenase (ldh)
abnormal arterial blood gases
unspecified abnormal function study of cardiovascular system
nonspecific abnormal electrocardiogram (ecg) (ekg)
other nonspecific abnormal function study of cardiovascular system
nonspecific abnormal results of function study of kidney
nonspecific abnormal results of function study of thyroid
nonspecific low blood pressure reading
asphyxia
hypoxemia
respiratory arrest
nervousness
debility unspecified
cachexia
closed fracture of rib(s) unspecified
closed fracture of one rib
closed fracture of two ribs
closed fracture of three ribs
closed fracture of four ribs
closed fracture of five ribs
closed fracture of six ribs
closed fracture of seven ribs
closed fracture of eight or more ribs
open fracture of rib(s) unspecified
open fracture of one rib
open fracture of two ribs
open fracture of three ribs
open fracture of four ribs
open fracture of five ribs
open fracture of six ribs
open fracture of seven ribs
open fracture of eight or more ribs
closed fracture of sternum
open fracture of sternum
flail chest
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
state of consciousness unspecified
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
no loss of consciousness
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
brief (less than one hour) loss of consciousness
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
moderate (1-24 hours) loss of consciousness
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
prolonged (more than 24 hours) loss of consciousness and return to pre- existing conscious level
other and unspecified intracranial hemorrhage following injury. without open intracranial wound with
prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
loss of consciousness of unspecified duration
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
853.09
853.10
853.11
853.12
853.13
853.14
853.15
853.16
853.19
860.0
860.1
860.2
860.3
860.4
860.5
861.00
861.01
861.02
861.03
861.10
861.11
861.12
861.13
861.20
861.21
861.22
861.30
861.31
861.32
862.0
862.1
862.21
862.22
862.29
862.31
862.32
862.39
862.8
862.9
875.0
875.1
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
concussion unspecified
other and unspecified intracranial hemorrhage following injury with open intracranial wound with state
of consciousness unspecified
other and unspecified intracranial hemorrhage following injury with open intracranial wound with no
loss of consciousness
other and unspecified intracranial hemorrhage following injury with open intracranial wound with brief
(less than one hour) loss of consciousness
other and unspecified intracranial hemorrhage following injury with open intracranial wound with
moderate (1-24 hours) loss of consciousness
other and unspecified intracranial hemorrhage following injury with open intracranial wound with prolonged( more than 24 hours) loss of consciousness and return to pre-existing conscious level
other and unspecified intracranial hemorrhage following injury with open intracranial wound with prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level
other and unspecified intracranial hemorrhage following injury with open intracranial wound with loss
of consciousness of unspecified duration
other and unspecified intracranial hemorrhage following injury with open intracranial wound with concussion unspecified
traumatic pneumothorax without open wound into thorax
traumatic pneumothorax with open wound into thorax
traumatic hemothorax without open wound into thorax
traumatic hemothorax with open wound into thorax
traumatic pneumohemothorax without open wound into thorax
traumatic pneumohemothorax with open wound into thorax
unspecified injury of heart without open wound into thorax
contusion of heart without open wound into thorax
laceration of heart without penetration of heart chambers or open wound into thorax
laceration of heart with penetration of heart chambers without open wound into thorax
unspecified injury of heart with open wound into thorax
contusion of heart with open wound into thorax
laceration of heart without penetration of heart chambers with open wound into thorax
laceration of heart with penetration of heart chambers and open wound into thorax
unspecified injury of lung without open wound into thorax
contusion of lung without open wound into thorax
laceration of lung without open wound into thorax
unspecified injury of lung with open wound into thorax
contusion of lung with open wound into thorax
laceration of lung with open wound into thorax
injury to diaphragm without open wound into cavity
injury to diaphragm with open wound into cavity
injury to bronchus without open wound into cavity
injury to esophagus without open wound into cavity
injury to other specified intrathoracic organs without open wound into cavity
injury to bronchus with open wound into cavity
injury to esophagus with open wound into cavity
injury to other specified intrathoracic organs with open wound into cavity
injury to multiple and unspecified intrathoracic organs without open wound into cavity
injury to multiple and unspecified intrathoracic organs with open wound into cavity
open wound of chest (wall) without complication
open wound of chest (wall) complicated
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
900.00
900.01
900.02
900.03
900.1
900.81
900.82
900.89
900.9
901.0
901.1
901.2
901.3
901.40
901.41
901.42
901.81
901.82
901.83
901.89
901.9
902.0
902.10
902.11
902.19
902.20
902.21
902.22
902.23
902.24
902.25
902.26
902.27
902.29
902.31
902.32
902.33
902.34
902.39
902.40
902.41
902.42
902.49
902.50
902.51
902.52
902.53
902.54
902.55
902.56
injury to carotid artery unspecified
injury to common carotid artery
injury to external carotid artery
injury to internal carotid artery
injury to internal jugular vein
injury to external jugular vein
injury to multiple blood vessels of head and neck
injury to other specified blood vessels of head and neck
injury to unspecified blood vessel of head and neck
injury to thoracic aorta
injury to innominate and subclavian arteries
injury to superior vena cava
injury to innominate and subclavian veins
injury to pulmonary vessel(s) unspecified
injury to pulmonary artery
injury to pulmonary vein
injury to intercostal artery or vein
injury to internal mammary artery or vein
injury to multiple blood vessels of thorax
injury to other specified blood vessels of thorax
injury to unspecified blood vessel of thorax
injury to abdominal aorta
injury to inferior vena cava unspecified
injury to hepatic veins
injury to other specified branches of inferior vena cava
injury to celiac and mesenteric arteries unspecified
injury to gastric artery
injury to hepatic artery
injury to splenic artery
injury to other specified branches of celiac axis
injury to superior mesenteric artery (trunk)
injury to primary branches of superior mesenteric artery
injury to inferior mesenteric artery
injury to other celiac and mesenteric arteries
injury to superior mesenteric vein and primary subdivisions
injury to inferior mesenteric vein
injury to portal vein
injury to splenic vein
injury to other portal and splenic veins
injury to renal vessel(s) unspecified
injury to renal artery
injury to renal vein
injury to other renal blood vessels
injury to iliac vessel(s) unspecified
injury to hypogastric artery
injury to hypogastric vein
injury to iliac artery
injury to iliac vein
injury to uterine artery
injury to uterine vein
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
902.59
902.81
902.82
902.87
902.89
908.0
909.2
922.1
926.8
947.1
958.0
958.1
958.4
958.7
959.11
960.7
962.7
962.8
963.1
965.1
966.0
966.1
966.2
966.3
966.4
967.0
967.1
967.2
967.3
967.4
967.5
967.6
967.8
967.9
968.0
968.1
968.2
968.3
968.4
968.5
968.6
968.7
968.9
969.0
969.1
969.2
969.3
969.4
969.5
969.6
injury to other iliac blood vessels
injury to ovarian artery
injury to ovarian vein
injury to multiple blood vessels of abdomen and pelvis
injury to other specified blood vessels of abdomen and pelvis
late effect of internal injury to chest
late effect of radiation
contusion of chest wall
crushing injury of multiple sites of trunk
burn of larynx trachea and lung
air embolism as an early complication of trauma
fat embolism as an early complication of trauma
traumatic shock
traumatic subcutaneous emphysema
other injury of chest wall
poisoning by antineoplastic antibiotics
poisoning by thyroid and thyroid derivatives
poisoning by antithyroid agents
poisoning by antineoplastic and immunosuppressive drugs
poisoning by salicylates
poisoning by oxazolidine derivatives
poisoning by hydantoin derivatives
poisoning by succinimides
poisoning by other and unspecified anticonvulsants
poisoning by anti-parkinsonism drugs
poisoning by barbiturates
poisoning by chloral hydrate group
poisoning by paraldehyde
poisoning by bromine compounds
poisoning by methaqualone compounds
poisoning by glutethimide group
poisoning by mixed sedatives not elsewhere classified
poisoning by other sedatives and hypnotics
poisoning by unspecified sedative or hypnotic
poisoning by central nervous system muscle-tone depressants
poisoning by halothane
poisoning by other gaseous anesthetics
poisoning by intravenous anesthetics
poisoning by other and unspecified general anesthetics
poisoning by surface (topical) and infiltration anesthetics
poisoning by peripheral nerve- and plexus-blocking anesthetics
poisoning by spinal anesthetics
poisoning by other and unspecified local anesthetics
poisoning by antidepressants
poisoning by phenothiazine-based tranquilizers
poisoning by butyrophenone-based tranquilizers
poisoning by other antipsychotics neuroleptics and major tranquilizers
poisoning by benzodiazepine-based tranquilizers
poisoning by other tranquilizers
poisoning by psychodysleptics (hallucinogens)
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
969.7
969.8
969.9
970.0
970.1
970.8
970.9
971.0
971.1
971.2
971.3
971.9
972.0
972.1
972.2
972.3
972.4
972.5
972.6
972.7
972.8
972.9
974.0
974.1
974.2
974.3
974.4
974.5
974.6
974.7
975.1
975.7
977.8
977.9
980.0
980.1
980.2
980.3
981
982.0
982.1
982.2
982.3
982.4
982.8
986
989.0
989.3
989.4
989.5
poisoning by psychostimulants
poisoning by other specified psychotropic agents
poisoning by unspecified psychotropic agent
poisoning by analeptics
poisoning by opiate antagonists
poisoning by other specified central nervous system stimulants
poisoning by unspecified central nervous system stimulant
poisoning by parasympathomimetics (cholinergics)
poisoning by parasympatholytics (anticholinergics and antimuscarinics) and spasmolytics
poisoning by sympathomimetics (adrenergics)
poisoning by sympatholytics (antiadrenergics)
poisoning by unspecified drug primarily affecting autonomic nervous system
poisoning by cardiac rhythm regulators
poisoning by cardiotonic glycosides and drugs of similar action
poisoning by antilipemic and antiarteriosclerotic drugs
poisoning by ganglion-blocking agents
poisoning by coronary vasodilators
poisoning by other vasodilators
poisoning by other antihypertensive agents
poisoning by antivaricose drugs including sclerosing agents
poisoning by capillary-active drugs
poisoning by other and unspecified agents primarily affecting the cardiovascular system
poisoning by mercurial diuretics
poisoning by purine derivative diuretics
poisoning by carbonic acid anhydrase inhibitors
poisoning by saluretics
poisoning by other diuretics
poisoning by electrolytic caloric and water-balance agents
poisoning by other mineral salts not elsewhere classified
poisoning by uric acid metabolism drugs
poisoning by smooth muscle relaxants
poisoning by antiasthmatics
poisoning by other specified drugs and medicinal substances
poisoning by unspecified drug or medicinal substance
toxic effect of ethyl alcohol
toxic effect of methyl alcohol
toxic effect of isopropyl alcohol
toxic effect of fusel oil
toxic effect of petroleum products
toxic effect of benzene and homologues
toxic effect of carbon tetrachloride
toxic effect of carbon disulfide
toxic effect of other chlorinated hydrocarbon solvents
toxic effect of nitroglycol
toxic effect of other nonpetroleum-based solvents
toxic effect of carbon monoxide
toxic effect of hydrocyanic acid and cyanides
toxic effect of organophosphate and carbamate
toxic effect of other pesticides not elsewhere classified
toxic effect of venom
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
990
991.6
992.0
992.1
992.3
993.2
993.3
994.0
994.1
994.7
994.8
995.0
995.4
995.60
995.61
995.62
995.63
995.64
995.65
995.66
995.67
995.68
995.69
995.89
995.90
995.91
995.92
995.94
996.00
996.01
996.02
996.03
996.04
996.09
996.1
996.61
996.62
996.71
996.72
996.81
996.82
996.83
996.84
996.85
996.86
996.87
997.1
998.0
998.11
998.12
effects of radiation unspecified
hypothermia
heat stroke and sunstroke
heat syncope
heat exhaustion anhydrotic
other and unspecified effects of high altitude
caisson disease
effects of lightning
drowning and nonfatal submersion
asphyxiation and strangulation
electrocution and nonfatal effects of electric current
other anaphylactic shock not elsewhere classified
shock due to anesthesia not elsewhere classified
anaphylactic shock due to unspecified food
anaphylactic shock due to peanuts
anaphylactic shock due to crustaceans
anaphylactic shock due to fruits and vegetables
anaphylactic shock due to tree nuts and seeds
anaphylactic shock due to fish
anaphylactic shock due to food additives
anaphylactic shock due to milk products
anaphylactic shock due to eggs
anaphylactic shock due to other specified food
other specified adverse effects not elsewhere classified
systemic inflammatory response syndrome unspecified
sepsis
severe sepsis
systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction
mechanical complications of unspecified cardiac device implant and graft
mechanical complication due to cardiac pacemaker (electrode)
mechanical complication due to heart valve prosthesis
mechanical complication due to coronary bypass graft
mechanical complication of automatic implantable cardiac defibrillator
other mechanical complication of cardiac device implant and graft
mechanical complication of other vascular device implant and graft
infection and inflammatory reaction due to cardiac device implant and graft
infection and inflammatory reaction due to other vascular device implant and graft
other complications due to heart valve prosthesis
other complications due to other cardiac device implant and graft
complications of transplanted kidney
complications of transplanted liver
complications of transplanted heart
complications of transplanted lung
complications of transplanted bone marrow
complications of transplanted pancreas
complications of transplanted organ intestine
cardiac complications not elsewhere classified
postoperative shock not elsewhere classified
hemorrhage complicating a procedure
hematoma complicating a procedure
CMS Limitations
Electrocardiography (ECG or EKG) (con’t)
998.13
998.2
998.51
998.59
998.7
998.81
999.1
999.4
999.5
v15.1
v42.1
v42.2
v42.6
v43.21
v43.22
v43.3
v45.00
v45.01
v45.02
v45.09
v45.81
v45.82
v47.2
v53.31
v53.32
v53.39
v58.0
v58.11
v58.12
v58.69
v71.82
v71.83
seroma complicating a procedure
accidental puncture or laceration during a procedure not elsewhere classified
infected postoperative seroma
other postoperative infection
acute reaction to foreign substance accidentally left during a procedure not elsewhere classified
emphysema (subcutaneous) (surgical) resulting from procedure
air embolism as a complication of medical care not elsewhere classified
anaphylactic shock due to serum not elsewhere classified
other serum reaction not elsewhere classified
personal history of surgery to heart and great vessels presenting hazards to health
heart replaced by transplant
heart valve replaced by transplant
lung replaced by transplant
heart replaced by heart assist device
heart replaced by fully implantable artificial heart
heart valve replaced by other means
unspecified cardiac device in situ
cardiac pacemaker in situ
automatic implantable cardiac defibrillator in situ
other specified cardiac device in situ
postsurgical aortocoronary bypass status
percutaneous transluminal coronary angioplasty status
other cardiorespiratory problems
fitting and adjustment of cardiac pacemaker
fitting and adjustment of automatic implantable cardiac defibrillator
fitting and adjustment of other cardiac device
radiotherapy
encounter for antineoplastic chemotherapy
encounter for immunotherapy for neoplastic condition
long-term (current) use of other medications
observation and evaluation for suspected exposure to anthrax
observation and evaluation for suspected exposure to other biological agent
ICD-9-CM code 729.5 should be utilized when patient is experiencing left arm pain.
ICD-9-CM code 526.9 should be utilized when patient is experiencing jaw pain.
When cardiotoxicity may be involved in either radiation therapy or chemotherapy, ICD-9-CM code 990, V58.0, or V58.1
should be reported as appropriate.
CMS Limitations
Holter Monitor Testing
LCD # L1241, Effective date: 09/01/2008
ICD-9 codes that SUPPORT medical necessity for Holter Monitor Testing:
410.00*
410.01*
410.02*
410.10*
410.11*
410.12*
410.20*
410.21*
410.22*
410.30*
410.31*
410.32*
410.40*
410.41*
410.42*
410.50*
410.51*
410.52*
410.60*
410.61*
410.62*
410.70*
410.71*
410.72*
410.80*
410.81*
410.82*
410.90*
410.91*
410.92*
411.0
411.1
411.81
411.89
413.0
413.1
413.9
426.0
426.10
426.11
426.12
426.13
426.6
426.7
426.81
acute myocardial infarction of anterolateral wall episode of care unspecified
acute myocardial infarction of anterolateral wall initial episode of care
acute myocardial infarction of anterolateral wall subsequent episode of care
acute myocardial infarction of other anterior wall episode of care unspecified
acute myocardial infarction of other anterior wall initial episode of care
acute myocardial infarction of other anterior wall subsequent episode of care
acute myocardial infarction of inferolateral wall episode of care unspecified
acute myocardial infarction of inferolateral wall initial episode of care
acute myocardial infarction of inferolateral wall subsequent episode of care
acute myocardial infarction of inferoposterior wall episode of care unspecified
acute myocardial infarction of inferoposterior wall initial episode of care
acute myocardial infarction of inferoposterior wall subsequent episode of care
acute myocardial infarction of other inferior wall episode of care unspecified
acute myocardial infarction of other inferior wall initial episode of care
acute myocardial infarction of other inferior wall subsequent episode of care
acute myocardial infarction of other lateral wall episode of care unspecified
acute myocardial infarction of other lateral wall initial episode of care
acute myocardial infarction of other lateral wall subsequent episode of care
true posterior wall infarction episode of care unspecified
true posterior wall infarction initial episode of care
true posterior wall infarction subsequent episode of care
subendocardial infarction episode of care unspecified
subendocardial infarction initial episode of care
subendocardial infarction subsequent episode of care
acute myocardial infarction of other specified sites episode of care unspecified
acute myocardial infarction of other specified sites initial episode of care
acute myocardial infarction of other specified sites subsequent episode of care
acute myocardial infarction of unspecified site episode of care unspecified
acute myocardial infarction of unspecified site initial episode of care*
acute myocardial infarction of unspecified site subsequent episode of care
postmyocardial infarction syndrome
intermediate coronary syndrome
acute coronary occlusion without myocardial infarction
other acute and subacute forms of ischemic heart disease other
angina decubitus
prinzmetal angina
other and unspecified angina pectoris
atrioventricular block complete
atrioventricular block unspecified
first degree atrioventricular block
mobitz (type) ii atrioventricular block
other second degree atrioventricular block
other heart block
anomalous atrioventricular excitation
lown-ganong-levine syndrome
CMS Limitations
Holter Monitor Testing (con’t)
426.82
426.89
426.9
427.0*
427.1*
427.2*
427.31*
427.32*
427.41*
427.42*
427.5
427.60*
427.61*
427.69*
427.81*
427.89*
427.9
434.10
434.11
435.8
435.9
780.2
780.4
785.0
785.1
786.05
786.50
786.51
786.59
996.01
V58.69*
long qt syndrome
other specified conduction disorders
conduction disorder unspecified
paroxysmal supraventricular tachycardia
paroxysmal ventricular tachycardia
paroxysmal tachycardia unspecified
atrial fibrillation
atrial flutter
ventricular fibrillation
ventricular flutter
cardiac arrest
premature beats unspecified
supraventricular premature beats
other premature beats
sinoatrial node dysfunction
other specified cardiac dysrhythmias
cardiac dysrhythmia unspecified
cerebral embolism without cerebral infarction
cerebral embolism with cerebral infarction
other specified transient cerebral ischemias
unspecified transient cerebral ischemia
syncope and collapse
dizziness and giddiness
tachycardia unspecified
palpitations
shortness of breath
unspecified chest pain
precordial pain
other chest pain
mechanical complication due to cardiac pacemaker (electrode)
long-term (current) use of other medications
*Repeat long-term ECG monitoring within a six-month period will not be covered unless it is indicated for the asterisked
diagnoses.
CMS Limitations
Nuclear Medicine: Cardiac Blood Pool Studies
LCD # L26859, Effective date: 01/01/2009
CPT/HCPCS Codes: CPT 78494, CPT 78496
ICD-9 codes that SUPPORT medical necessity for Cardiac Blood Pool Gated Equilibrium, SPECT Study (CPT 78494)
and Cardiac Blood Pool Gated Equilibrium, Right Ventricular, Single Study (CPT 78496):
V58.11
V58.12
V67.2
encounter for antineoplastic chemotherapy
encounter for immunotherapy for neoplastic condition
follow-up examination following chemotherapy
CMS Limitations
Nuclear Medicine: Myocardial Infarct Avidity Studies
LCD # L26859, Effective date: 01/01/2009
CPT/HCPCS Codes: CPT 78466, CPT 78468, CPT 78469
ICD-9 codes that SUPPORT medical necessity for Myocardial Imaging Infarct Avid, Planar, Qualitative, or Quantitative
(CPT 78466), with Ejection Fraction by First Pass (CPT 78468) and Tomographic SPECT with or without Quantification
(CPT 78469):
410.00
410.01
410.02
410.10
410.11
410.12
410.20
410.21
410.22
410.30
410.31
410.32
410.40
410.41
410.42
410.50
410.51
410.52
410.60
410.61
410.62
410.70
410.71
410.72
410.80
410.81
410.82
410.90
410.91
410.92
414.2
786.50
786.51
786.59
794.31
acute myocardial infarction of anterolateral wall episode of care unspecified
acute myocardial infarction of anterolateral wall initial episode of care
acute myocardial infarction of anterolateral wall subsequent episode of care
acute myocardial infarction of other anterior wall episode of care unspecified
acute myocardial infarction of other anterior wall initial episode of care
acute myocardial infarction of other anterior wall subsequent episode of care
acute myocardial infarction of inferolateral wall episode of care unspecified
acute myocardial infarction of inferolateral wall initial episode of care
acute myocardial infarction of inferolateral wall subsequent episode of care
acute myocardial infarction of inferoposterior wall episode of care unspecified
acute myocardial infarction of inferoposterior wall initial episode of care
acute myocardial infarction of inferoposterior wall subsequent episode of care
acute myocardial infarction of other inferior wall episode of care unspecified
acute myocardial infarction of other inferior wall initial episode of care
acute myocardial infarction of other inferior wall subsequent episode of care
acute myocardial infarction of other lateral wall episode of care unspecified
acute myocardial infarction of other lateral wall initial episode of care
acute myocardial infarction of other lateral wall subsequent episode of care
true posterior wall infarction episode of care unspecified
true posterior wall infarction initial episode of care
true posterior wall infarction subsequent episode of care
subendocardial infarction episode of care unspecified
subendocardial infarction initial episode of care
subendocardial infarction subsequent episode of care
acute myocardial infarction of other specified sites episode of care unspecified
acute myocardial infarction of other specified sites initial episode of care
acute myocardial infarction of other specified sites subsequent episode of care
acute myocardial infarction of unspecified site episode of care unspecified
acute myocardial infarction of unspecified site initial episode of care
acute myocardial infarction of unspecified site subsequent episode of care
chronic total occlusion of coronary artery
unspecified chest pain
precordial pain
other chest pain
nonspecific abnormal electrocardiogram (ecg) (ekg)
CMS Limitations
Nuclear Medicine: Myocardial Perfusion with or without Functional Studies
LCD # L26859, Effective date: 01/01/2009
CPT/HCPCS Codes: CPT 78460, CPT 78461, CPT 78464, CPT 78465, CPT 78472, CPT 78473, CPT 78478, CPT 78480,
CPT 78481, CPT 78483, CPT 93015, CPT 93016, CPT 93017, CPT 93018
ICD-9 codes that SUPPORT medical necessity for Myocardial Perfusion with or without Functional Studies, Single Planar Study (CPT 78460), Multiple Planar Studies (CPT 78461), SPECT Single Study (CPT 78464), SPECT Multiple Studies
(CPT 78465), Gated Equilibrium, Planar, Single Study** (CPT 78472), Gated Equilibrium, Planar, Multiple Studies** (CPT
78473), Myocardial Perfusion Study with Wall Motion (CPT 78478), Myocardial Perfusion Study With Ejection Fraction
(CPT 78480), Cardiac Blood Pool Imaging Planar First Pass (CPT 78481), Cardiac Blood Pool Multiple Studies (CPT
78483), Cardiovascular Stress Test with Report, Interpretation, and Physician Supervision (CPT 93015), Cardiovascular
Stress Test with Physician Supervision but without Interpretation and Report (CPT 93016), Cardiovascular Stress Test
Tracing only (CPT 93017), and Cardiovascular Stress Test Interpretation and Report only (CPT 93018):
410.00
410.01
410.02
410.10
410.11
410.12
410.20
410.21
410.22
410.30
410.31
410.32
410.40
410.41
410.42
410.50
410.51
410.52
410.60
410.61
410.62
410.70
410.71
410.72
410.80
410.81
410.82
410.90
410.91
414.02
414.03
414.04
414.06
414.07
414.10
414.11
acute myocardial infarction of anterolateral wall episode of care unspecified
acute myocardial infarction of anterolateral wall initial episode of care
acute myocardial infarction of anterolateral wall subsequent episode of care
acute myocardial infarction of other anterior wall episode of care unspecified
acute myocardial infarction of other anterior wall initial episode of care
acute myocardial infarction of other anterior wall subsequent episode of care
acute myocardial infarction of inferolateral wall episode of care unspecified
acute myocardial infarction of inferolateral wall initial episode of care
acute myocardial infarction of inferolateral wall subsequent episode of care
acute myocardial infarction of inferoposterior wall episode of care unspecified
acute myocardial infarction of inferoposterior wall initial episode of care
acute myocardial infarction of inferoposterior wall subsequent episode of care
acute myocardial infarction of other inferior wall episode of care unspecified
acute myocardial infarction of other inferior wall initial episode of care
acute myocardial infarction of other inferior wall subsequent episode of care
acute myocardial infarction of other lateral wall episode of care unspecified
acute myocardial infarction of other lateral wall initial episode of care
acute myocardial infarction of other lateral wall subsequent episode of care
true posterior wall infarction episode of care unspecified
true posterior wall infarction initial episode of care
true posterior wall infarction subsequent episode of care
subendocardial infarction episode of care unspecified
subendocardial infarction initial episode of care
subendocardial infarction subsequent episode of care
acute myocardial infarction of other specified sites episode of care unspecified
acute myocardial infarction of other specified sites initial episode of care
acute myocardial infarction of other specified sites subsequent episode of care
acute myocardial infarction of unspecified site episode of care unspecified
acute myocardial infarction of unspecified site initial episode of care
coronary atherosclerosis of autologous vein bypass graft
coronary atherosclerosis of nonautologous biological bypass graft
coronary atherosclerosis of artery bypass graft
coronary atherosclerosis of native coronary artery of transplanted heart
coronary atherosclerosis of bypass graft (artery) (vein) of transplanted heart
aneurysm of heart (wall)
aneurysm of coronary vessels
CMS Limitations
Nuclear Medicine: Myocardial Perfusion with or without Functional Studies (con’t)
414.12
414.19
414.2
414.8
414.9
427.41
427.42
427.5
428.0
428.1
428.20
428.21
428.22
428.23
428.40
428.41
428.42
428.43
429.79
429.83
429.89
746.85
786.05
786.50
786.51
786.59
794.31
996.72
996.83
V42.1
V45.81
V45.82
dissection of coronary artery
other aneurysm of heart
chronic total occlusion of coronary artery
other specified forms of chronic ischemic heart disease
chronic ischemic heart disease unspecified
ventricular fibrillation
ventricular flutter
cardiac arrest
congestive heart failure unspecified
left heart failure
unspecified systolic heart failure
acute systolic heart failure
chronic systolic heart failure
acute on chronic systolic heart failure
unspecified combined systolic and diastolic heart failure
acute combined systolic and diastolic heart failure
chronic combined systolic and diastolic heart failure
acute on chronic combined systolic and diastolic heart failure
certain sequelae of myocardial infarction not elsewhere classified other
takotsubo syndrome
other ill-defined heart diseases
coronary artery anomaly congenital
shortness of breath
unspecified chest pain
precordial pain
other chest pain
nonspecific abnormal electrocardiogram (ecg) (ekg)
other complications due to other cardiac device implant and graft
complications of transplanted heart
heart replaced by transplant
postsurgical aortocoronary bypass status
percutaneous transluminal coronary angioplasty status
**In addition to the diagnosis listed above, the following are also considered medically necessary for Cardiac Blood Pool
Studies, Gated Equilibrium, Planar, Single Study, (CPT 78472), Gated Equilibrium, Planar, Multiple Studies (CPT 78473):
V58.11
V58.12
V67.2
encounter for antineoplastic chemotherapy
encounter for immunotherapy for neoplastic condition
follow-up examination following chemotherapy
CMS Limitations Guide - Laboratory Services
Starting July 1, 2008, CMS has placed numerous medical necessity limits on tests and procedures. This reference guide provides you with all of the latest changes.
This guide is not an all-inclusive list of National Coverage
Documents (NCD) and Local Coverage Documents (LCD).
Please consult the CMS website for additional information
at cms.hhs.gov/mcd/search.asp?clickon=search. You can
search by LCD or NCD or keyword and region.
CMS will deny payment if the correct diagnosis codes are
not entered on the order form, and your patient’s test or
procedure will not be covered. We compiled this information in one location to make it easier for you to find the
proper codes for medically necessary diagnoses.
It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g. to the fourth or
fifth digit). The correct use of an ICD-9-CM code listed
below does not assure coverage of a service. The service
must be reasonable and necessary in the specific case and
must meet the criteria specified in this determination.
We will continue to update this list as new CMS limitations
are announced. You can always find the most current list
on mymunson.org.
If you have any questions, please contact Kari Smith,
Office Coordinator, at (231) 935-2296, or Karen Popa,
Director, Patient Access Services, at (231) 935-7493.
CMS Limitations
Acid Phosphatase, Total and Prostatic
LCD # 25879, Effective date: 03/01/2009
CPT/HCPCS Codes: CPT 84060, CPT 84066
ICD-9 Codes that SUPPORT Medical Necessity for Total Acid Phosphatase (CPT 84060):
198.5
205.00
205.01
205.02
205.10
205.11
205.12
205.20
205.21
205.22
205.30
205.31
205.32
205.80
205.81
205.82
205.90
205.91
205.92
252.00
252.01
252.02
252.08
272.7
731.0
secondary malignant neoplasm of bone and bone marrow
acute myeloid leukemia, without mention of having achieved remission
myeloid leukemia acute in remission
acute myeloid leukemia, in relapse
chronic myeloid leukemia, without mention of having achieved remission
myeloid leukemia chronic in remission
chronic myeloid leukemia, in relapse
subacute myeloid leukemia, without mention of having achieved remission
myeloid leukemia subacute in remission
subacute myeloid leukemia, in relapse
myeloid sarcoma, without mention of having achieved remission
myeloid sarcoma in remission
myeloid sarcoma, in relapse
other myeloid leukemia, without mention of having achieved remission
other myeloid leukemia in remission
other myeloid leukemia, in relapse
unspecified myeloid leukemia, without mention of having achieved remission
unspecified myeloid leukemia in remission
unspecified myeloid leukemia, in relapse
hyperparathyroidism, unspecified
primary hyperparathyroidism
secondary hyperparathyroidism, non-renal
other hyperparathyroidism
lipidoses
osteitis deformans without bone tumor
ICD-9 Codes that SUPPORT medical necessity for Prostatic Acid Phospatase (CPT 84066):
CPT Code 84066 is NOT covered for any indication. There are no diagnoses that support medical necessity.
ICD-9 Codes that DO NOT SUPPORT Medical Necessity for Total and Prostatic Acid Phosphatase:
185malignant neoplasm of prostate
600.00
hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract (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
CMS Limitations
Acid Phosphatase, Total and Prostatic (con’t)
600.90
600.91
601.0
601.1
601.2
601.3
601.4
601.8
601.9
602.0
602.1
602.2
602.3
602.8
602.9
hyperplasia of prostate, unspecified, without urinary obstruction and other lower urinary symptoms (luts)
hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (luts)
acute prostatitis
chronic prostatitis
abscess of prostate
prostatocystitis
prostatitis in diseases classified elsewhere
other specified inflammatory diseases of prostate
prostatitis unspecified
calculus of prostate
congestion or hemorrhage of prostate
atrophy of prostate
dysplasia of prostate
other specified disorders of prostate
unspecified disorder of prostate
Alpha-fetoprotein
CMS Limitations
LCD # 190.25, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 82105
ICD-9 Codes that SUPPORT medical necessity for Alpha-fetoprotein; serum (CPT 82105):
070.22-070.23
070.32-070.33
070.44
070.54
095.3
121.1
121.3
155.0-155.2
164.2-164.9
183.0
186.0
186.9
197.1
197.7
198.6
198.82
*209.20-
209.27, 209.29
211.5
235.3
272.2
273.4
275.0
275.1
277.00
277.03
277.6
285.0
338.3
571.2
571.40
571.41
*571.42
571.49
571.5
608.89
793.1
793.2
793.3
793.6
795.89
v10.07
v10.43
v10.47
v86.0
v86.1
chronic viral hepatitis b with hepatic coma, with or without mention of hepatitis delta
chronic viral hepatitis b without mention of hepatic coma, with or without mention of hepatitis delta
chronic hepatitis c with hepatic coma
chronic hepatitis c without mention of hepatic coma
syphilis of liver
clonorchiasis
fascioliasis
malignant neoplasm of the liver and intrahepatic bile ducts
malignant neoplasm of the mediastinum
malignant neoplasm, ovary
malignant neoplasm of undescended testis
malignant neoplasm, other and unspecific testis
secondary malignant neoplasm of mediastinum
secondary malignant neoplasm of liver
secondary malignant neoplasm of ovary
secondary malignant neoplasm, genital organs
*malignant carcinoid tumors of other and unspecified sites
benign neoplasm of liver and biliary passages
neoplasm of uncertain behavior of liver and biliary passages
mixed hyperlipidemia
alpha-1-antitrypsin deficiency
disorder of iron metabolites
disorder of copper metabolism
cystic fibrosis without mention of meconium ileus
cystic fibrosis with gastrointestinal manifestations
other deficiencies of circulating enzymes
sideroblastic anemia
neoplasm related pain (acute) (chronic)
alcoholic cirrhosis of liver
chronic hepatitis, unspecified
chronic persistent hepatitis
*autoimmune hepatitis
other chronic hepatitis
cirrhosis of liver without mention of alcohol
other specified disorders of male genital organs
non-specific abnormal findings of lung field
non-specific abnormal findings of other intrathoracic organs
non-specific abnormal findings of biliary tract
non-specific abnormal findings of abdominal area, including retro peritoneum
other abnormal tumor markers
personal history of malignant neoplasm, liver
personal history of malignant neoplasm, ovary
personal history of malignant neoplasm, testis
estrogen receptor positive status [er+]
estrogen receptor negative status [er-]
CMS Limitations
Blood Counts
LCD # 190.15, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 85004, CPT 85007, CPT 85008, CPT 85013, CPT 85014, CPT 85018, CPT 85025, CPT 85027,
CPT 85032, CPT 85048, CPT 85049
ICD-9 Codes that DO NOT SUPPORT medical necessity for Blood count, automated differential white blood cell (WBC)
count (CPT 85004); Blood count; blood smear, microscopic examination with manual differential WBC count (CPT
85007); Blood count; blood smear, microscopic examination without manual differential WBC count (CPT 85008);
Blood count, Spun microhematocrit (CPT 85013); Blood count, hematocrit (Hct) (CPT 85014); Blood count, Hemoglobin (CPT 85018); Blood count, complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated
differential WBC count (CPT 85025); Blood count, complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet
count) (CPT 85027); Blood count; manual cell count (erythrocyte, leukocyte, platelet) each (CPT 85032); Blood count,
leukocyte (WBC), automated (CPT 85048); Blood count; platelet, automated (CPT 85049):
078.10
*078.12
078.19
210.0-210.9
214.0
216.0-216.9
217
222.0-222.9
224.0
230.0
232.0-232.9
300.00-300.09
301.0-301.9
302.0-302.9
307.0
307.20-307.23
307.3
307.80-307.89
312.00-312.9
313.0-313.9
314.00-314.9
338.0
338.11
338.12
338.18
338.19
338.21
338.22
338.28
338.29
338.4
363.30-363.35
363.40-363.43
363.50-363.57
363.70-363.9
366.00-366.9
viral warts
*plantar warts
viral warts
benign neoplasm of lip, oral cavity, and pharynx
lipoma, skin and subcutaneous tissue of face
benign neoplasm of skin
benign neoplasm of breast
benign neoplasm of male genital organs
benign neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid
carcinoma in situ of lip, oral cavity and pharynx
carcinoma in situ of skin
neurotic disorders
personality disorders
sexual and gender identity disorders
stuttering
tics
stereotypic movement disorder
pain disorders related to psychological factors
disturbance of conduct, not elsewhere classified
disturbance of emotions specific to childhood and adolescence
hyperkinetic syndrome of childhood
central pain syndrome
acute pain due to trauma
acute post-thoracotomy pain
other acute postoperative pain
other acute pain
chronic pain due to trauma
chronic post-thoracotomy pain
other chronic postoperative pain
other chronic pain
chronic pain syndrome
chorioretinal scars
choroidal degeneration
hereditary choroidal dystrophies
choroidal detachment
cataract
CMS Limitations
Blood Counts (con’t)
367.0-367.9
371.00-371.9
373.00-373.9
375.00-375.9
376.21-376.9
377.10-377.16
377.21-377.24
384.20-384.25
384.81-384.82
385.00-385.9
387.0-387.9
388.0-388.3
388.40-388.45
388.5
389.00-
389.06, 389.08
389.10-389.18
389.20-389.22
389.7
389.8, 389.9
440.0-440.1
443.81443.9
448.1
457.0
470
471.0-471.9
478.0
478.11
478.19
478.4
520.0-520.9
521.00-521.15, 521.20-521.25,
521.30-521.35,
521.40-521.42,
521.49, 521.5521.7, 521.81,
521.89, 521.9
524.00-524.9
525.0, 525.10-
525.13, 525.19,
525.20-525.26,
525.3, 525.40525.44, 525.50525.54, 525.60525.67, 525.69,
525.8, 525.9
526.0-526.3
526.61
526.62
disorders of refraction and accommodation
corneal opacity and other disorders of cornea
inflammation of eyelids
disorders of lacrimal system
disorders of the orbit, except 376.3 other exophthalmic conditions
optic atrophy
other disorders of optic disc
perforation of tympanic membrane
other specified disorders of tympanic membrane
other disorders of middle ear and mastoid
otosclerosis
other disorders of ear
other abnormal auditory perception
disorders of acoustic nerve
conductive hearing loss
sensorineural hearing loss
mixed hearing loss
deaf, non-speaking, not elsewhere classifiable
hearing loss
atherosclerosis of aorta and renal artery
other and unspecified peripheral vascular disease
capillary nevus, non neoplastic
postmastectomy lymphedema syndrome
deviated nasal septum
nasal polyps
hypertrophy of nasal turbinates
nasal mucositis (ulcerative)
other disease of nasal cavity and sinuses
polyp of vocal cord or larynx
disorders of tooth development and eruption
diseases of hard tissues of teeth
dentofacial anomalies, including malocclusion
other diseases and conditions of teeth and supporting structures
diseases of the jaws
perforation of root canal space
endodontic overfill
CMS Limitations
Blood Counts (con’t)
526.63
526.69
527.6-527.9
575.6
600.00-600.91
603.0
603.8
603.9
605
606.0-606.1
608.1
608.20
608.21
608.22
608.23
608.24
608.3
610.0-610.9
611.1-611.6
611.9
616.2
618.00-618.05, 618.09, 618.1618.7, 618.81618.83, 618.84,
618.89, 618.9
620.0-620.3
621.6-621.7
627.2-627.9
628.0-628.9
676.00-676.94
691.0-691.8
692.0-692.9
700
701.0-701.9
702.0-702.8
703.9
706.0-706.9
709.00-709.4
715.00-715.98
716.00-716.99
718.00-718.99
726.0-726.91
727.00-727.9
728.10-728.85
732.0-732.9
733.00-733.09
734
735.0-735.9
736.00-736.9
endodontic underfill
other periradicular pathology associated with previous endodontic treatment
diseases of salivary glands
cholesterolosis of gallbladder
hyperplasia of prostate
encysted hydrocele
other specified types of hydrocele
hydrocele, unspecified
redundant prepuce and phimosis
infertility, male azoospermia and oligospremia
spermatocele
torsion of testis, unspecified
extravaginal torsion of spermatic cord
intravaginal torsion of spermatic cord
torsion of appendix testis
torsion of appendix epididymis
atrophy of testis
benign mammary dysplasia
other disorders of breast
unspecified breast disorder
cyst of bartholin’s gland
genital prolapse
noninflammatory disorders of ovary, fallopian tube, and broad ligament
malposition or chronic inversion of uterus
menopausal and post menopausal disorders
infertility, female
other disorders of breast associated with childbirth and disorders of lactation
atopic dermatitis and related disorders
contact dermatitis and other eczema
corns and callosities
other hypertrophic and atrophic conditions of skin
other dermatoses
unspecified disease of nail
diseases of sebaceous glands
other disorders of skin and subcutaneous tissue
osteoarthrosis
other and unspecified arthropathies
other derangement of joint
peripheral enthesopathies and allied syndromes
other disorders of synovium, tendon, and bursa
disorders of muscle ligament and fascia
osteochondropathies
osteoporosis
flat foot
acquired deformities of toe
other acquired deformities of limb
CMS Limitations
Blood Counts (con’t)
737.0-737.9
curvature of spine
738.0-738.9
other acquired deformity
739.0-739.9
nonallopathic lesions, not elsewhere classified
799.81
decreased libido
830.0-839.9
dislocations
840.0-848.9
sprains and strains of joints and adjacent muscles
905.0-909.9
late effects of musculoskeletal and connective tissue injuries
910.0-919.9
superficial injuries
930.0-932
foreign body on external eye, in ear, in nose
955.0-957.9
injury to peripheral nerve
v03.0-v06.9
need for prophylactic vaccination
v11.0-v11.9
personal history of mental disorder
v14.0-v14.8
personal history of allergy to medicinal agents
v16.0
family history of malignant neoplasm, gastrointestinal tract
v16.3
family history of malignant neoplasm, breast
v21.0-v21.9
constitutional states in development
v25.01-v25.04, encounter for contraceptive management
v25.09, v25.1v25.3, v25.40v25.43, v25.49,
v25.5, v25.8, v25.9
v26.0-v26.1,
procreative management
v26.21v26.22,
v26.29, v26.31v26.33, v26.34,
v26.35, v26.9
v26.41
procreative counseling and advice using natural family planning
v26.49
other procreative management counseling and advice
v26.51, v26.52 procreative management, sterilization status
v26.81
encounter for assisted reproductive fertility procedure cycle
v26.89
other specified procreative management
v26.9
procreative management
v40.0-v40.9
mental and behavioral problems
v41.0-v41.9
problems with special senses and other special functions
v43.0-v43.1
organ or tissue replaced by other means, eye globe or lens
v44.0-v44.9
artificial opening status
v45.00-v45.02, other post surgical states
v45.09
*v45.11
*renal dialysis status
*v45.12
*non-compliance with renal dialysis
v45.2-v45.4, other post surgical states
v45.51, v45.52,
v45.59, v45.61,
v45.69, v45.71v45.79, v45.81v45.85, v45.86,
v45.89
v48.0-v48.9
problems with head, neck, and trunk
*v49.83
*awaiting organ transplant status
*v51.0
*encounter for breast reconstruction following mastectomy
CMS Limitations
Blood Counts (con’t)
*v51.8
v52.0-v52.9
v53.01-v53.09
v53.1
v53.31-v53.39
v53.4
v53.5
v53.6
v53.7
v53.8
v53.90-v53.99
v54.01-v54.9
v55.0-v55.9
v57.0-v57.9
v58.5
v59.01-v59.9
v61.0
*v61.01
*v61.02
*v61.03
*v61.04
*v61.05
*v61.06
*v61.09
v61.10-v61.12, v61.20-v61.22,
v61.29, v61.3,
v61.41, v61.49,
v61.5-v61.9
*v62.21
*v62.22
*v62.29
v62.3-v62.9
v65.2
v65.3
v65.40-v65.49
v65.5
v65.8
v65.9
v66.0-v66.9
v67.3
v67.4
v69.3
v71.01-v71.09
v72.0, v72.11
v72.12
v72.19, v72.2
v72.40-v72.41
*v72.42
v72.5
*other aftercare involving the use of plastic surgery
fitting and adjustment of prosthetic device and implant
fitting and adjustment of devices related to nervous system & special senses
fitting and adjustment of spectacles and contact lenses
fitting and adjustment of cardiac device
fitting and adjustment of orthodontic devices
fitting and adjustment of other intestinal appliance
fitting and adjustment of urinary devices
fitting and adjustment of orthopedic devices
fitting and adjustment of wheelchair
fitting and adjustment of other and unspecified device
other orthopedic aftercare
attention to artificial openings
care involving use of rehabilitation procedures
orthodontics
donors
family disruption
*family disruption due to family member on military deployment
*family disruption due to return of family member from military deployment
*family disruption due to divorce or legal separation
*family disruption due to parent-child estrangement
*family disruption due to child in welfare custody
*family disruption due to child in foster care or in care of non-parental family member
*other family disruption
other specified and unspecified family problems
*personal current military deployment
*personal history of return from military deployment
*other occupational circumstances or maladjustment
other psychosocial circumstances
person feigning illness
dietary surveillance and counseling
other counseling, not elsewhere classified
person with feared complaint in whom no diagnosis was made
other reasons for seeking consultation
unspecified reason for consultation
convalescence and palliative care
follow-up examination following psychotherapy
follow-up examination following treatment of healed fracture
problems related to lifestyle, gambling and betting
observation and evaluation for suspected conditions not found, mental
special investigations, examination of eyes and vision, ears and hearing, dental
encounter for hearing conservation and treatment
special investigations, pregnancy exam
special investigations, examination of eyes and vision, ears and hearing, dental
*pregnancy examination or test
radiological examination, not elsewhere classified
CMS Limitations
Blood Counts (con’t)
v72.6
v72.7
v72.9
v76.10-v76.19
v76.2
v76.44
v76.51
v77.1
v81.0-v81.2
laboratory examinations
diagnostic skin and sensitization tests
special investigation, unspecified
special screening for malignant neoplasms, breast
special screening for malignant neoplasms, cervix
special screening for malignant neoplasms, other sites, prostate
special screening for malignant neoplasms, intestine, colon
special screening for diabetes mellitus
special screening for cardiovascular diseases
LIMITATIONS: Testing of patients who are asymptomatic, or who do not have a condition that could be expected to
result in a hematological abnormality, is screening and is not a covered service.
In some circumstances it may be appropriate to perform only a hemoglobin or hematocrit to assess the oxygen carrying capacity of the blood. When the ordering provider requests only a hemoglobin or hematocrit, the remaining components of the CBC are not covered
CMS Limitations
Blood Glucose
LCD # 190.20, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 82947, CPT 82948, CPT 82962
ICD-9 Codes that SUPPORT medical necessity for Blood Glucose, quantitative (except reagent strip) (CPT 82947);
Blood Glucose, reagent strip (CPT 82948); Glucose, blood by glucose (CPT 82962):
011.00-011.96
038.0-038.9
*038.12
112.1
112.3
118
157.4
158.0
211.7
242.00-242.91
250.00-250.93
251.0-251.9
253.0-253.9
255.0
263.0-263.9
271.0-271.9
272.0-272.4
275.0
276.0-276.9
278.3
293.0
294.9
298.9
300.9
310.1
331.83
337.9
345.10-345.11
348.31
355.9
356.9
357.9
362.10
362.18
362.29
362.50-362.57
362.60-362.66
362.81-362.89
362.9
365.04
365.32
366.00-366.09
366.10-366.19
tuberculosis
septicemia
*methicillin resistant staphylococcus aureus septicemia
recurrent vaginal candidiasis
interdigital candidiasis
opportunistic mycoses
malignant neoplasm of islets of langerhans
malignant neoplasm of retroperitoneum
benign neoplasm of islets of langerhans
thyrotoxicosis
diabetes mellitus
disorders of pancreatic internal secretion
disorders of the pituitary gland
cushing syndrome
malnutrition
disorders of carbohydrate transport and metabolism
disorders of lipoid metabolism
hemochromatosis
disorders of fluid, electrolyte and acid-base balance
hypercarotinemia
delirium due to conditions classified elsewhere
unspecified persistent mental disorders due to conditions classified elsewhere
unspecified psychosis
unspecified nonpsychotic mental disorder
personality change due to conditions classified elsewhere
mild cognitive impairment, so stated
autonomic nervous system neuropathy
generalized convulsive epilepsy
metabolic encephalopathy
neuropathy, not otherwise specified
unspecified hereditary and idiopathic peripheral neuropathy
unspecified inflammatory and toxic neuropathy
background retinopathy
retinal vasculitis
nondiabetic proliferative retinopathy
degeneration of macular posterior pole
peripheral retinal degeneration
other retinal disorders
unspecified retinal disorders
borderline glaucoma, ocular hypertension
corticosteroid-induced glaucoma residual
presenile cataract
senile cataract
CMS Limitations
Blood Glucose (con’t)
367.1
368.8
373.00
377.24
377.9
378.50-378.55
379.45
410.00-410.92
414.00-414.19
414.07
425.9
440.23
440.24
440.9
458.0
462
466.0
480.0-486
490
491.0-491.9
527.7
528.00
528.09
535.50-535.51
536.8
571.8
572.0-572.8
574.50-574.51
575.0-575.12
576.1
577.0
577.1
577.8
590.00-590.9
595.9
596.4
596.53
599.0
607.84
608.89
616.10
626.0
626.4
628.9
648.00
648.03
648.04
acute myopia
other specified visual disturbance
blepharitis
pseudopapilledema
unspecified disorder of optic nerve and visual pathways
paralytic strabismus
argyll-robertson pupils
acute myocardial infarctions
coronary atherosclerosis and aneurysm of heart
coronary atherosclerosis, of bypass graft (artery) (vein) of transplanted heart
secondary cardiomyopathy, unspecified
arteriosclerosis of extremities with ulceration
arteriosclerosis of extremities with gangrene
arteriosclerosis, not otherwise specified
postural hypotension
acute pharyngitis
acute bronchitis
pneumonia
recurrent bronchitis, not specified as acute or chronic
chronic bronchitis
disturbance of salivary secretion (drymouth)
stomatitis and mucositis, unspecified
other stomatitis and mucositis (ulcerative)
gastritis
dyspepsia
other chronic nonalcoholic liver disease
liver abscess and sequelae of chronic liver disease
choledocholithiasis
cholecystitis
cholangitis
acute pancreatitis
chronic pancreatitis
pancreatic multiple calculi
infections of the kidney
recurrent cystitis
bladder atony
bladder paresis
urinary tract infection, recurrent
impotence of organic origin
other disorders male genital organs
vulvovaginitis
amenorrhea
irregular menses
infertility-female
diabetes mellitus complicating pregnancy, childbirth or the puerperium, unspecified as to episode of care or not applicable
diabetes mellitus complicating pregnancy, childbirth or the puerperium, antipartum condition or
complication
diabetes mellitus complicating pregnancy, childbirth or the puerperium, postpartum condition or
complication
CMS Limitations
Blood Glucose (con’t)
648.80
abnormal glucose tolerance complicating pregnancy, childbirth or the puerperium, unspecified as to episode of care or not applicable
648.83
abnormal glucose tolerance complicating pregnancy, childbirth or the
648.84
abnormal glucose tolerance complicating pregnancy, childbirth or the puerperium, postpartum
condition or complication
649.20
bariatric surgery status complicating pregnancy, childbirth, or the puerperium, unspecified as to
episode of care or not applicable
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
fetal problems affecting management of mother
656.63
large for-date of fetus
657.00-657.03 polyhydramnios
680.0-680.9
carbuncle and furuncle
686.00-686.9 infections of skin and subcutaneous tissue
698.0
pruritus ani
698.1
pruritus of genital organs
704.1
hirsutism
705.0
anhidrosis
707.00-707.9
chronic ulcer of skin
*707.20-707.25 *pressure ulcer stages
709.3
degenerative skin disorders
729.1
myalgia
730.07
acute osteomyelitis of ankle and foot
730.17
chronic osteomyelitis of ankle and foot
730.27
unspecified osteomyelitis of ankle and foot
780.01
coma
780.02
transient alteration of awareness
780.09
alteration of consciousness, other
780.2
syncope and collapse
780.31
febrile convulsions (simple), unspecified
780.32
complex febrile convulsions
780.39
seizures, not otherwise specified
780.4
dizziness and giddiness
780.71
malaise and fatigue
*780.72
*functional quadriplegia
780.79
other malaise and fatigue
780.8
generalized hyperhidrosis
781.0
abnormal involuntary movements
782.0
loss of vibratory sensation
783.1
abnormal weight gain
783.21
abnormal loss of weight
783.5
polydipsia
783.6
polyphagia
785.0
tachycardia
CMS Limitations
Blood Glucose (con’t)
785.4
786.01
786.09
786.50
787.6
787.91
788.41-788.43
789.1
790.21-790.29
790.6
791.0
791.5
796.1
799.4
v23.0-v23.9
*v23.85
*v23.86
v58.63-v58.65
v58.67
v58.69
v67.2
v67.51
v77.1**
gangrene
hyperventilation
dyspnea
chest pain, unspecified
fecal incontinence
diarrhea
frequency of urination and polyuria
hepatomegaly
abnormal glucose tolerance test
other abnormal blood chemistry (hyperglycemia)
proteinuria
glycosuria
abnormal reflex
cachexia
supervision of high risk pregnancy
*pregnancy resulting from assisted reproductive technology
*pregnancy with history of in utero procedure during previous pregnancy
long-term (current) drug use
long-term (current) use of insulin
long term current use of other medication
follow-up examination, following chemotherapy
follow-up examination with high-risk medication not elsewhere classified
special screening for endocrine, nutrition, metabolic, and immunity disorders
** covered for procedure code 82947 only
LIMITATIONS: In some patients presenting with nonspecific signs, symptoms, or diseases not normally associated
with disturbances in glucose metabolism, a single blood glucose test may be medically necessary. Repeat testing may
not be indicated unless abnormal results are found or unless there is a change in clinical condition. If repeat testing is
performed, a specific diagnosis code (e.g., diabetes) should be reported to support medical necessity. However, repeat
testing may be indicated where results are normal in patients with conditions where there is a continuing risk of glucose
metabolism abnormality (e.g., monitoring glucocorticoid therapy).
CMS Limitations
B-type Natriuretic Peptide (BNP) Testing
LCD # 26375, Effective date: 02/01/2009
CPT/HCPCS Codes: CPT 83880
ICD-9 Codes that SUPPORT medical necessity for B-type Natriuretic Peptide (BNP) Testing (CPT 83880):
402.01*
402.11*
402.91*
404.01*
404.03*
404.11*
404.13*
404.91*
404.93*
410.00
410.01
410.02
410.10
410.11
410.12
410.20
410.21
410.22
410.30
410.31
410.32
410.40
410.41
410.42
410.50
410.51
410.52
410.60
410.61
410.62
410.70
410.71
410.72
410.80
410.81
410.82
410.90
410.91
malignant hypertensive heart disease with heart failure
benign hypertensive heart disease with heart failure
unspecified hypertensive heart disease with heart failure
hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney
disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney
disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney
disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease
stage v or end stage renal disease
hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney
disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney
disease stage v or end stage renal disease
acute myocardial infarction of anterolateral wall episode of care unspecified
acute myocardial infarction of anterolateral wall initial episode of care
acute myocardial infarction of anterolateral wall subsequent episode of care
acute myocardial infarction of other anterior wall episode of care unspecified
acute myocardial infarction of other anterior wall initial episode of care
acute myocardial infarction of other anterior wall subsequent episode of care
acute myocardial infarction of inferolateral wall episode of care unspecified
acute myocardial infarction of inferolateral wall initial episode of care
acute myocardial infarction of inferolateral wall subsequent episode of care
acute myocardial infarction of inferoposterior wall episode of care unspecified
acute myocardial infarction of inferoposterior wall initial episode of care
acute myocardial infarction of inferoposterior wall subsequent episode of care
acute myocardial infarction of other inferior wall episode of care unspecified
acute myocardial infarction of other inferior wall initial episode of care
acute myocardial infarction of other inferior wall subsequent episode of care
acute myocardial infarction of other lateral wall episode of care unspecified
acute myocardial infarction of other lateral wall initial episode of care
acute myocardial infarction of other lateral wall subsequent episode of care
true posterior wall infarction episode of care unspecified
true posterior wall infarction initial episode of care
true posterior wall infarction subsequent episode of care
subendocardial infarction episode of care unspecified
subendocardial infarction initial episode of care
subendocardial infarction subsequent episode of care
acute myocardial infarction of other specified sites episode of care unspecified
acute myocardial infarction of other specified sites initial episode of care
acute myocardial infarction of other specified sites subsequent episode of care
acute myocardial infarction of unspecified site episode of care unspecified
acute myocardial infarction of unspecified site initial episode of care
CMS Limitations
B-type Natriuretic Peptide (BNP) Testing (con’t)
410.92
411.1
423.2
425.4
428.0*
428.1*
428.20*
428.21*
428.22*
428.23*
428.30*
428.31*
428.32*
428.33*
428.40*
428.41*
428.42*
428.43*
428.9*
786.00*
786.02*
786.05*
786.06*
786.07*
786.09*
acute myocardial infarction of unspecified site subsequent episode of care
intermediate coronary syndrome
constrictive pericarditis
other primary cardiomyopathies
congestive heart failure unspecified
left heart failure
unspecified systolic heart failure
acute systolic heart failure
chronic systolic heart failure
acute on chronic systolic heart failure
unspecified diastolic heart failure
acute diastolic heart failure
chronic diastolic heart failure
acute on chronic diastolic heart failure
unspecified combined systolic and diastolic heart failure
acute combined systolic and diastolic heart failure
chronic combined systolic and diastolic heart failure
acute on chronic combined systolic and diastolic heart failure
heart failure unspecified
respiratory abnormality unspecified
orthopnea
shortness of breath
tachypnea
wheezing
respiratory abnormality other
*Only ICD-9-CM codes with an asterisk (*) support medical necessity in non-hospital setting.
CMS Limitations
Carcinoembryonic Antigen
LCD # 190.26, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 82378
ICD-9 Codes that SUPPORT medical necessity for Carcinoembryonic antigen(CEA) (CPT 82378):
150.0-150.9
malignant neoplasm of the esophagus
151.0-151.9
malignant neoplasm of stomach
152.0-154.8
malignant neoplasm of small intestine, including duodenum, rectum, rectosigmoid junction and anus.
157.0-157.9
primary malignancy of pancreas
159.0
malignant neoplasm of intestinal tract, part unspecified
162.0-162.9
malignant neoplasm of trachea, bronchus, lung
174.0-174.9
malignant neoplasm of female breast
175.0-175.9
malignant neoplasm of male breast
183.0
malignant neoplasm of ovary
197.0
secondary malignant neoplasm of neoplasm of lung
197.4
secondary malignant neoplasm of small intestine
197.5
secondary malignant neoplasm of large intestine and rectum
*209.00-209.03*malignant carcinoid tumors of the small intestine
*209.10-209.17 *malignant carcinoid tumors of the appendix, large intestine and rectum
*209.20-209.27, *malignant carcinoid tumors of other and unspecified sites
209.29
230.3
carcinoma in situ of colon
230.4
carcinoma in situ of rectum
230.7
carcinoma in situ of other/unspecified parts of intestine
230.9
carcinoma in situ other and unspecified digestive organs
235.2
neoplasm of uncertain behavior of stomach, intestines, rectum
338.3
neoplasm related pain (acute) (chronic)
790.99
other nonspecific findings on examination of blood
795.81
elevated carcinoembryonic antigen [cea]
795.89
other abnormal tumor markers
v10.00
personal history of malignant neoplasm of gastro-intestinal tract, unspecified
v10.05
personal history of malignant neoplasm, large intestine
v10.06
personal history of malignant neoplasm, rectum, rectosigmoid junction, anus
v10.11
personal history of malignant neoplasm, bronchus, and lung
v10.3
personal history of malignant neoplasm, breast
v10.43
personal history of malignant neoplasm, ovary
v67.2
follow-up examination following chemotherapy
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. However, it may be proper to order the test more frequently in
certain situations, for example, 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.
CMS Limitations
Collagen Crosslinks, Any Method
LCD # 190.19, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 82523
ICD-9 Codes that SUPPORT medical necessity for Collagen cross links, any method (CPT 82523):
242.00-242.91 thyrotoxicosis
245.2
chronic lymphocytic thyroiditis (only if thyrotoxic)
246.9
unspecified disorder of thyroid
252.00-252.02, hyperparathyroidism
252.08
256.2
postablative ovarian failure
256.31-256.39 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
symptomatic menopausal or female climacteric state
627.4
symptomatic states associated with artificial menopause
627.8
other specified menopausal and postmenopausal disorders
627.9
unspecified menopausal & postmenopausal disorder
731.0
osteitis deformans without mention of bone tumor (paget’s disease of bone)
733.00-733.09 osteoporosis
733.10-733.19
pathological fracture
733.90
disorder of bone and cartilage, unspecified
805.8
fracture of vertebral column without mention of spiral cord injury, unspecified, closed
v58.65
long-term (current) use of steroids
v58.69
long-term (current) use of other medications
LIMITATIONS: Because of significant specimen to specimen collagen crosslink physiologic variability (15-20%), 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.
CMS Limitations
Diagnostic PAP Tests
LCD # L18030, Effective Date: 10/01/07
CPT/HCPCS Codes: CPT 88141, CPT 88142, CPT 88143, CPT 88147, CPT 88148, CPT 88150, CPT 88152, CPT 88153, CPT
88154, CPT 88164, CPT 88165, CPT 88166, CPT 88167, CPT 88174, CPT 88175
ICD-9 codes that SUPPORT medical necessity for cytopathology, cervical or vaginal (any reporting system), requiring
interpretation by physician (CPT 88141); cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision (CPT 88142); cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with
manual screening and rescreening under physician supervision (CPT 88143); cytopathology smears, cervical or vaginal;
screening by automated system under physician supervision (CPT 88147); cytopathology smears, cervical or vaginal;
screening by automated system with manual rescreening under physician supervision (CPT 88148); cytopathology,
slides, cervical or vaginal; manual screening under physician supervision (CPT 88150); cytopathology, slides, cervical
or vaginal; with manual screening and computer-assisted rescreening under physician supervision (CPT 88152); cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision (CPT 88153);
cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening using cell selection
and review under physician supervision (CPT 88154); cytopathology, slides, cervical or vaginal (the bethesda system);
manual screening under physician supervision (CPT 88164); cytopathology, slides, cervical or vaginal (the bethesda
system); with manual screening and rescreening under physician supervision (CPT 88165); cytopathology, slides, cervical or vaginal (the bethesda system); with manual screening and computer-assisted rescreening under physician
supervision (CPT 88166); cytopathology, slides, cervical or vaginal (the bethesda system); with manual screening and
computer-assisted rescreening using cell selection and review under physician supervision (CPT 88167); cytopathology,
cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening
by automated system, under physician supervision (CPT 88174); and cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and
manual rescreening or review, under physician supervision (CPT 88175):
016.70 - 016.76 tuberculosis of other female genital organs unspecified examination - tuberculosis of other female
genital organs tubercle bacilli not found by bacteriological or histological examination but tuberculosis
confirmed by other methods (inoculation of animals)
042
human immunodeficiency virus (hiv) disease
054.10 - 054.12 genital herpes unspecified - herpetic ulceration of vulva
078.10 - 078.19 viral warts unspecified - other specified viral warts
079.4
human papillomavirus in conditions classified elsewhere and of unspecified site
091.3
secondary syphilis of skin or mucous membranes
098.0
gonococcal infection (acute) of lower genitourinary tract
098.2
gonococcal infection chronic of lower genitourinary tract
099.53
other venereal diseases due to chlamydia trachomatis lower genitourinary sites
131.00
urogenital trichomoniasis unspecified
131.01
trichomonal vulvovaginitis
158.8
malignant neoplasm of specified parts of peritoneum
179 - 184.9 malignant neoplasm of uterus-part uns - malignant neoplasm of female genital organ site unspecified
195.3
malignant neoplasm of pelvis
197.6
secondary malignant neoplasm of retroperitoneum and peritoneum
198.6
secondary malignant neoplasm of ovary
198.82
secondary malignant neoplasm of genital organs
218.0 - 221.9 submucous leiomyoma of uterus - benign neoplasm of female genital organ site unspecified
233.1 - 233.39 carcinoma in situ of cervix uteri - carcinoma in situ, other female genital organ
236.0 - 236.3 neoplasm of uncertain behavior of uterus - neoplasm of uncertain behavior of other and unspecified
female genital organs
CMS Limitations
Diagnostic PAP Tests (con’t)
239.5
neoplasm of unspecified nature of other genitourinary organs
256.31
premature menopause
256.39
other ovarian failure
614.0 - 616.9 acute salpingitis and oophoritis - unspecified inflammatory disease of cervix vagina and vulva
617.0 - 617.4 endometriosis of uterus - endometriosis of rectovaginal septum and vagina
620.0 - 621.8 follicular cyst of ovary - other specified disorders of uterus not elsewhere classified
622.10 - 622.12 dysplasia of cervix, unspecified - moderate dysplasia of cervix
622.2 - 622.8 leukoplakia of cervix (uteri) - other specified noninflammatory disorders of cervix
623.0
dysplasia of vagina
623.1
leukoplakia of vagina
623.5
leukorrhea not specified as infective
623.7
polyp of vagina
623.8
other specified noninflammatory disorders of vagina
624.6
polyp of labia and vulva
624.8
other specified noninflammatory disorders of vulva and perineum
626.0 - 627.9 absence of menstruation - unspecified menopausal and postmenopausal disorder
654.80 - 654.84 congenital or acquired abnormality of vulva unspecified as to episode of care in pregnancy - congenital or acquired abnormality of vulva postpartum condition or complication
789.30 - 789.37 abdominal or pelvic swelling mass or lump unspecified site - abdominal or pelvic swelling mass or
lump generalized
789.39
abdominal or pelvic swelling mass or lump other specified site
795.00
abnormal glandular papanicolaou smear of cervix
795.01
papanicolaou smear of cervix with atypical squamous cells of undetermined significance (asc-us)
795.02
papanicolaou smear of cervix with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (asc-h)
795.03
papanicolaou smear of cervix with low grade squamous intraepithelial lesion (lgsil)
795.04
papanicolaou smear of cervix with high grade squamous intraepithelial lesion (hgsil)
795.05
cervical high risk human papillomavirus (hpv) dna test positive
795.06
papanicolaou smear of cervix with cytologic evidence of malignancy
795.08
nonspecific abnormal papanicolaou smear of cervix, unsatisfactory smear
795.09
other abnormal papanicolaou smear of cervix and cervical hpv
v01.6
contact with or exposure to venereal diseases
v02.7
carrier or suspected carrier of gonorrhea
v02.8
carrier or suspected carrier of other venereal diseases
v10.40 - v10.44 personal history of malignant neoplasm of unspecified female genital organ - personal history of malignant neoplasm of other female genital organs
v67.01
following surgery follow-up vaginal pap smear
v69.2
high-risk sexual behavior
CMS Limitations
Digoxin Therapeutic Drug Assay
LCD # 190.24, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 80162
ICD-9 Codes that SUPPORT medical necessity for Digoxin (Therapeutic Drug Assay) (CPT 80162):
242.00-242.91
243
244.0-244.9
245.0-245.9
275.2
275.40-275.49
*275.5
276.0
276.1
276.2
276.3
276.4
276.50-276.52
276.6
276.7
276.8
276.9
293.0
293.1
307.47
*339.3
368.16
368.8
368.9
397.9
398.0
398.91
402.01
402.11
402.91
403.00-403.91
404.00-404.93
410.00-410.92
411.0-411.89
413.0-413.9
422.0-422.99
425.0-425.9
426.0– 426.9
427.0-427.9
428.0-428.9
429.2
429.4
429.5
429.6
thyrotoxicosis with or without goiter
congenital hypothyroidism
acquired hypothyroidism
thyroiditis
disorders of magnesium metabolism
disorders of calcium metabolism
*hungry bone syndrome
hyperosmolality
hyposmolality
acidosis
alkalosis
mixed acid-base balance disorder
volume depletion
fluid overload
hyperpotassemia
hypopotassemia
electrolyte and fluid disorder (not elsewhere classified)
delirium due to conditions classified elsewhere
subacute delirium
other dysfunctions of sleep stages or arousal from sleep
*drug induced headache, not elsewhere classified
psychophysical visual disturbances
other specified visual disturbances
unspecified visual disturbances
rheumatic diseases of endocardium
rheumatic myocarditis
rheumatic heart failure
hypertensive heart disease, malignant with heart failure
hypertensive heart disease, benign with heart failure
hypertensive heart disease, unspecified with heart failure
hypertensive chronic kidney disease
hypertensive heart and chronic kidney disease
acute myocardial infarction
other acute & subacute forms of ischemic heart disease
angina pectoris
acute myocarditis
cardiomyopathy
conduction disorders
cardiac dysrhythmias
heart failure
cardiovascular disease, unspecified
heart disturbances postcardiac surgery
rupture chordae tendineae
rupture papillary muscle
CMS Limitations
Digoxin Therapeutic Drug Assay (con’t)
429.71
514
579.9
584.5-584.9
585.1-585.9
586
587
588.0
588.1
588.81
588.89
588.9
780.01
780.02
780.09
780.1
780.2
780.4
780.71
*780.72
780.79
783.0
784.0
787.01-787.03
787.91
794.31
799.2
972.0
972.1
995.20
995.21
995.27
995.29
*e942.1
v58.69
acquired cardiac septal defect
pulmonary congestion & hypostasis
unspecified intestinal malabsorption
acute renal failure
chronic kidney disease
renal failure, unspecified
renal sclerosis, unspecified
renal osteodystrophy
nephrogenic diabetes insipidus
secondary hyperparathyroidism (of renal origin)
other specified disorders resulting from impaired renal function
unspecified disorder resulting from impaired renal function
coma
transient alteration of awareness
other ill-defined general symptoms (drowsiness, semicoma, somnolence, stupor, unconsciousness)
hallucinations
syncope & collapse
dizziness and giddiness
malaise & fatigue
*functional quadriplegia
other malaise and fatigue
anorexia
headache
nausea & vomiting
diarrhea
abnormal electrocardiogram
nervousness
poisoning by cardiac rhythm regulators
poisoning by cardiotonic glycosides & drugs of similar action
unspecified adverse effect of unspecified drug, medicinal and biological substance
arthus phenomenon
other drug allergy
unspecified adverse effect of other drug, medicinal and biological substance
adverse effect of cardiotonic glycosides and drugs of similar action
encounter long term medication use (not elsewhere classified)
CMS Limitations
Erythrocyte Sedimentation Rates (ESR)
LCD # 25639, Effective date: 10/01/2008
CPT/HCPCS Codes: CPT 85651, CPT 85652
Effective Dec. 1, 2007, ANY of the following conditions must be met to SUPPORT medical necessity for ESR testing
when it is performed for the evaluation of any of the following conditions:
• Aiding in the diagnosis of temporal arteritis (giant cell arteritis) and polymyalgia rheumatica
• Monitoring disease activity in temporal arteritis and polymyalgia rheumatica for the principal indication of
adjusting the dosage of corticosteroids
• Monitoring patients with treated Hodgkin’s disease
• Monitoring patients with autoimmune diseases, inflammatory disorders caused by infection, or connective
tissue diseases
ICD-9 Codes that SUPPORT medical necessity for ESR – Sedimentation Rate, Erythrocyte, Non-Automated (CPT
85651), Sedimentation Rate, Erythrocyte, Automated (CPT 85652):
200.20
200.21
200.22
200.23
200.24
200.25
200.26
200.27
200.28
200.30
200.31
200.32
200.33
200.34
200.35
200.36
200.37
200.38
200.40
200.41
200.42
200.43
200.44
200.45
200.46
200.47
200.48
200.50
200.51
200.52
200.53
200.54
200.55
200.56
burkitt’s tumor or lymphoma unspecified site
burkitt’s tumor or lymphoma involving lymph nodes of head face and neck
burkitt’s tumor or lymphoma involving intrathoracic lymph nodes
burkitt’s tumor or lymphoma involving intra-abdominal lymph nodes
burkitt’s tumor or lymphoma involving lymph nodes of axilla and upper limb
burkitt’s tumor or lymphoma involving lymph nodes of inguinal region and lower limb
burkitt’s tumor or lymphoma involving intrapelvic lymph nodes
burkitt’s tumor or lymphoma involving spleen
burkitt’s tumor or lymphoma involving lymph nodes of multiple sites
marginal zone lymphoma, unspecified site, extranodal and solid organ sites
marginal zone lymphoma,lymph nodes of head, face, and neck
marginal zone lymphoma,intrathoracic lymph nodes
marginal zone lymphoma, intraabdominal lymph nodes
marginal zone lymphoma, lymph nodes of axilla and upper limb
marginal zone lymphoma, lymph nodes of inguinal region and lower limb
marginal zone lymphoma, intrapelvic lymph nodes
marginal zone lymphoma, spleen
marginal zone lymphoma, lymph nodes of multiple sites
mantle cell lymphoma, unspecified site, extranodal and solid organ sites
mantle cell lymphoma, lymph nodes of head, face, and neck
mantle cell lymphoma, intrathoracic lymph nodes
mantle cell lymphoma, intra-abdominal lymph nodes
mantle cell lymphoma, lymph nodes of axilla and upper limb
mantle cell lymphoma, lymph nodes of inguinal region and lower limb
mantle cell lymphoma, intrapelvic lymph nodes
mantle cell lymphoma, spleen
mantle cell lymphoma, lymph nodes of multiple sites
primary central nervous system lymphoma, unspecified site, extranodal and solid organ sites
primary central nervous system lymphoma, lymph nodes of head, face, and neck
primary central nervous system lymphoma, intrathoracic lymph nodes
primary central nervous system lymphoma, intra-abdominal lymph nodes
primary central nervous system lymphoma, lymph nodes of axilla and upper limb
primary central nervous system lymphoma, lymph nodes of inguinal region and lower limb
primary central nervous system lymphoma, intrapelvic lymph nodes
CMS Limitations
Erythrocyte Sedimentation Rates (ESR) (con’t)
200.57
200.58
200.60
200.61
200.62
200.63
200.64
200.65
200.66
200.67
200.68
200.70
200.71
200.72
200.73
200.74
200.75
200.76
200.77
200.78
200.80
200.81
primary central nervous system lymphoma, spleen
primary central nervous system lymphoma, lymph nodes of multiple sites
anaplastic large cell lymphoma, unspecified site, extranodal and solid organ sites
anaplastic large cell lymphoma, lymph nodes of head, face, and neck
anaplastic large cell lymphoma, intrathoracic lymph nodes
anaplastic large cell lymphoma, intra-abdominal lymph nodes
anaplastic large cell lymphoma, lymph nodes of axilla and upper limb
anaplastic large cell lymphoma, lymph nodes of inguinal region and lower limb
anaplastic large cell lymphoma, intrapelvic lymph nodes
anaplastic large cell lymphoma, spleen
anaplastic large cell lymphoma, lymph nodes of multiple sites
large cell lymphoma, unspecified site, extranodal and solid organ sites
large cell lymphoma, lymph nodes of head, face, and neck
large cell lymphoma, intrathoracic lymph nodes
large cell lymphoma, intra-abdominal lymph nodes
large cell lymphoma, lymph nodes of axilla and upper limb
large cell lymphoma, lymph nodes of inguinal region and lower limb
large cell lymphoma, intrapelvic lymph nodes
large cell lymphoma, spleen
large cell lymphoma, lymph nodes of multiple sites
other named variants of lymphosarcoma and reticulosarcoma unspecified site
other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of head face and
neck
200.82
other named variants of lymphosarcoma and reticulosarcoma involving intrathoracic lymph nodes
200.83
other named variants of lymphosarcoma and reticulosarcoma involving intra-abdominal lymph nodes
200.84
other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of axilla and up
per limb
200.85
other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of inguinal region and lower limb
200.86
other named variants of lymphosarcoma and reticulosarcoma involving intrapelvic lymph nodes
200.87
other named variants of lymphosarcoma and reticulosarcoma involving spleen
200.88
other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of multiple sites
201.00-201.08 hodgkin’s paragranuloma unspecified site-hodgkin’s paragranuloma involving lymph nodes of multiple sites
201.10-201.18
hodgkin’s granuloma unspecified site-hodgkin’s granuloma involving lymph nodes of multiple sites
201.20-201.28 hodgkin’s sarcoma unspecified site-hodgkin’s sarcoma involving lymph nodes of multiple sites
201.40-201.48 hodgkin’s disease lymphocytic-histiocytic predominance unspecified site-hodgkin’s disease lympho-
cytic-histiocytic predominance involving lymph nodes of multiple sites
201.50-201.58 hodgkin’s disease nodular sclerosis unspecified site-hodgkin’s disease nodular sclerosis involving lymph nodes of multiple sites
201.60-201.68 hodgkin’s disease mixed cellularity unspecified site-hodgkin’s disease mixed cellularity involving lymph nodes of multiple sites
201.70-201.78 hodgkin’s disease lymphocytic depletion unspecified site-hodgkin’s disease lymphocytic depletion involving lymph nodes of multiple sites
201.90-201.98 hodgkin’s disease unspecified type unspecified site-hodgkin’s disease unspecified type involving lymph nodes of multiple sites
202.00-202.08 nodular lymphoma unspecified site-nodular lymphoma involving lymph nodes of multiple sites
202.10-202.18 mycosis fungoides unspecified site-mycosis fungoides involving lymph nodes of multiple sites
202.20
sezary’s disease unspecified site
202.21
sezary’s disease involving lymph nodes of head face and neck
CMS Limitations
Erythrocyte Sedimentation Rates (ESR) (con’t)
202.22
202.23
202.24
202.25
202.26
202.27
202.28
202.30
202.31
202.32
202.33
202.34
202.35
202.36
202.37
202.38
202.40
202.41
202.42
202.43
202.44
202.45
202.46
202.47
202.48
202.50
202.51
202.52
202.53
202.54
202.55
202.56
202.57
202.58
202.60
202.61
202.62
202.63
202.64
202.65
202.66
202.67
202.68
202.70
202.71
202.72
202.73
202.74
202.75
202.76
sezary’s disease involving intrathoracic lymph nodes
sezary’s disease involving intra-abdominal lymph nodes
sezary’s disease involving lymph nodes of axilla and upper limb
sezary’s disease involving lymph nodes of inguinal region and lower limb
sezary’s disease involving intrapelvic lymph nodes
sezary’s disease involving spleen
sezary’s disease involving lymph nodes of multiple sites
malignant histiocytosis unspecified site
malignant histiocytosis involving lymph nodes of head face and neck
malignant histiocytosis involving intrathoracic lymph nodes
malignant histiocytosis involving intra-abdominal lymph nodes
malignant histiocytosis involving lymph nodes of axilla and upper limb
malignant histiocytosis involving lymph nodes of inguinal region and lower limb
malignant histiocytosis involving intrapelvic lymph nodes
malignant histiocytosis involving spleen
malignant histiocytosis involving lymph nodes of multiple sites
leukemic reticuloendotheliosis unspecified site
leukemic reticuloendotheliosis involving lymph nodes of head face and neck
leukemic reticuloendotheliosis involving intrathoracic lymph nodes
leukemic reticuloendotheliosis involving intra-abdominal lymph nodes
leukemic reticuloendotheliosis involving lymph nodes of axilla and upper arm
leukemic reticuloendotheliosis involving lymph nodes of inguinal region and lower limb
leukemic reticuloendotheliosis involving intrapelvic lymph nodes
leukemic reticuloendotheliosis involving spleen
leukemic reticuloendotheliosis involving lymph nodes of multiple sites
letterer-siwe disease unspecified site
letterer-siwe disease involving lymph nodes of head face and neck
letterer-siwe disease involving intrathoracic lymph nodes
letterer-siwe disease involving intra-abdominal lymph nodes
letterer-siwe disease involving lymph nodes of axilla and upper limb
letterer-siwe disease involving lymph nodes of inguinal region and lower limb
letterer-siwe disease involving intrapelvic lymph nodes
letterer-siwe disease involving spleen
letterer-siwe disease involving lymph nodes of multiple sites
malignant mast cell tumors unspecified site
malignant mast cell tumors involving lymph nodes of head face and neck
malignant mast cell tumors involving intrathoracic lymph nodes
malignant mast cell tumors involving intra-abdominal lymph nodes
malignant mast cell tumors involving lymph nodes of axilla and upper limb
malignant mast cell tumors involving lymph nodes of inguinal region and lower limb
malignant mast cell tumors involving intrapelvic lymph nodes
malignant mast cell tumors involving spleen
malignant mast cell tumors involving lymph nodes of multiple sites
peripheral t cell lymphoma, unspecified site, extranodal and solid organ sites
peripheral t cell lymphoma, lymph nodes of head, face, and neck
peripheral t cell lymphoma, intrathoracic lymph nodes
peripheral t cell lymphoma, intra-abdominal lymph nodes
peripheral t cell lymphoma, lymph nodes of axilla and upper limb
peripheral t cell lymphoma, lymph nodes of inguinal region and lower limb
peripheral t cell lymphoma, intrapelvic lymph nodes
CMS Limitations
Erythrocyte Sedimentation Rates (ESR) (con’t)
202.77
202.78
202.80
202.81
202.82
202.83
202.84
202.85
202.86
202.87
202.88
245.1
279.4
379.91
391.0
391.1
391.2
391.8
446.0
446.5
447.6
480.0
480.1
480.2
480.3
480.8
480.9
481
482.0-482.2
482.30-482.32
482.39
482.40
482.41*
482.42*
482.49
482.81-482.84
482.89
482.9
483.0
483.1
483.8
484.1
484.3
484.5-484.8
485
486
487.0
487.1
487.8
555.0-555.2
peripheral t cell lymphoma, spleen
peripheral t cell lymphoma, lymph nodes of multiple sites
other malignant lymphomas unspecified site
other malignant lymphomas involving lymph nodes of head face and neck
other malignant lymphomas involving intrathoracic lymph nodes
other malignant lymphomas involving intra-abdominal lymph nodes
other malignant lymphomas involving lymph nodes of axilla and upper limb
other malignant lymphomas involving lymph nodes of inguinal region and lower limb
other malignant lymphomas involving intrapelvic lymph nodes
other malignant lymphomas involving spleen
other malignant lymphomas involving lymph nodes of multiple sites
subacute thyroiditis
autoimmune disease not elsewhere classified
pain in or around eye
acute rheumatic pericarditis
acute rheumatic endocarditis
acute rheumatic myocarditis
other acute rheumatic heart disease
polyarteritis nodosa
giant cell arteritis
arteritis unspecified
pneumonia due to adenovirus
pneumonia due to respiratory syncytial virus
pneumonia due to parainfluenza virus
pneumonia due to sars-associated coronavirus
pneumonia due to other virus not elsewhere classified
viral pneumonia unspecified
pneumococcal pneumonia [streptococcus pneumoniae pneumonia]
pneumonia due to klebsiella pneumoniae-pneumonia due to hemophilus influenzae (h. influenzae)
pneumonia due to streptococcus unspecified-pneumonia due to streptococcus group b
pneumonia due to other streptococcus
pneumonia due to staphylococcus unspecified
methicillin susceptible pneumonia due to staphylococcus aureus
methicillin resistant pneumonia due to staphylococcus aureus
other staphylococcus pneumonia
pneumonia due to anaerobes-pneumonia due to legionnaires’ disease
pneumonia due to other specified bacteria
bacterial pneumonia unspecified
pneumonia due to mycoplasma pneumoniae
pneumonia due to chlamydia
pneumonia due to other specified organism
pneumonia in cytomegalic inclusion disease
pneumonia in whooping cough
pneumonia in anthrax-pneumonia in other infectious diseases classified elsewhere
bronchopneumonia organism unspecified
pneumonia organism unspecified
influenza with pneumonia
influenza with other respiratory manifestations
influenza with other manifestations
regional enteritis of small intestine-regional enteritis of small intestine with large intestine
CMS Limitations
Erythrocyte Sedimentation Rates (ESR) (con’t)
555.9
556.0-556.6
556.8
556.9
580.0
580.4
580.81
580.89
580.9
581.0-581.3
581.81
581.89
581.9
582.0-582.2
582.4
582.81
582.89
582.9
583.0-583.2
583.4
583.6
583.7
583.81
583.89
583.9
696.0
710.0
710.1
710.2
710.3
710.4
710.8
710.9
714.0-714.2
714.30-714.33
714.81
714.89
714.9
719.40
719.41
719.42
719.43
regional enteritis of unspecified site
ulcerative (chronic) enterocolitis-universal ulcerative (chronic) colitis
other ulcerative colitis
ulcerative colitis unspecified
acute glomerulonephritis with lesion of proliferative glomerulonephritis
acute glomerulonephritis with lesion of rapidly progressive glomerulonephritis
acute glomerulonephritis in diseases classified elsewhere
acute glomerulonephritis with other specified pathological lesion in kidney
acute glomerulonephritis with unspecified pathological lesion in kidney
nephrotic syndrome with lesion of proliferative glomerulonephritis-nephrotic syndrome with lesion of minimal change glomerulonephritis
nephrotic syndrome in diseases classified elsewhere
other nephrotic syndrome with specified pathological lesion in kidney
nephrotic syndrome with unspecified pathological lesion in kidney
chronic glomerulonephritis with lesion of proliferative glomerulonephritis-chronic glomerulonephritis with lesion of membranoproliferative glomerulonephritis
chronic glomerulonephritis with lesion of rapidly progressive glomerulonephritis
chronic glomerulonephritis in diseases classified elsewhere
other chronic glomerulonephritis with specified pathological lesion in kidney
chronic glomerulonephritis with unspecified pathological lesion in kidney
nephritis and nephropathy not specified as acute or chronic with lesion of proliferative glomerulone-
phritis-nephritis and nephropathy not specified as acute or chronic with lesion of membranoprolifera-
tive glomerulonephritis
nephritis and nephropathy not specified as acute or chronic with lesion of rapidly progressive glomer
ulonephritis
nephritis and nephropathy not specified as acute or chronic with lesion of renal cortical necrosis
nephritis and nephropathy not specified as acute or chronic with lesion of renal medullary necrosis
nephritis and nephropathy not specified as acute or chronic in diseases classified elsewhere
other nephritis and nephropathy not specified as acute or chronic with specified pathological lesion in kidney
nephritis and nephropathy not specified as acute or chronic with unspecified pathological lesion in kidney
psoriatic arthropathy
systemic lupus erythematosus
systemic sclerosis
sicca syndrome
dermatomyositis
polymyositis
other specified diffuse diseases of connective tissue
unspecified diffuse connective tissue disease
rheumatoid arthritis-other rheumatoid arthritis with visceral or systemic involvement
chronic or unspecified polyarticular juvenile rheumatoid arthritis-monoarticular juvenile rheumatoid arthritis
rheumatoid lung
other specified inflammatory polyarthropathies
unspecified inflammatory polyarthropathy
pain in joint site unspecified
pain in joint involving shoulder region
pain in joint involving upper arm
pain in joint involving forearm
CMS Limitations
Erythrocyte Sedimentation Rates (ESR) (con’t)
719.44
719.45
719.46
719.47
720.0
725
729.1
730.00-730.09
730.10-730.19
730.80-730.89
784.0
v10.72
pain in joint involving hand
pain in joint involving pelvic region and thigh
pain in joint involving lower leg
pain in joint involving ankle and foot
ankylosing spondylitis
polymyalgia rheumatica
myalgia and myositis unspecified
acute osteomyelitis site unspecified, acute osteomyelitis involving multiple sites
chronic osteomyelitis site unspecified-chronic osteomyelitis involving multiple sites
other infections involving bone in diseases classified elsewhere site unspecified-other infections
involving bone of multiple sites in diseases classified elsewhere
headache
personal history of hodgkin’s disease
CMS Limitations
Fecal Occult Blood Test
LCD # 190.34, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 82272, HCPCS G0394
ICD-9 Codes that SUPPORT medical necessity for Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces,
1-3 simultaneous determinations, performed for other than colorectal neoplasm screening (CPT 82272); Blood occult
test (e.g., guaiac), feces, for single determination for colorectal neoplasm (HCPCS G0394):
003.0
003.1
004.0-004.9
005.0-005.4, 005.81, 005.89,
005.9
006.0-006.9
007.0-007.9
008.41-008.49
009.0-009.3
014.00-014.86
040.2
095.2
095.3
098.0
098.7
098.84
123.0-123.9
124
127.0-127.9
139.8
150.0-157.9
159.0-159.9
176.3
197.4-197.5
197.8
286.0-286.9
287.0-287.9
338.3
448.0
455.0-455.8
456.0-456.21
530.10-530-12
*530.13
530.19, 530.20-
530.21, 530.3530.7, 530.81530.86, 530.87,
530.89, 530.9
531.00-535.61
536.2
salmonella gastroenteritis
salmonella septicemia
shigellosis
other food poisoning (bacterial)
amebiasis
other protozoal intestinal diseases
intestinal infections due to other specified bacteria
ill-defined intestinal infections
tuberculosis of intestines, peritoneum, and mesenteric glands
whipple’s disease
syphilitic peritonitis
syphilis of liver
gonococcal infection, acute, lower genitourinary tract
gonococcal infection anus and rectum
gonococcal endocaritis
other cestode infection
trichinosis
other intestinal helminthiases
late effects of other and unspecified infectious and parasitic diseases
malignant neoplasm of digestive organisms
malignant neoplasm of other and ill-defined sites within the digestive organs and peritoneum
kaposi’s sarcoma, gastrointestinal sites
secondary malignant neoplasm of intestines
secondary malignant neoplasm of other digestive organs and spleen
coagulation defects
purpura and other hemorrhagic conditions
neoplasm related pain (acute) (chronic)
hereditary hemorrhagic telangiectasia
hemorrhoids
esophageal varices with or without mention of bleeding
diseases of the esophasus, stomach and duodenum
*eosinophilic esophagitis
diseases of the esophagus, stomach, and duodenum
gastric ulcer; duodenal ulcer; peptic ulcer, site unspecified; gastrojejunal ulcer; and gastritis and
duodenitis
persistent vomiting
CMS Limitations
Fecal Occult Blood Test (con’t)
536.8-536.9
dyspepsia and other specified and unspecified functional disorders of the stomach
537.0-537.4
other disorders of stomach and duodenum
537.82-537.83 angiodysplasia of stomach and duodenum
537.84
dieulafoy lesion (hemorrhagic) of stomach and duodenum
537.89
other specified disorders of stomach and duodenum
555.0-558.3
non-infectious enteritis and colitis
*558.41
*eosinophilis gastroenteritis
*558.42
*eosinophilic colitis
199.0
disseminated malignant neoplasm
204.00-204.91 lymphoid leukemia
205.00-208.91 leukemia
*209.00-209.03*malignant carcinoid tumors of the small intestine
*209.10-209.17 *malignant carcinoid tumors of the appendix, large intestine and rectum
*209.40-209.43 *benign carcinoid tumors of the small intestine
*209.50-209.57 *benign carcinoid tumors of the appendix, large intestine and rectum
211.0-211.9
benign neoplasm of other parts of digestive system
228.04
hemangioma of intra-abdominal structures
230.2-230.9
carcinoma in situ of 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
neoplasm of unspecified nature, digestive system
280.0-280.9
iron deficiency anemias
284.2
myelophthisis
285.0-285.9
other and unspecified anemias
558.9
non-infectious enteritis and colitis
560.0-560.39 intestinal obstruction/impaction without mention of hernia
562.10-562.13 diverticulosis/diverticulitis of colon
564.00-564.9 functional digestive disorders, not elsewhere classified
565.0-565.1
anal fissure and fistula
569.0
anal and rectal polyp
569.1
rectal prolapse
569.3
hemorrhage of rectum and anus
569.41-569.42 anal sphincter tear (healed) (old)
*569.44
*dysplasia of anus
569.49
anal sphincter tear (healed) (old)
569.82-569.83 ulceration and perforation of intestine
569.84-569.85 angiodysplasia of intestine with or without mention of hemorrhage
569.86
dieulafoy lesion (hemorrhagic) of intestine
571.0-571.41
chronic liver disease and cirrhosis
*571.42
*autoimmune hepatitis
571.49
chronic liver disease and cirrhosis
577.0-577.9
diseases of the pancreas
578.0-578.9
gastrointestinal hemorrhage
579.0
celiac disease
579.8
other specified intestinal malabsorption
596.1
intestinovesical fistula
617.5
endometriosis of intestine
780.71
chronic fatigue syndrome
*780.72
*functional quadriplegia
780.79
other malaise and fatigue
CMS Limitations
Fecal Occult Blood Test (con’t)
783.0
783.21
787.01-787.03
787.1
787.20
787.21
787.22
787.23
787.24
787.29
787.7
787.91
787.99
789.00-789.09
789.30-789.39
789.40-789.49
789.51
789.59
789.60-789.69
790.92
792.1
793.6
anorexia
abnormal loss of weight
nausea and vomiting
heartburn
dysphagia, unspecified
dysphagia, oral phase
dysphagia, oropharyngeal phase
dysphagia, pharyngeal phase
dysphagia, pharyngo-esophageal phase
other dysphagia
abnormal feces
diarrhea
other symptoms involving digestive system
abdominal pain
abdominal or pelvic swelling, mass, or lump
abdominal rigidity
malignant ascites
other ascites
abdominal tenderness
abnormal coagulation profile
nonspecific abnormal findings in stool contents
nonspecific abnormal findings on radiological and other examination, abdominal area, including retroperitoneum
794.8
nonspecific abnormal results of function studies, liver
863.0-863.90 injury to gastrointestinal tract
863.91-863.95, injury to gastrointestinal tract
863.99
864.00-864.09 injury to liver without mention of open wound into cavity
864.11-864.19
injury to liver with open wound into cavity
866.00-866.03 injury to kidney without mention of open wound into cavity
866.10-866.13 injury to kidney with open wound into cavity
902.0 -902.9
injury to blood vessels of abdomen and pelvis
926.11-926.19
crushing injury of trunk, other specified sites
926.8
crushing injury of trunk, multiple sites
926.9
crushing injury of trunk, unspecified site
964.2
poisoning by agents primarily affecting blood constituents, anticoagulants
995.20
unspecified adverse effect of unspecified drug, medicinal and biological substance
v10.00-v10.09 personal history of malignant neoplasm, gastrointestinal tract
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-v58.65 long-term (current) drug use
v58.66
long-term (current) use of aspirin
v58.69
long term (current) use of other medications
v67.51
following treatment with high risk medication, not elsewhere specified
LIMITATIONS
• The FOBT is reported once for the testing of up to three separate specimens (comprising either one or two
tests per specimen).
CMS Limitations
Fecal Occult Blood Test (con’t)
•
•
In patients who are taking non-steroidal anti-inflammatory drugs and have a history of gastrointestinal
bleeding but no other signs, symptoms, or complaints associated with gastrointestinal blood loss, testing for
occult blood may generally be appropriate no more than once every three months.
When testing is done for the purpose of screening for colorectal cancer in the absence of signs, symptoms,
conditions, or complaints associated with gastrointestinal blood loss, report the HCPCS code for colorectal
cancer screening; fecal-occult blood test, 1-3 simultaneous determinations should be used.
CMS Limitations
Flow Cytometry
LCD # L27386, Effective Date: 03/01/2009
Includes Hematocrit, Platelet Count, Frustosamine and Glycated Hemoglobin/Glycated Protein
CPT/HCPCS Codes: CPT 86355, CPT 86356, CPT 86357, CPT 86359, CPT 86360, CPT 86361, CPT 86367, CPT 88182,
CPT 88184, CPT 88185, CPT 88187, CPT 88188, CPT 88189
ICD-9 codes that SUPPORT medical necessity for b cells, total count (CPT 86355); mononuclear cell antigen, quantitative (eg, flow cytometry), not otherwise specified, each antigen (CPT 86356); natural killer (nk) cells, total count (CPT
86357); t cells; total count (CPT 86359); t cells; absolute cd4 and cd8 count, including ratio (CPT 86360); t cells; absolute cd4 count (CPT 86361); stem cells (ie, cd34), total count (CPT 86367); flow cytometry, cell cycle or dna analysis
(CPT 88182); flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker (CPT
88184); flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker
(list separately in addition to code for first marker) (CPT 88185); flow cytometry, interpretation; 2 to 8 markers (CPT
88187); flow cytometry, interpretation; 9 to 15 markers (CPT 88188); and flow cytometry, interpretation; 16 or more
markers (CPT 88189):
042
079.51
079.52
079.53
142.0
142.1
147.0 - 147.9 150.0
150.3
151.9
152.9
153.0
153.1
153.2
153.3
153.4
153.5
153.6
153.7
153.8
153.9
154.0
154.1
154.2
154.3
154.8
155.2
157.9
158.8
159.1
160.0
160.1
160.2
human immunodeficiency virus (hiv) disease
human t-cell lymphotrophic virus type i [htlv-i]
human t-cell lymphotrophic virus type ii [htlv-ii]
human immunodeficiency virus type 2 [hiv-2]
malignant neoplasm of parotid gland
malignant neoplasm of submandibular gland
malignant neoplasm of superior wall of nasopharynx - malignant neoplasm of nasopharynx unspecified site
malignant neoplasm of cervical esophagus
malignant neoplasm of upper third of esophagus
malignant neoplasm of stomach unspecified site
malignant neoplasm of small intestine unspecified site
malignant neoplasm of hepatic flexure
malignant neoplasm of transverse colon
malignant neoplasm of descending colon
malignant neoplasm of sigmoid colon
malignant neoplasm of cecum
malignant neoplasm of appendix vermiformis
malignant neoplasm of ascending colon
malignant neoplasm of splenic flexure
malignant neoplasm of other specified sites of large intestine
malignant neoplasm of colon unspecified site
malignant neoplasm of rectosigmoid junction
malignant neoplasm of rectum
malignant neoplasm of anal canal
malignant neoplasm of anus unspecified site
malignant neoplasm of other sites of rectum rectosigmoid junction and anus
malignant neoplasm of liver not specified as primary or secondary
malignant neoplasm of pancreas part unspecified
malignant neoplasm of specified parts of peritoneum
malignant neoplasm of spleen not elsewhere classified
malignant neoplasm of nasal cavities
malignant neoplasm of auditory tube middle ear and mastoid air cells
malignant neoplasm of maxillary sinus
CMS Limitations
Flow Cytometry (con’t)
160.3
160.4
160.5
160.8
160.9
161.0
161.1
161.2
161.3
161.8
161.9
162.0
162.2
162.9
163.9
164.2 - 164.9 170.0
170.1
170.9
171.0
171.3
171.4
172.0
172.1
172.2
172.3
172.4
173.0
173.4
173.5
173.7
173.8
174.0
174.1
174.2
174.3
174.4
174.5
174.6
174.8
174.9
175.0
175.9
179
182.0
182.1
182.8
183.0
183.2
183.3
malignant neoplasm of ethmoidal sinus
malignant neoplasm of frontal sinus
malignant neoplasm of sphenoidal sinus
malignant neoplasm of other accessory sinuses
malignant neoplasm of accessory sinus unspecified
malignant neoplasm of glottis
malignant neoplasm of supraglottis
malignant neoplasm of subglottis
malignant neoplasm of laryngeal cartilages
malignant neoplasm of other specified sites of larynx
malignant neoplasm of larynx unspecified
malignant neoplasm of trachea
malignant neoplasm of main bronchus
malignant neoplasm of bronchus and lung unspecified
malignant neoplasm of pleura unspecified
malignant neoplasm of anterior mediastinum - malignant neoplasm of mediastinum part unspecified
malignant neoplasm of bones of skull and face except mandible
malignant neoplasm of mandible
malignant neoplasm of bone and articular cartilage site unspecified
malignant neoplasm of connective and other soft tissue of head face and neck
malignant neoplasm of connective and other soft tissue of lower limb including hip
malignant neoplasm of connective and other soft tissue of thorax
malignant melanoma of skin of lip
malignant melanoma of skin of eyelid including canthus
malignant melanoma of skin of ear and external auditory canal
malignant melanoma of skin of other and unspecified parts of face
malignant melanoma of skin of scalp and neck
other malignant neoplasm of skin of lip
other malignant neoplasm of scalp and skin of neck
other malignant neoplasm of skin of trunk except scrotum
other malignant neoplasm of skin of lower limb including hip
other malignant neoplasm of other specified sites of skin
malignant neoplasm of nipple and areola of female breast
malignant neoplasm of central portion of female breast
malignant neoplasm of upper-inner quadrant of female breast
malignant neoplasm of lower-inner quadrant of female breast
malignant neoplasm of upper-outer quadrant of female breast
malignant neoplasm of lower-outer quadrant of female breast
malignant neoplasm of axillary tail of female breast
malignant neoplasm of other specified sites of female breast
malignant neoplasm of breast (female) unspecified site
malignant neoplasm of nipple and areola of male breast
malignant neoplasm of other and unspecified sites of male breast
malignant neoplasm of uterus-part uns
malignant neoplasm of corpus uteri except isthmus
malignant neoplasm of isthmus
malignant neoplasm of other specified sites of body of uterus
malignant neoplasm of ovary
malignant neoplasm of fallopian tube
malignant neoplasm of broad ligament of uterus
CMS Limitations
Flow Cytometry (con’t)
183.4
183.5
183.8
185
188.0
188.1
188.2
188.3
188.4
188.5
188.6
188.7
188.8
188.9
189.0 - 189.8 190.0
190.1
190.2
190.3
190.4
190.5
190.6
190.7
190.8
191.0
191.1
191.2
191.3
191.4
191.5
191.6
191.7
191.8
192.0
192.1
193
194.0
194.1
194.3
194.4
194.5
195.0
195.5
196.0
197.1
197.2
197.6
197.8
198.3
malignant neoplasm of parametrium
malignant neoplasm of round ligament of uterus
malignant neoplasm of other specified sites of uterine adnexa
malignant neoplasm of prostate
malignant neoplasm of trigone of urinary bladder
malignant neoplasm of dome of urinary bladder
malignant neoplasm of lateral wall of urinary bladder
malignant neoplasm of anterior wall of urinary bladder
malignant neoplasm of posterior wall of urinary bladder
malignant neoplasm of bladder neck
malignant neoplasm of ureteric orifice
malignant neoplasm of urachus
malignant neoplasm of other specified sites of bladder
malignant neoplasm of bladder part unspecified
malignant neoplasm of kidney except pelvis - malignant neoplasm of other specified sites of urinary
organs
malignant neoplasm of eyeball except conjunctiva cornea retina and choroid
malignant neoplasm of orbit
malignant neoplasm of lacrimal gland
malignant neoplasm of conjunctiva
malignant neoplasm of cornea
malignant neoplasm of retina
malignant neoplasm of choroid
malignant neoplasm of lacrimal duct
malignant neoplasm of other specified sites of eye
malignant neoplasm of cerebrum except lobes and ventricles
malignant neoplasm of frontal lobe
malignant neoplasm of temporal lobe
malignant neoplasm of parietal lobe
malignant neoplasm of occipital lobe
malignant neoplasm of ventricles
malignant neoplasm of cerebellum nos
malignant neoplasm of brain stem
malignant neoplasm of other parts of brain
malignant neoplasm of cranial nerves
malignant neoplasm of cerebral meninges
malignant neoplasm of thyroid gland
malignant neoplasm of pineal gland
malignant neoplasm of parathyroid gland
malignant neoplasm of pituitary gland and craniopharyngeal duct
malignant neoplasm of pineal gland
malignant neoplasm of carotid body
malignant neoplasm of head face and neck
malignant neoplasm of lower limb
secondary and unspecified malignant neoplasm of lymph nodes of head face and neck
secondary malignant neoplasm of mediastinum
secondary malignant neoplasm of pleura
secondary malignant neoplasm of retroperitoneum and peritoneum
secondary malignant neoplasm of other digestive organs and spleen
secondary malignant neoplasm of brain and spinal cord
CMS Limitations
Flow Cytometry (con’t)
198.81
secondary malignant neoplasm of breast
198.82
secondary malignant neoplasm of genital organs
199.1
other malignant neoplasm of unspecified site
199.2
malignant neoplasm associated with transplant organ
200.00-200.08 reticulosarcoma unspecified site-reticulosarcoma involving lymph nodes of multiple sites
200.10-200.18 lymphosarcoma unspecified site-lymphosarcoma involving lymph nodes of multiple sites
200.20-200.28 burkitt’s tumor or lymphoma unspecified site-burkitt’s tumor or lymphoma involving lymph nodes of
multiple sites
200.30-200.38 marginal zone lymphoma, unspecified site, extranodal and solid organ sites-marginal zone lymphoma,
lymph nodes of multiple sites
200.40-200.48 mantle cell lymphoma, unspecified site, extranodal and solid organ sites-mantle cell lymphoma, lymph
nodes of multiple sites
200.50-200.58 primary central nervous system lymphoma, unspecified site, extranodal and solid organ sites-primary
central nervous system lymphoma, lymph nodes of multiple sites
200.60-200.68 anaplastic large cell lymphoma, unspecified site, extranodal and solid organ sites-anaplastic large cell
lymphoma, lymph nodes of multiple sites
200.70-200.78 large cell lymphoma, unspecified site, extranodal and solid organ sites-large cell lymphoma, lymph
nodes of multiple sites
200.80-200.88 other named variants of lymphosarcoma and reticulosarcoma unspecified site-other named variants of
lymphosarcoma and reticulosarcoma involving lymph nodes of multiple sites
201.00-201.08 hodgkin’s paragranuloma unspecified site-hodgkin’s paragranuloma involving lymph nodes of multiple
sites
201.10-201.18 hodgkin’s granuloma unspecified site-hodgkin’s granuloma involving lymph nodes of multiple sites
201.20-201.28 hodgkin’s sarcoma unspecified site-hodgkin’s sarcoma involving lymph nodes of multiple sites
201.40-201.48 hodgkin’s disease lymphocytic-histiocytic predominance unspecified site-hodgkin’s disease lymphocytic-histiocytic predominance involving lymph nodes of multiple sites
201.50-201.58 hodgkin’s disease nodular sclerosis unspecified site-hodgkin’s disease nodular sclerosis involving
lymph nodes of multiple sites
201.60-201.68 hodgkin’s disease mixed cellularity unspecified site-hodgkin’s disease mixed cellularity involving lymph
nodes of multiple sites
201.70-201.78 hodgkin’s disease lymphocytic depletion unspecified site-hodgkin’s disease lymphocytic depletion
involving lymph nodes of multiple sites
201.90-201.98 hodgkin’s disease unspecified type unspecified site-hodgkin’s disease unspecified type involving
lymph nodes of multiple sites
202.00-202.08 nodular lymphoma unspecified site-nodular lymphoma involving lymph nodes of multiple sites
202.10-202.18 mycosis fungoides unspecified site-mycosis fungoides involving lymph nodes of multiple sites
202.20-202.28 sezary’s disease unspecified site-sezary’s disease involving lymph nodes of multiple sites
202.30-202.38 malignant histiocytosis unspecified site-malignant histiocytosis involving lymph nodes of multiple sites
202.40-202.48 leukemic reticuloendotheliosis unspecified site-leukemic reticuloendotheliosis involving lymph nodes
of multiple sites
202.50-202.58 letterer-siwe disease unspecified site-letterer-siwe disease involving lymph nodes of multiple sites
202.60-202.68 malignant mast cell tumors unspecified site-malignant mast cell tumors involving lymph nodes of multiple sites
202.70-202.78 peripheral t cell lymphoma, unspecified site, extranodal and solid organ sites-peripheral t cell lymphoma, lymph nodes of multiple sites
202.80-202.88 other malignant lymphomas unspecified site-other malignant lymphomas involving lymph nodes of
multiple sites
202.90-202.98 other and unspecified malignant neoplasms of lymphoid and histiocytic tissue unspecified site-other
and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes of multiple sites
CMS Limitations
Flow Cytometry (con’t)
203.00-203.02 multiple myeloma, without mention of having achieved remission-multiple myeloma, in relapse
203.10-203.12 plasma cell leukemia, without mention of having achieved remission-plasma cell leukemia, in relapse
203.80 - 203.82 other immunoproliferative neoplasms, without mention of having achieved remission - other immunoproliferative neoplasms, in relapse
204.00-204.02 acute lymphoid leukemia, without mention of having achieved remission-acute lymphoid leukemia, in
relapse
204.10-204.12 chronic lymphoid leukemia, without mention of having achieved remission-chronic lymphoid leukemia,
in relapse
204.20-204.22 subacute lymphoid leukemia, without mention of having achieved remission-subacute lymphoid leukemia, in relapse
204.80-204.82 other lymphoid leukemia, without mention of having achieved remission-other lymphoid leukemia, in
relapse
204.90-204.92 unspecified lymphoid leukemia, without mention of having achieved remission-unspecified lymphoid
leukemia, in relapse
205.00-205.02 acute myeloid leukemia, without mention of having achieved remission-acute myeloid leukemia, in
relapse
205.10-205.12 chronic myeloid leukemia, without mention of having achieved remission-chronic myeloid leukemia, in
relapse
205.20-205.22 subacute myeloid leukemia, without mention of having achieved remission-subacute myeloid leukemia,
in relapse
205.30-205.32 myeloid sarcoma, without mention of having achieved remission-myeloid sarcoma, in relapse
205.80-205.82 other myeloid leukemia, without mention of having achieved remission-other myeloid leukemia, in
relapse
205.90-205.92 unspecified myeloid leukemia, without mention of having achieved remission-unspecified myeloid leukemia, in relapse
206.00-206.02 acute monocytic leukemia, without mention of having achieved remission-acute monocytic leukemia,
in relapse
206.10-206.12 chronic monocytic leukemia, without mention of having achieved remission-chronic monocytic leukemia, in relapse
206.20-206.22 subacute monocytic leukemia, without mention of having achieved remission-subacute monocytic
leukemia, in relapse
206.80-206.82 other monocytic leukemia, without mention of having achieved remission-other monocytic leukemia,
in relapse
206.90-206.92 unspecified monocytic leukemia, without mention of having achieved remission-unspecified monocytic leukemia, in relapse
207.00-207.02 acute erythremia and erythroleukemia, without mention of having achieved remission-acute erythremia and erythroleukemia, in relapse
207.10-207.12 chronic erythremia, without mention of having achieved remission-chronic erythremia, in relapse
207.20-207.22 megakaryocytic leukemia, without mention of having achieved remission-megakaryocytic leukemia, in
relapse
207.80-207.82 other specified leukemia, without mention of having achieved remission-other specified leukemia, in
relapse
208.00-208.02 acute leukemia of unspecified cell type, without mention of having achieved remission-acute leukemia
of unspecified cell type, in relapse
208.10-208.12 chronic leukemia of unspecified cell type, without mention of having achieved remission-chronic leukemia of unspecified cell type, in relapse
208.20-208.22 subacute leukemia of unspecified cell type, without mention of having achieved remission-subacute
leukemia of unspecified cell type, in relapse
208.80-208.82 other leukemia of unspecified cell type, without mention of having achieved remission-other leukemia
of unspecified cell type, in relapse
CMS Limitations
Flow Cytometry (con’t)
208.90-208.92 210.0
210.1
210.2
210.3
210.4
210.5
210.6
210.7
210.8
211.3
212.0
212.1
212.2
212.3
213.0
213.1
215.0
216.0
216.1
216.2
216.3
216.4
224.0
224.1
224.2
224.3
224.4
224.5
224.6
224.7
224.8
225.0
225.1
225.2
226
227.0
227.1
227.3
227.4
227.5
229.0
231.0
231.1
232.0
232.1
232.2
232.3
233.2
235.0
unspecified leukemia, without mention of having achieved remission-unspecified leukemia, in relapse
benign neoplasm of lip
benign neoplasm of tongue
benign neoplasm of major salivary glands
benign neoplasm of floor of mouth
benign neoplasm of other and unspecified parts of mouth
benign neoplasm of tonsil
benign neoplasm of other parts of oropharynx
benign neoplasm of nasopharynx
benign neoplasm of hypopharynx
benign neoplasm of colon
benign neoplasm of nasal cavities middle ear and accessory sinuses
benign neoplasm of larynx
benign neoplasm of trachea
benign neoplasm of bronchus and lung
benign neoplasm of bones of skull and face
benign neoplasm of lower jaw bone
other benign neoplasm of connective and other soft tissue of head face and neck
benign neoplasm of skin of lip
benign neoplasm of eyelid including canthus
benign neoplasm of ear and external auditory canal
benign neoplasm of skin of other and unspecified parts of face
benign neoplasm of scalp and skin of neck
benign neoplasm of eyeball except conjunctiva cornea retina and choroid
benign neoplasm of orbit
benign neoplasm of lacrimal gland
benign neoplasm of conjunctiva
benign neoplasm of cornea
benign neoplasm of retina
benign neoplasm of choroid
benign neoplasm of lacrimal duct
benign neoplasm of other specified parts of eye
benign neoplasm of brain
benign neoplasm of cranial nerves
benign neoplasm of cerebral meninges
benign neoplasm of thyroid glands
benign neoplasm of adrenal gland
benign neoplasm of parathyroid gland
benign neoplasm of pituitary gland and craniopharyngeal duct
benign neoplasm of pineal gland
benign neoplasm of carotid body
benign neoplasm of lymph nodes
carcinoma in situ of larynx
carcinoma in situ of trachea
carcinoma in situ of skin of lip
carcinoma in situ of eyelid including canthus
carcinoma in situ of skin of ear and external auditory canal
carcinoma in situ of skin of other and unspecified parts of face
carcinoma in situ of other and unspecified parts of uterus
neoplasm of uncertain behavior of major salivary glands
CMS Limitations
Flow Cytometry (con’t)
235.1
235.2
235.3
235.6
235.7
235.8 - 236.1 neoplasm of uncertain behavior of lip oral cavity and pharynx
neoplasm of uncertain behavior of stomach intestines and rectum
neoplasm of uncertain behavior of liver and biliary passages
neoplasm of uncertain behavior of larynx
neoplasm of uncertain behavior of trachea bronchus and lung
neoplasm of uncertain behavior of pleura thymus and mediastinum - neoplasm of uncertain behavior
of placenta
236.2
neoplasm of uncertain behavior of ovary
236.7
neoplasm of uncertain behavior of bladder
237.0
neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct
237.1
neoplasm of uncertain behavior of pineal gland
237.71
neurofibromatosis type 1 von recklinghausen’s disease
237.72
neurofibromatosis type 2 acoustic neurofibromatosis
238.0
neoplasm of uncertain behavior of bone and articular cartilage
238.1
neoplasm of uncertain behavior of connective and other soft tissue
238.4
polycythemia vera
238.5
neoplasm of uncertain behavior of histiocytic and mast cells
238.6
neoplasm of uncertain behavior of 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
238.77
post-transplant lymphoproliferative disorder (ptld)
238.79
other lymphatic and hematopoietic tissues
239.6
neoplasm of unspecified nature of brain
239.8
neoplasm of unspecified nature of other specified sites
273.1
monoclonal paraproteinemia
273.2
other paraproteinemias
273.3
macroglobulinemia
277.30
amyloidosis, unspecified
277.31
familial mediterranean fever
277.39
other amyloidosis
279.00 - 279.10 hypogammaglobulinemia unspecified - immunodeficiency with predominant t-cell defect unspecified
279.2 - 279.4 combined immunity deficiency - autoimmune disease not elsewhere classified
279.50-279.53 graft-versus-host disease, unspecified - acute on chronic graft-versus-host disease
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
283.0
autoimmune hemolytic anemias
283.2
hemoglobinuria due to hemolysis from external causes
283.9
acquired hemolytic anemia unspecified
284.01
constitutional red blood cell aplasia
284.09
other constitutional aplastic anemia
CMS Limitations
Flow Cytometry (con’t)
284.1
284.2
284.81
284.89
284.9
285.0
285.8
285.9
287.1
287.30 - 287.5 288.00
288.01
288.02
288.03
288.04
288.09
288.1
288.2
288.3
288.4
288.50
288.51
288.59
288.60
288.61
288.62
288.63
288.64
288.65
288.69
288.8
289.1
289.2 - 289.4 289.50
289.51
289.52
289.53
289.59
289.81
289.82
289.83
289.84
289.89
423.8
474.2
478.11
478.19
511.81
511.89
511.9
pancytopenia
myelophthisis
red cell aplasia (acquired) (adult) (with thymoma)
other specified aplastic anemias
aplastic anemia unspecified
sideroblastic anemia
other specified anemias
anemia unspecified
qualitative platelet defects
primary thrombocytopenia,unspecified - thrombocytopenia unspecified
neutropenia, unspecified
congenital neutropenia
cyclic neutropenia
drug induced neutropenia
neutropenia due to infection
other neutropenia
functional disorders of polymorphonuclear neutrophils
genetic anomalies of leukocytes
eosinophilia
hemophagocytic syndromes
leukocytopenia, unspecified
lymphocytopenia
other decreased white blood cell count
leukocytosis, unspecified
lymphocytosis (symptomatic)
leukemoid reaction
monocytosis (symptomatic)
plasmacytosis
basophilia
other elevated white blood cell count
other specified disease of white blood cells
chronic lymphadenitis
nonspecific mesenteric lymphadenitis - hypersplenism
disease of spleen unspecified
chronic congestive splenomegaly
splenic sequestration
neutropenic splenomegaly
other diseases of spleen
primary hypercoagulable state
secondary hypercoagulable state
myelofibrosis
heparin-induced thrombocytopenia (hit)
other specified diseases of blood and blood-forming organs
other specified diseases of pericardium
adenoid vegetations
nasal mucositis (ulcerative)
other disease of nasal cavity and sinuses
malignant pleural effusion
other specified forms of effusion, except tuberculous
unspecified pleural effusion
CMS Limitations
Flow Cytometry (con’t)
568.82
710.0
782.2
784.2
785.6
786.6
789.2
789.30
789.39
789.51
789.59
996.80
996.81
996.82
996.83
996.84
996.85
996.86
996.87
996.89
v08
v10.60 - v10.69 v10.79
v42.0
v42.1
v42.2
v42.3
v42.4
v42.5
v42.6
v42.7
v42.81
v42.82
v42.83
v59.02
v59.3
v71.1
peritoneal effusion (chronic)
systemic lupus erythematosus
localized superficial swelling mass or lump
swelling mass or lump in head and neck
enlargement of lymph nodes
swelling mass or lump in chest
splenomegaly
abdominal or pelvic swelling mass or lump unspecified site
abdominal or pelvic swelling mass or lump other specified site
malignant ascites
other ascites
complications of unspecified transplanted organ
complications of transplanted kidney
complications of transplanted liver
complications of transplanted heart
complications of transplanted lung
complications of transplanted bone marrow
complications of transplanted pancreas
complications of transplanted organ intestine
complications of other specified transplanted organ
asymptomatic human immunodeficiency virus (hiv) infection status
personal history of unspecified leukemia - personal history of other leukemia
personal history of other lymphatic and hematopoietic neoplasms
kidney replaced by transplant
heart replaced by transplant
heart valve replaced by transplant
skin replaced by transplant
bone replaced by transplant
cornea replaced by transplant
lung replaced by transplant
liver replaced by transplant
bone marrow replaced by transplant
peripheral stem cells replaced by transplant
pancreas replaced by transplant
blood donors stem cells
bone marrow donors
observation for suspected malignant neoplasm
CMS Limitations
Gamma Glutamyl Transferase
LCD # 190.32, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 82977
ICD-9 Codes that SUPPORT medical necessity for Glutamyltransferase, gamma (GGT) (CPT 82977):
003.1
006.0-006.9
014.00-014.86
017.90-017.96
018.90-018.96
020.0-020.9
022.3
027.0
027.1
030.1
032.83
036.1
036.2
038.0-038.9
*038.12
039.2
040.0
042
054.0
054.5
060.0-060.1
070.0-070.9
072.71
073.0
074.8
075
078.5
079.99
082.0-082.9
084.9
086.1
088.81
091.62
095.3
100.0
112.5
115.00
120.9
121.1
121.3
122.0
122.5
122.8
122.9
salmonella septicemia
amebiasis
tuberculosis of intestines, peritoneum, and mesenteric glands
tuberculosis of other specified organs
miliary tuberculosis, unspecified
plague
anthrax septicemia
listeriosis
erysipelothrix infection
tuberculoid leprosy [type t]
diphtheritic peritonitis
meningococcal encephalitis
meningococcemia
septicemia
*methicillin resistant staphylococcus aureus septicemia
actinomycotic infections, abdominal
gas gangrene
human immunodeficiency virus (hiv) disease
eczema herpeticum
herpetic septicemia
yellow fever
viral hepatitis
mumps hepatitis
ornithosis, with pneumonia
other specified diseases due to coxsackie virus
infectious mononucleosis
cytomegaloviral disease
unspecified viral infection
tick-borne rickettsioses, stet
other pernicious complications of malaria
chagas disease with organ involvement other than heart
lyme disease
secondary syphilitic hepatitis
syphilis of liver
leptospirosis icterohemorrhagica
candidiasis, disseminated
infection by histoplasma capsulatum without mention of manifestation
schistosomiasis, unspecified
clonorchiasis
fascioliasis
echinococcus granulosus infection of liver
echinococcus multilocularis infection of liver
echinococcosis, unspecified, of liver
echinococcus, other and unspecified
CMS Limitations
Gamma Glutamyl Transferase (con’t)
130.5
hepatitis due to toxoplasmosis
135
sarcoidosis
150.0-159.9
malignant neoplasm of digestive organs and peritoneum
160.0-165.9
malignant neoplasm of respiratory and intrathoracic organs
170.0-176.9
malignant neoplasm of bone, connective tissue, skin, and breast
179-189.9
malignant neoplasm of genitourinary organs
200.00-208.91 malignant neoplasm of lymphatic and hematopoietic tissue
*209.20-209.27, *malignant carcinoid tumors of other and unspecified sites
209.29
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 other and unspecified digestive organs
235.0-236.7, neoplasms of uncertain behavior
236.90-236.91,
236.99, 237.0237.6, 237.70237.72, 237.9238.6, 238.71238.76
*238.77
*post-transplant lymphoproliferative disorder (ptld)
238.79, 238.8, neoplasms of uncertain behavior
238.9
239.0
neoplasm of unspecified nature of digestive system
250.00-250.93 diabetes mellitus
252.00-252.02, hyperparathyroidism
252.08
263.1
malnutrition of mild degree
263.9
unspecified protein-calorie malnutrition
268.0
rickets, active
268.2
osteomalacia, unspecified
269.0
deficiency of vitamin k
270.2
other disturbances of aromatic amino acid metabolism
270.9
unspecified disorder of amino acid metabolism
271.0
glycogenosis
272.0
pure hypercholesterolemia
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 – 275.3
disorders of iron, magnesium, copper, and phosphorus metabolism
275.40-275.49 disorders of calcium metabolism
*275.5
*hungry bone syndrome
277.1
disorders of porphyrin metabolism
277.30
amyloidosis, unspecified
CMS Limitations
Gamma Glutamyl Transferase (con’t)
277.31
277.39
277.4
277.6
282.60-282.69
286.6
286.7
289.4
289.52
291.0-291.9
303.00-303.03
303.90-303.93
304.00-304.93
305.00-305.93
357.5
359.21
359.22
359.23
359.24
359.29
452
453.0-453.9
453.40
453.41
453.42
456.0-456.21
555.0-555.9
556.0-556.9
557.0
558.1-558.9
*558.41
*558.42
560.0-560.9
562.01
562.03
562.11
562.13
567.0-567.29, 567.38-567.9
570
585.6
569.83
571.0-571.9
*571.42
572.0-572.8
573.0-573.9
574.00-574.91
575.0-575.9
576.0-576.9
581.0-581.9
familial mediterranean fever
other amyloidosis
disorders of bilirubin excretion
other deficiencies of circulating enzymes
sickle cell disease
defibrination syndrome
acquired coagulation factor deficiency
hypersplenism
splenic sequestration
alcoholic psychoses
acute alcoholic intoxication
other and unspecified alcohol dependence
drug dependence
non-dependent abuse of drugs
alcoholic polyneuropathy
myotonic muscular dystrophy
myotonia congenita
myotonic chondrodystrophy
drug induced myotonia
other specified myotonic disorder
portal vein thrombosis
other vein embolism and thrombosis
venous embolism and thrombosis of unspecified deep vessels of lower extremity
venous embolism and thrombosis of deep vessels of proximal lower extremity
venous embolism and thrombosis of deep vessels of distal lower extremity
esophageal varices
regional enteritis
ulcerative colitis
acute vascular insufficiency of intestine
other noninfectious gastroenteritis and colitis
*eosinophilis gastroenteritis
*eosinophilis colitis
intestinal obstruction without mention of hernia
diverticulitis of small intestine (without mention of hemorrhage)
diverticulitis of small intestine with hemorrhage
diverticulitis of colon (without mention of hemorrhage)
diverticulitis of colon with hemorrhage
peritonitis
acute and subacute necrosis of liver
end stage renal disease
perforation of intestine
chronic liver disease and cirrhosis
*autoimmune hepatitis
liver abscess and sequelae of chronic liver disease
other disorders of liver
cholelithiasis
other disorders of gallbladder
other disorders of biliary tract
nephrotic syndrome
CMS Limitations
Gamma Glutamyl Transferase (con’t)
582.0-582.9
583.0-583.9
584.5-584.9
586
587
588.0-588.9
590.00-590.9
642.50-642.54
646.70, 646.71, 646.73
782.4
789.1
790.4
790.5
960.0-979.9
980.0-989.89
v42.7
v58.61-v58.64, v58.69
v67.1
v67.2
v67.51
chronic glomerulonephritis
nephritis and nephropathy not specified as acute or chronic
acute renal failure
renal failure, unspecified
renal sclerosis, unspecified
disorders resulting from impaired renal function
infections of kidney
severe pre-eclampsia
liver disorders in pregnancy
jaundice, unspecified, not of newborn
hepatomegaly
nonspecific elevation of levels of transaminase or lactic acid dehydrogenase
other nonspecific abnormal serum enzyme levels
poisoning by drugs, medicinal, and biological substances
toxic effects of substances chiefly nonmedicinal as to source
organ replaced by transplant, liver
long-term (current) drug use
follow-up examination, radiotherapy
follow-up examination, chemotherapy
follow-up examination after completed treatment with high-risk medications, not elsewhere classified
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.
CMS Limitations
Glycated Hemoglobin/Glycated Protein
NCD # 190.21, Effective Date: 04/01/2009
CPT/HCPCS Codes: CPT 82985, CPT 83036
ICD-9 codes that SUPPORT medical necessity for glycated protein (CPT 82985) and hemoglobin, glycated (CPT
83036):
211.7 249.00-249.01 249.10-249.11 249.20-249.21 249.30-249.31 249.40-249.41 249.50-249.51 249.60-249.61 249.70-249.71 249.80-249.81 249.90-249.91 250.00-250.93 251.0 251.1 251.2 251.3 251.4 251.8 251.9 258.0 - 258.9 271.4 275.0 577.1 579.3 648.00 Benign neoplasm of islets of Langerhans
Secondary diabetes mellitus without mention of complication
Secondary diabetes mellitus with ketoacidosis
Secondary diabetes mellitus with hyperosmolarity
Secondary diabetes mellitus with other coma
Secondary diabetes mellitus with renal manifestations
Secondary diabetes mellitus with ophthalmic manifestations
Secondary diabetes mellitus with neurological manifestations
Secondary diabetes mellitus with peripheral circulatory disorders
Secondary diabetes mellitus with other specified manifestations
Secondary diabetes mellitus with unspecified complication
Diabetes mellitus & various related codes
Hypoglycemic coma
Other specified hypoglycemia
Hypoglycemia unspecified
Post-surgical hypoinsulinemia
Abnormality of secretion of glucagon
Other specified disorders of pancreatic internal secretion
Unspecified disorder of pancreatic internal secretion
Polyglandular dysfunction and related disorders
Renal glycosuria
Disorders of iron metabolism
Chronic pancreatitis
Other and unspecified postsurgical nonabsorption
Diabetes mellitus complicating pregnancy, Childbirth or the puerperium, unspecified as to episode of
care or not applicable
648.03 Diabetes mellitus complicating pregnancy, Childbirth or the puerperium, antepartum condition or
complication
648.04 Diabetes mellitus complicating pregnancy, Childbirth or the puerperium, postpartum condition or
complication
648.80 Abnormal glucose tolerance complicating pregnancy, childbirth or the puerperium, unspecified as to
episode of care or not applicable
648.83 Abnormal glucose tolerance complicating pregnancy, childbirth or the puerperium, antepartum condition or complication
648.84 Abnormal glucose tolerance complicating pregnancy, childbirth or the puerperium, postpartum condition or complication
790.21-790.29 Abnormal glucose tolerance test
790.6 Other abnormal blood chemistry (hyperglycemia)
962.3 Poisoning by insulin 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 use of other medication
CMS Limitations
Glycated Hemoglobin/Glycated Protein (con’t)
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. The above Description Section provides the clinical basis for those
situations in which testing more frequently than four times per annum is indicated, and medical necessity documentation must support such testing in excess of the above guidelines.
Many methods for the analysis of glycated hemoglobin show significant interference from elevated levels of fetal hemoglobin or by variant hemoglobin molecules. When the glycated hemoglobin assay is initially performed in these patients, the laboratory may inform the ordering physician of a possible analytical interference. Alternative testing, including glycated protein, for example, fructosamine, may be indicated for the monitoring of the degree of glycemic control
in this situation. It is therefore conceivable that a patient will have both a glycated hemoglobin and glycated protein
ordered on the same day. This should be limited to the initial assay of glycated hemoglobin, with subsequent exclusive
use of glycated protein. These tests are not considered to be medically necessary for the diagnosis of diabetes.
CMS Limitations
High Sensitivity C-Reactive Protein (hsCRP)
LCD # L26445, Effective date: 03/01/2009
CPT/HCPCS Codes: CPT 86141
Documentation Requirements: The patient’s medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See “Indications and Limitations of Coverage.”) This documentation
includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or
procedures.
Utilization Guidelines: The measurement of hsCRP should only be performed in a metabolically stable patient without
obvious inflammatory or infectious conditions. The test may be performed twice (averaging results), optimally two
weeks apart with the average expressed in mg/L. A result of >10mg/L should be discarded and not repeated for at
least two weeks after the source of infection or inflammation has been identified and cleared. It is expected that no
more than two tests per beneficiary will be performed with only an occasional beneficiary needing a third test due to
one level >10.0 mg/L needing to be discarded. Testing will be limited to three tests per beneficiary lifetime.
Use of hsCRP testing for monitoring lipid or other therapy is not considered necssary and will be denied.
ICD-9 Codes that SUPPORT medical necessity for hsCRP Testing (CPT 86141):
272.0
272.1
272.2
272.3
272.4
pure hypercholesterolemia
pure hyperglyceridemia
mixed hyperlipidemia
hyperchylomicronemia
other and unspecified hyperlipidemia
ICD-9 Codes that DO NOT SUPPORT medical necessity for hsCRP Testing:
Use of any ICD-9-CM code not listed in the “ICD-9-CM Codes that Support Medical Necessity” section of this LCD will
be denied. In addition, the following ICD-9 CM codes are specifically listed as not supporting medical necessity for emphasis and to avoid claim payment errors.
v71.7
v81.0
v81.2
v82.9
observation for suspected cardiovascular disease
screening for ischemic heart disease
screening for other and unspecified cardiovascular conditions
screening for unspecified condition
CMS Limitations
Hepatitis Panel/Acute Hepatitis Panel
Hepatitis B: LCD # L1641, Effective Date: 09/01/2008
Viral Hepatitis: LCD # L28427, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 80074
ICD-9 Codes that SUPPORT medical necessity for Acute Hepatitis Panel (CPT 80074):
070.0-070.9
456.0-456.21
570
571.5
572.0-572.8
573.3
780.31
780.32
780.71
*780.72
780.79
782.4
783.0-783.6
787.01-787.03
789.00-789.09
789.1
789.61
790.4
794.8
996.82
v72.85
viral hepatitis
esophageal varices with or without mention of bleeding
acute and subacute necrosis of liver
cirrhosis of liver without mention of alcohol
liver abscess and sequelae of chronic liver disease
hepatitis, unspecified
febrile convulsions (simple), unspecified
complex febrile convulsions
chronic fatigue syndrome
*functional quadriplegia
other malaise and fatigue
jaundice, unspecified, not of newborn
symptoms concerning nutrition, metabolism, and development
nausea and vomiting
abdominal pain
hepatomegaly
localized abdominal tenderness (ruq)
nonspecific elevation of levels of transaminase or lactic acid dehydrogenase (ldh)
nonspecific abnormal results of function studies, liver
complications of transplanted organ, liver
liver transplant recipient evaluation
CMS Limitations
Homocysteine Level, Serum
LCD # L25650, Effective date: 03/01/2009
CPT/HCPCS Codes: CPT 83090
ICD-9 Codes that SUPPORT Medical Necessity for Homocysteine Level, Serum (CPT 86090):
250.00
250.01
250.02
250.03
250.10
250.11
250.12
250.13
250.20
250.21
250.22
250.23
250.30
250.31
250.32
250.33
250.40
250.41
250.42
250.43
250.50
250.51
250.52
250.53
250.60
250.61
250.62
250.63
250.70
250.71
250.72
250.73
250.80
250.81
250.82
250.83
250.90
250.91
250.92
250.93
272.0
272.1
272.2
diabetes mellitus without mention of complication, type ii or unspecified type, not stated as
uncontrolled
diabetes mellitus without mention of complication, type i [juvenile type], not stated as uncontrolled
diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled
diabetes mellitus without mention of complication, type i [juvenile type], uncontrolled
diabetes with ketoacidosis, type ii or unspecified type, not stated as uncontrolled
diabetes with ketoacidosis, type i [juvenile type], not stated as uncontrolled
diabetes with ketoacidosis, type ii or unspecified type, uncontrolled
diabetes with ketoacidosis, type i [juvenile type], uncontrolled
diabetes with hyperosmolarity, type ii or unspecified type, not stated as uncontrolled
diabetes with hyperosmolarity, type i [juvenile type], not stated as uncontrolled
diabetes with hyperosmolarity, type ii or unspecified type, uncontrolled
diabetes with hyperosmolarity, type i [juvenile type], uncontrolled
diabetes with other coma, type ii or unspecified type, not stated as uncontrolled
diabetes with other coma, type i [juvenile type], not stated as uncontrolled
diabetes with other coma, type ii or unspecified type, uncontrolled
diabetes with other coma, type i [juvenile type], uncontrolled
diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled
diabetes with renal manifestations, type i [juvenile type], not stated as uncontrolled
diabetes with renal manifestations, type ii or unspecified type, uncontrolled
diabetes with renal manifestations, type i [juvenile type], uncontrolled
diabetes with ophthalmic manifestations, type ii or unspecified type, not stated as uncontrolled
diabetes with ophthalmic manifestations, type i [juvenile type], not stated as uncontrolled
diabetes with ophthalmic manifestations, type ii or unspecified type, uncontrolled
diabetes with ophthalmic manifestations, type i [juvenile type], uncontrolled
diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled
diabetes with neurological manifestations, type i [juvenile type], not stated as uncontrolled
diabetes with neurological manifestations, type ii or unspecified type, uncontrolled
diabetes with neurological manifestations, type i [juvenile type], uncontrolled
diabetes with peripheral circulatory disorders, type ii or unspecified type, not stated as uncontrolled
diabetes with peripheral circulatory disorders, type i [juvenile type], not stated as uncontrolled
diabetes with peripheral circulatory disorders, type ii or unspecified type, uncontrolled
diabetes with peripheral circulatory disorders, type i [juvenile type], uncontrolled
diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled
diabetes with other specified manifestations, type i [juvenile type], not stated as uncontrolled
diabetes with other specified manifestations, type ii or unspecified type, uncontrolled
diabetes with other specified manifestations, type i [juvenile type], uncontrolled
diabetes with unspecified complication, type ii or unspecified type, not stated as uncontrolled
diabetes with unspecified complication, type i [juvenile type], not stated as uncontrolled
diabetes with unspecified complication, type ii or unspecified type, uncontrolled
diabetes with unspecified complication, type i [juvenile type], uncontrolled
pure hypercholesterolemia
pure hyperglyceridemia
mixed hyperlipidemia
CMS Limitations
Homocysteine Level, Serum (con’t)
272.3
272.4
281.0
281.1
281.2
281.3
401.0
401.1
401.9
402.00
402.01
402.10
402.11
402.90
402.91
403.00
403.01
403.10
403.11
403.90
403.91
404.00
404.01
404.02
404.03
404.10
404.11
404.12
404.13
404.90
404.91
404.92
hyperchylomicronemia
other and unspecified hyperlipidemia
pernicious anemia
other vitamin b12 deficiency anemia
folate-deficiency anemia
other specified megaloblastic anemias not elsewhere classified
malignant essential hypertension
benign essential hypertension
unspecified essential hypertension
malignant hypertensive heart disease without heart failure
malignant hypertensive heart disease with heart failure
benign hypertensive heart disease without heart failure
benign hypertensive heart disease with heart failure
unspecified hypertensive heart disease without heart failure
unspecified hypertensive heart disease with heart failure
hypertensive chronic kidney disease, malignant, with chronic kidney disease stage i through stage iv,
or unspecified
hypertensive chronic kidney disease, malignant, with chronic kidney disease stage v or end stage renal
disease
hypertensive chronic kidney disease, benign, with chronic kidney disease stage i through stage iv, or
unspecified
hypertensive chronic kidney disease, benign, with chronic kidney disease stage v or end stage renal
disease
hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv,
or unspecified
hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage
renal disease
hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic
kidney disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney
disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic
kidney disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney
disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, benign, without heart failure and with chronic kidney
disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney
disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, benign, without heart failure and with chronic kidney
disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease
stage v or end stage renal disease
hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic
kidney disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney
disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic
kidney disease stage v or end stage renal disease
CMS Limitations
Homocysteine Level, Serum (con’t)
404.93
405.01
405.09
405.11
405.19
405.91
405.99
410.00
410.01
410.02
410.10
410.11
410.12
410.20
410.21
410.22
410.30
410.31
410.32
410.40
410.41
410.42
410.50
410.51
410.52
410.60
410.61
410.62
410.70
410.71
410.72
410.80
410.81
410.82
410.90
410.91
410.92
411.0
411.1
411.81
411.89
412
413.0
413.1
413.9
414.00
414.01
414.02
414.03
hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney
disease stage v or end stage renal disease
malignant renovascular hypertension
other malignant secondary hypertension
benign renovascular hypertension
other benign secondary hypertension
unspecified renovascular hypertension
other unspecified secondary hypertension
acute myocardial infarction of anterolateral wall episode of care unspecified
acute myocardial infarction of anterolateral wall initial episode of care
acute myocardial infarction of anterolateral wall subsequent episode of care
acute myocardial infarction of other anterior wall episode of care unspecified
acute myocardial infarction of other anterior wall initial episode of care
acute myocardial infarction of other anterior wall subsequent episode of care
acute myocardial infarction of inferolateral wall episode of care unspecified
acute myocardial infarction of inferolateral wall initial episode of care
acute myocardial infarction of inferolateral wall subsequent episode of care
acute myocardial infarction of inferoposterior wall episode of care unspecified
acute myocardial infarction of inferoposterior wall initial episode of care
acute myocardial infarction of inferoposterior wall subsequent episode of care
acute myocardial infarction of other inferior wall episode of care unspecified
acute myocardial infarction of other inferior wall initial episode of care
acute myocardial infarction of other inferior wall subsequent episode of care
acute myocardial infarction of other lateral wall episode of care unspecified
acute myocardial infarction of other lateral wall initial episode of care
acute myocardial infarction of other lateral wall subsequent episode of care
true posterior wall infarction episode of care unspecified
true posterior wall infarction initial episode of care
true posterior wall infarction subsequent episode of care
subendocardial infarction episode of care unspecified
subendocardial infarction initial episode of care
subendocardial infarction subsequent episode of care
acute myocardial infarction of other specified sites episode of care unspecified
acute myocardial infarction of other specified sites initial episode of care
acute myocardial infarction of other specified sites subsequent episode of care
acute myocardial infarction of unspecified site episode of care unspecified
acute myocardial infarction of unspecified site initial episode of care
acute myocardial infarction of unspecified site subsequent episode of care
postmyocardial infarction syndrome
intermediate coronary syndrome
acute coronary occlusion without myocardial infarction
other acute and subacute forms of ischemic heart disease other
old myocardial infarction
angina decubitus
prinzmetal angina
other and unspecified angina pectoris
coronary atherosclerosis of unspecified type of vessel native or graft
coronary atherosclerosis of native coronary artery
coronary atherosclerosis of autologous vein bypass graft
coronary atherosclerosis of nonautologous biological bypass graft
CMS Limitations
Homocysteine Level, Serum (con’t)
414.04
414.05
414.06
414.07
414.10
414.11
414.12
414.19
414.8
414.9
433.00
433.01
433.10
433.11
433.20
433.21
433.30
433.31
433.80
433.81
433.90
433.91
434.00
434.01
434.10
434.11
434.90
434.91
437.0
437.6
440.0
440.1
440.20
440.21
440.22
440.23
440.24
440.29
440.30
440.31
440.32
440.8
440.9
453.0
453.1
453.2
453.3
453.40
453.41
453.42
coronary atherosclerosis of artery bypass graft
coronary atherosclerosis of unspecified bypass graft
coronary atherosclerosis of native coronary artery of transplanted heart
coronary atherosclerosis of bypass graft (artery) (vein) of transplanted heart
aneurysm of heart (wall)
aneurysm of coronary vessels
dissection of coronary artery
other aneurysm of heart
other specified forms of chronic ischemic heart disease
chronic ischemic heart disease unspecified
occlusion and stenosis of basilar artery without cerebral infarction
occlusion and stenosis of basilar artery with cerebral infarction
occlusion and stenosis of carotid artery without cerebral infarction
occlusion and stenosis of carotid artery with cerebral infarction
occlusion and stenosis of vertebral artery without cerebral infarction
occlusion and stenosis of vertebral artery with cerebral infarction
occlusion and stenosis of multiple and bilateral precerebral arteries without cerebral infarction
occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction
occlusion and stenosis of other specified precerebral artery without cerebral infarction
occlusion and stenosis of other specified precerebral artery with cerebral infarction
occlusion and stenosis of unspecified precerebral artery without cerebral infarction
occlusion and stenosis of unspecified precerebral artery with cerebral infarction
cerebral thrombosis without cerebral infarction
cerebral thrombosis with cerebral infarction
cerebral embolism without cerebral infarction
cerebral embolism with cerebral infarction
cerebral artery occlusion unspecified without cerebral infarction
cerebral artery occlusion unspecified with cerebral infarction
cerebral atherosclerosis
nonpyogenic thrombosis of intracranial venous sinus
atherosclerosis of aorta
atherosclerosis of renal artery
atherosclerosis of native arteries of the extremities unspecified
atherosclerosis of native arteries of the extremities with intermittent claudication
atherosclerosis of native arteries of the extremities with rest pain
atherosclerosis of native arteries of the extremities with ulceration
atherosclerosis of native arteries of the extremities with gangrene
other atherosclerosis of native arteries of the extremities
atherosclerosis of unspecified bypass graft of the extremities
atherosclerosis of autologous vein bypass graft of the extremities
atherosclerosis of nonautologous biological bypass graft of the extremities
atherosclerosis of other specified arteries
generalized and unspecified atherosclerosis
budd-chiari syndrome
thrombophlebitis migrans
embolism and thrombosis of vena cava
embolism and thrombosis of renal vein
venous embolism and thrombosis of unspecified deep vessels of lower extremity
venous embolism and thrombosis of deep vessels of proximal lower extremity
venous embolism and thrombosis of deep vessels of distal lower extremity
CMS Limitations
Human Chorionic Gonadotropin
LCD # 190.27, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 84702
ICD-9 Codes that SUPPORT medical necessity for Gonadotropin, chorionic (hCG); quantitative (CPT 84702):
158.0
158.8
164.2
164.3
164.8
164.9
181
183.0
183.8
186.0
186.9
194.4
197.1
197.6
198.6
198.82
236.1
338.3
623.8
625.9
630
631
632
633.90-633.91
634.00-634.02
640.00-640.03
642.30-642.34
642.40-642.74
642.90-642.94
795.89
v10.09
v10.29
v10.43
v10.47
v22.0-v22.1
malignant neoplasm of retroperitoneum
malignant neoplasm of specified parts of peritoneum
malignant neoplasm of anterior mediastinum
malignant neoplasm of posterior mediastinum
malignant neoplasm, other (includes malignant neoplasm of contiguous overlapping sites of thymus,
heart, and mediastinum whose point of origin cannot be determined
malignant neoplasm of mediastinum, part specified
malignant neoplasm of placenta
malignant neoplasm of ovary
other specified sites of uterine adnexa
malignant neoplasm of undescended testis
malignant neoplasm of other and unspecified testis
malignant neoplasm of pineal gland
secondary malignant neoplasm of mediastinum
secondary malignant neoplasm of retroperitoneum and peritoneum
secondary malignant neoplasm of ovary
secondary malignant neoplasm of other genital organs
neoplasm of uncertain behavior, placenta
neoplasm related pain (acute) (chronic)
vaginal bleeding
pelvic pain
hydatidiform mole
pregnancy, molar
missed abortion
unspecified ectopic pregnancy
spontaneous abortion, complicated by genital tract and pelvic infection
threatened abortion
transient hypertension of pregnancy
pre-eclampsia or eclampsia
unspecified hypertension complicating pregnancy, childbirth, or the puerperium
other abnormal tumor markers
personal history of malignant neoplasm, other gastrointestinal sites
personal history of malignant neoplasm of other respiratory and intrathoracic organs
personal history of malignant neoplasm, ovary
personal history of malignant neoplasm, testis
normal pregnancy
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.
CMS Limitations
Human Immunodeficiency Virus (HIV) Testing (Diagnosis)
LCD # 190.14, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 86689, CPT 86701, CPT 86702, CPT 86703, CPT 87390, CPT 87391, CPT 87534, CPT 87535,
CPT 87537, CPT 87538
ICD-9 Codes that SUPPORT medical necessity for Qualitative or Semiquantitative Immunoassays Performed by Multiple
Step Methods, HTLV or HIV Antibody, Confirmatory Test (e.g., Western Blot) (CPT 86689); Antibody, HIV-1 (CPT 86701);
Antibody, HIV-2 (CPT 86702); Antibody, HIV-1 and HIV-2, Single Assay (CPT 86703); Infectious Agent Antigen Detection by Enzyme Immunoassay Technique, Qualitative or Semiquantitative, Multiple Step Method, HIV-1 (CPT 87390);
Infectious Agent Antigen Detection by Enzyme Immunoassay Technique, Qualitative or Semiquantitative, Multiple Step
Method, HIV-2 (CPT 87391); Infectious Agent Detection by Nucleic Acid (DNA or RNA), HIV-1, Direct Probe Tech
nique (CPT 87534); Infectious Agent Detection by Nucleic Acid (DNA or RNA), HIV-1, Amplified Probe Technique (CPT
87535); Infectious Agent Detection by Nucleic Acid (DNA or RNA), HIV-2, Direct Probe Technique (CPT 87537); Infectious Agent Detection by Nucleic Acid (DNA or RNA), HIV-2, Amplified Probe Technique (CPT 87538):
003.1
007.2
007.4
007.8
010.00-010.96
011.00-011.96
012.00-012.86
013.00-013.96
014.00-014.86
015.00-015.96
016.00-016.96
017.00-017.96
018.00-018.96
027.0
031.0-031.9
038.2
038.43
039.0-039.9
041.7
042
046.3
049.0-049.9
052.0-052.1, 052.2, 052.7052.8
053.0, 053.10-
053.13, 053.14,
053.19-053.22,
053.29, 053.71,
053.79, 053.8,
053.9
salmonella septicemia
coccidiosis (isoporiasis)
cryptosporidiosis
other specified protozoal intestinal diseases
primary tuberculous infection
pulmonary tuberculosis
other respiratory tuberculosis
tuberculosis of meninges--+ and central nervous system
tuberculosis of intestines, peritoneum and mesenteric glands
tuberculosis of bones and joints
tuberculosis of genitourinary system
tuberculosis of other organs
miliary tuberculosis
listeriosis
diseases due to other mycobacteria
pneumococcal septicemia
septicemia (pseudomonas)
actinomycotic infections (includes nocardia)
pseudomonas infection
hiv disease (acute retroviral syndrome, aids-related complex)
progressive multifocal leukoencephalopathy
other non-arthropod-borne viral diseases of central nervous system
chickenpox (with complication)
herpes zoster
CMS Limitations
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) (con’t)
054.0, 054.10-
054.13, 054.19,
054.2, 054.3,
054.40-054.44,
054.49, 054.5,
054.6, 054.71054.73, 054.74,
054.79, 054.8,
054.9
055.0-055.8
070.20-070.23
070.30-070.33
070.41
070.42
070.44
070.49
070.51
070.52
070.54
070.59
070.6
070.70
070.71
070.9
078.0
078.10
*078.12
078.19
078.3
078.5
078.88
079.50
079.51
079.52
079.53
079.59
079.83
079.88
079.98
085.0-085.9
088.0
090.0-090.9
091.0-091.9
093.0-093.9
094.0-094.9
095.0-095.9
096
097.0-097.9
098.0-098.89
099.0
herpes simplex
measles (with complication)
viral hepatitis b with hepatic coma
viral hepatitis b without mention of hepatic coma
acute hepatitis c with hepatic coma
hepatitis delta without mention of active hepatitis b disease with hepatic coma
chronic hepatitis c with hepatic coma
other specified viral hepatitis with hepatic coma
acute hepatitis c without mention of hepatic coma
hepatitis delta without mention of active hepatitis b disease without hepatic coma
chronic hepatitis c without hepatic coma
other specified viral hepatitis without hepatic coma
unspecified viral hepatitis with hepatic coma
unspecified viral hepatitis c without hepatic coma
unspecified viral hepatitis c with hepatic coma
unspecified viral hepatitis without hepatic coma
molluscum contagiosum
viral warts
*plantar warts
viral warts
cat-scratch disease
cytomegaloviral disease
other specified diseases due to chlamydiae
retrovirus unspecified
htlv-i
htlv-ii
human immunodeficiency virus, type 2
other specified retrovirus
parvovirus b19
other specified chlamydial infection
unspecified chlamydial infection
leishmaniasis
bartonellosis
congenital syphilis
early syphilis symptomatic
cardiovascular syphilis
neurosyphilis
other forms of late syphilis, with symptoms
late syphilis, latent
other and unspecified syphilis
gonococcal infections
chancroid
CMS Limitations
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) (con’t)
099.1
099.2
099.3
099.40-099.49
099.50-099.59
099.8
099.9
110.1
111.0
112.0-112.9
114.0-114.9
115.00-115.99
116.0-116.2
117.3
117.5
118
127.2
130.0-130.9
131.01
132.2
133.0
*136.21
*136.29
136.3
136.8
176.0-176.9
180.0-180.9
200.20-200.28
200.80-200.88
201.00-201.98
263.0
263.1
263.9
280.0-280.9
285.9
287.30-287.39
288.00
288.01
288.02
288.03
288.04
288.09
288.4
288.50
288.51
288.59
288.60
288.61
288.62
288.63
lymphogranuloma venereum
granuloma inguinale
reiter’s disease
other nongonococcal urethritis
other venereal diseases due to chlamydia trachomatis
other specified venereal diseases
veneral disease, unspecified
dermatophytosis of nail
ityriasis versicolor
candidiasis
coccidioidomycosis
histoplasmosis
blastomycotic infection
aspergillosis
cryptococcosis
opportunistic mycoses
strongyloidiasis
toxoplasmosis
trichomonal vulvovaginitis
phthirus pubis
scabies
*specific infection due to acanthamoeba
*other specific infections by free-living amebae
pneumocystosis
other specified infectious and parasitic disease (for example, microsporidiosis)
kaposi’s sarcoma
malignant neoplasm of cervix uteri
burkitt’s tumor or lymphoma
lymphosarcoma, other named variants
hodgkin’s disease
malnutrition of moderate degree
malnutrition of mild degree
unspecified protein-calorie malnutrition
iron deficiency anemias
anemia, unspecified
primary thrombocytopenia
neutropenia, unspecified
congenital neutropenia
cyclic neutropenia
drug induced neutropenia
neutropenia due to infection
other neutropenia
hemophagocytic syndromes
leukocytopenia, unspecified
lymphocytopenia
other decreased white blood cell count
leukocytosis, unspecified
lymphocytosis (symptomatic)
leukemoid reaction
monocytosis (symptomatic)
CMS Limitations
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) (con’t)
288.64
288.65
288.66
288.69
288.8
289.53
294.8
310.1
322.2
331.19
331.83
336.9
348.30
348.39
354.0-354.9
356.8
363.20
425.4
473.0-473.9
481-482.9
484.1
486
512.8
516.8
528.2
528.6
530.20-530.21
530.85
583.9
588.81
588.89
647.60-647.64
682.0-682.9
690.10-690.18
696.1
698.3
704.8
706.0-706.9
*780.60
*780.61
*780.62
*780.63
*780.64
*780.65
780.79
783.21
783.40
785.6
786.00
786.05
plasmacytosis
basophilia
bandemia
other elevated white blood cell count
other specified disease of white blood cells
neutropenic splenomegaly
other persistent mental disorders due to conditions classified elsewhere
personality change due to conditions classified elsewhere
chronic meningitis
other frontotemporal dementia
mild cognitive impairment, so stated
unspecified disease of spinal cord
encephalopathy unspecified
other encephalopathy
mononeuritis of upper limbs and mononeuritis multiplex
other specified idiopathic peripheral neuropathy
chorioretinitis, unspecified
other primary cardiomyopathies
chronic sinusitis
pneumococcal pneumonia
pneumonia in cytomegalic inclusion disease
pneumonia, organism unspecified
other spontaneous pneumothorax
other specified alveolar and parietoalveolar pneumonopathies
oral aphthae
leukoplakia of oral mucosa
ulcer of esophagus
barrett’s esophagus
nephropathy with unspecified pathological lesion in kidney
secondary hyperparathyroidism (of renal origin)
other specified disorders resulting from impaired renal function
other viral diseases complicating pregnancy (use for hiv i and ii)
other cellulitis and abscess
seborrheic dermatitis
other psoriasis
lichenification and lichen simplex chronicus
other specified diseases of hair and hair follicles
diseases of sebaceous glands
*fever, unspecified
*fever presenting with conditions classified elsewhere
*postprocedural fever
*postvaccination fever
*chills (without fever)
*hypothermia not associated with low environmental temperature
other malaise and fatigue
abnormal loss of weight
lack of expected normal physiological development
enlargement of lymph nodes
respiratory abnormality, unspecified
shortness of breath
CMS Limitations
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) (con’t)
786.2
786.3
786.4
787.91
795.71
799.4
v01.71
v01.79
v71.5
cough
hemoptysis
abnormal sputum
diarrhea
nonspecific serologic evidence of human immunodeficiency virus
wasting disease
contact or exposure to varicella
contact or exposure to other viral diseases
rape
CMS Limitations
Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring)
LCD # 190.13, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 87536, CPT 87539
ICD-9 Codes that SUPPORT medical necessity for Infectious agent detection by nucleic acid (DNA or RNA); HIV1, quantification (CPT 87536); Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification (CPT
87539):
v08
042
079.53
647.60-647.64
795.71
asymptomatic human immunodeficiency virus [hiv] infection status
human immunodeficiency virus [hiv] disease
human immunodeficiency virus, type 2 [hiv-2]
other viral diseases complicating pregnancy (including hiv-i and ii)
nonspecific serologic evidence of human immunodeficiency virus [hiv]
CMS Limitations
Intravenous Immunoglobulin (IVIG)
LCD # L1253, Effective Date: 09/01/2008
CPT/HCPCS Codes: HCPCS J1565, HCPCS J1566
HCPCS J1567 is no longer payable for Medicare, effective July 1, 2007. HCPCS codes Q4087, Q4088, Q4091, and Q4092
will no longer be payable, effective January 1, 2008. HCPCS codes J1561, J1568, J1569 and J1572 will be effective January 1, 2008.
ICD-9 codes that SUPPORT medical necessity for injection, respiratory syncytial virus immune globulin, intravenous, 50
mg (HCPCS J1565) and injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500
mg (HCPCS J1566):
042
human immunodeficiency virus (hiv) disease
204.10 - 204.11 chronic lymphoid leukemia, without mention of having achieved remission - lymphoid leukemia chronic in remission
279.00
hypogammaglobulinemia unspecified
279.03
other selective immunoglobulin deficiencies
279.04
congenital hypogammaglobulinemia
279.05
immunodeficiency with increased igm
279.06
common variable immunodeficiency
279.12
wiskott-aldrich syndrome
279.2
combined immunity deficiency
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
356.4
idiopathic progressive polyneuropathy
357.0
acute infective polyneuritis
357.81
chronic inflammatory demyelinating polyneuritis
358.01
myasthenia gravis with (acute) exacerbation
446.1
acute febrile mucocutaneous lymph node syndrome (mcls)
694.4
pemphigus
694.5
pemphigoid
694.60 - 694.61 benign mucous membrane pemphigoid without ocular involvement - benign mucous membrane pemphigoid with ocular involvement
694.8
other specified bullous dermatoses
710.3
dermatomyositis
710.4
polymyositis
996.85
complications of transplanted bone marrow
v42.81
bone marrow replaced by transplant
v42.82
peripheral stem cells replaced by transplant
CMS Limitations
Lipids
LCD # L27352, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 80061, CPT 82465, CPT 83700, CPT 83701, CPT 83704, CPT 83718, CPT 83721, CPT 84478
ICD-9 Codes that SUPPORT medical necessity for Lipid Panel (CPT 80061); Cholesterol, serum or whole blood, total
(CPT 82465); Lipoprotein, blood, electrophoretic separation and quantitation (CPT 83700); Lipoprotein, blood, high
resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (e.g. electrophoresis, ultracentrifugation) (CPT 83701); Lipoprotein, blood, quantitation of lipoprotein particle numbers and lipoprotein particles subclasses (CPT 83704); Lipoprotein, direct measurement, HDL cholesterol (CPT 83718); Lipoprotein,
direct measurement, LDL cholesterol (CPT 83721); Triglycerides (CPT 84478):
242.00-245.9
250.00-250.93
255.0
260
261
262
263.0
263.1
263.8
263.9
270.0
271.1
272.0
272.1
272.2
272.3
272.4
272.5
272.6
272.7
272.8
272.9
277.30
277.31
277.39
278.00
278.01
278.02
303.90-303.92
362.10-362.16
362.30-362.34
362.82
371.41
374.51
379.22
388.00
388.02
401.0, 401.1, 401.9
disorders of the thyroid gland with hormonal dysfunction
diabetes mellitus
cushing’s syndrome
kwashiorkor
nutritional marasmas
other severe, protein-calorie malnutrition
malnutrition of moderate degree
malnutrition of mild degree
other protein-calorie malnutrition
unspecified protein-calorie malnutrition
disturbances of amino-acid transport
galactosemia
pure hypercholesterolemia
hyperglyceridemia
mixed hyperlipidemia (tuberous xanthoma)
hyperchylomicronemia
other and unspecified hyperlipidemia (unspecified xanthoma)
lipoprotein deficiencies
lipodystrophy
lipidoses
other disorders of lipoid metabolism
unspecified disorders of lipoid metabolism
amyloidosis, unspecified
familial mediterranean fever
other amyloidosis
obesity
morbid obesity
overweight
alcoholism
other background retinopathy and retinal vascular change
retinal vascular occlusion
retinal exudates and deposits
senile corneal changes
xanthelasma
crystalline deposits in vitreous
degenerative & vascular disorder of ear, unspecified
transient ischemic deafness
essential hypertension
CMS Limitations
Lipids (con’t)
402.00-402.91
403.00-403.91
404.00-404.93
405.01-405.99
410.00-410.92
411.0-411.1
411.81
411.89
412
413.0-413.1
413.9
414.00-414.03
414.04
414.05
414.06
414.07
414.10
414.11
414.12
414.19
414.8
414.9
428.0-428.9
429.2
429.9
431
433.00-433.91
434.00-434.91
435.0-435.9
437.0
437.1
437.5
438.0-438.9
440.0-440.9
441.00-441.9
442.0
442.1
442.2
444.0-444.9
557.1
571.8
571.9
573.8
573.9
577.0-577.9
579.3
579.8
581.0-581.9
584.5
585.4-585.9
hypertensive heart disease
hypertensive chronic kidney disease
hypertensive heart and chronic kidney disease
secondary hypertension
acute myocardial infarction
other acute & subacute forms of ischemic heart disease
coronary occlusion without myocardial infarction
other acute and subacute ischemic heart disease
old myocardial infarction
angina pectoris
other and unspecified angina pectoris
coronary atherosclerosis
coronary atherosclerosis of artery bypass graft
coronary athrscl-unspec graft
coronary atherosclerosis of coronary artery of transplanted heart
coronary atherosclerosis, of bypass graft (artery) (vein) of transplanted heart
aneurysm of heart (wall)
coronary vessel aneurysm
dissection of coronary artery
other aneurysm of heart
other specified forms of chronic ischemic heart disease
chronic ischemic heart disease, unspecified
heart failure
heart disease, unspecified
heart disease nos
intracerebral hemorrhage
occlusion & stenosis of precerebral arteries
occlusion of cerebral arteries
transient cerebral ischemia
cerebral atherosclerosis
other generalized ischemic cerebrovascular disease
moyamoya disease
late effects of cerebrovascular disease
arteriosclerosis
aortic aneurysms
upper extremity aneurysm
renal artery aneurysm
iliac artery aneurysm
arterial embolism & thrombosis
chronic vascular insufficiency of intestine
other chronic non-alcoholic liver disease
unspecified chronic liver disease without mention of alcohol
other specified disorders of liver
unspecified disorders of liver
pancreatic disease
other & unspecified postsurgical nonabsorption
other specified intestinal malabsorption
nephrotic syndrome
acute renal failure with lesion of tubular necrosis
chronic kidney disease
CMS Limitations
Lipids (con’t)
588.0
588.1
588.81
588.89
588.9
607.84
646.70-646.71
646.73
648.10-648.14
696.0
696.1
751.61
764.10-764.19
786.50
786.51
786.59
789.1
790.4
790.5
790.6
793.4
987.9
996.81
v42.0
v42.7
v58.63[v58.64
v58.69
v81.0-v81.2*
renal osteodystrophy
nephrogenic diabetes insipidus
secondary hyperparathyroidism (of renal orgin)
other specified disorders resulting from impaired renal function
unspecified disorder resulting from impaired renal function
impotence of organic origin, penis disorder
liver disorders in pregnancy
liver disorder antepartum
thyroid disfunction in pregnancy and the puerperium
psoriatic arthropathy
other psoriasis
biliary atresia
“light for dates” with signs of fetal malnutrition
chest pain unspecified
precordial pain
chest pain, other
hepatomegaly
abnormal transaminase
abnormal alkaline phosphatase
other abnormal blood chemistry
abnormal imaging study
toxic effect of unspecified gas or vapor
complication of transplanted organ, kidney
transplanted organ, kidney
organ replacement by transplant,liver
long-term (current) drug use
long term (current) use of other medications
special screening for cardiovascular, respiratory, and genitourinary
*covered for procedure codes 80061, 82465, 83718, and 84478 only
LIMITATIONS: 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.
CMS Limitations
Parathormone (Parathyroid Hormone, PTH, Immunoreactive PTH)
LCD # L28443, Effective Date: 01/01/2009
CPT/HCPCS codes: CPT 83970
ICD-9 codes that SUPPORT medical necessity for parathormone (parathyroid hormone) (CPT 83970):
252.00
252.01
252.1
252.8
252.9
268.2
275.40
275.41
275.42
275.49
275.5
585.3
585.4
585.5
585.6
585.9
588.0
588.81
592.0
592.1
592.9
731.0
733.00
733.01
733.02
733.03
733.09
733.29
733.90
733.91
733.92
733.93
733.94
733.95
733.96
733.97
733.98
733.99
781.7
791.9*
v77.99*
hyperparathyroidism, unspecified
primary hyperparathyroidism
hypoparathyroidism
other specified disorders of parathyroid gland
unspecified disorder of parathyroid gland
osteomalacia unspecified
unspecified disorder of calcium metabolism
hypocalcemia
hypercalcemia
other disorders of calcium metabolism
hungry bone syndrome
chronic kidney disease, stage iii (moderate)
chronic kidney disease, stage iv (severe)
chronic kidney disease, stage v
end stage renal disease
chronic kidney disease, unspecified
renal osteodystrophy
secondary hyperparathyroidism (of renal origin)
calculus of kidney
calculus of ureter
urinary calculus unspecified
osteitis deformans without bone tumor
osteoporosis unspecified
senile osteoporosis
idiopathic osteoporosis
disuse osteoporosis
other osteoporosis
other bone cyst
disorder of bone and cartilage unspecified
arrest of bone development or growth
chondromalacia
stress fracture of tibia or fibula
stress fracture of the metatarsals
stress fracture of other bone
stress fracture of femoral neck
stress fracture of shaft of femur
stress fracture of pelvis
other disorders of bone and cartilage
tetany
other nonspecific findings on examination of urine
screening for other and unspecified endocrine nutritional metabolic and immunity disorders
*ICD-9-CM code 791.9 should be used for patients with hypercalciuria.
*ICD-9-CM code V77.99 should be used as a secondary diagnosis with a primary diagnosis of primary hyperparathyroidism for patients undergoing parathyroidectomy with acute intraoperative monitoring of parathormone.
CMS Limitations
Partial Thromboplastin Time (PTT)
LCD # 190.16, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 85730
ICD-9 Codes that SUPPORT medical necessity for Thromboplastin time, partial (PTT); plasma or whole blood (CPT
85730):
002.0-002.9
003.0-003.9
038.9
042
060.0-060.9
065.0-065.9
070.0-070.9
075
078.6
078.7
120.0
121.1
121.3
124
135
155.0-155.2
197.7
238.4
238.71
238.72
238.73
238.74
238.75
238.76
*238.77
238.79
239.9
246.3
250.40-250.43
269.0
273.0-273.3, 273.8-273.9
*275.5
277.1
277.30
277.31
277.39
285.1
286.0
286.1
286.2-286.3
286.4
286.5
typhoid and paratyphoid
other salmonella infections
unspecified septicemia
human immunodeficiency virus (hiv) disease
yellow fever
arthropod borne hemorrhagic fever
viral hepatitis
infectious mononucleosis
hemorrhagic nephrosonephritis
arenaviral hemorrhagic fever
schistosomiasis haematobium
clonorchiasis
fascioliasis
trichinosis
sarcoidosis
malignant neoplasm of liver and intrahepatic bile ducts
malignant neoplasm of liver, specified as secondary
polycythemia vera
essential thrombocythemia
low grade myelodysplastic syndrome lesions
high grade myelodysplastic syndrome lesions
myelodysplastic syndrome with 5q deletion
myelodysplastic syndrome, unspecified
myelofibrosis with myeloid metaplasia
*post-transplant lymphoproliferative disorder (ptld)
other lymphatic and hematopoietic tissues
neoplasm of unspecified nature, site unspecified
hemorrhage and infarction of thyroid
diabetic with renal manifestations
deficiency of vitamin k
disorders of plasma protein metabolism
*hungry bone syndrome
disorders of porphyrin metabolism
amyloidosis, unspecified
familial mediterranean fever
other amyloidosis
acute posthemorrhagic anemia
congenital factor viii disorder-hemophilia a
congenital factor ix disorder-hemophilia b
other congenital factor deficiencies
von willebrand’s disease
hemorrhagic disorder due to intrinsic circulating anticoagulants
CMS Limitations
Partial Thromboplastin Time (PTT) (con’t)
286.6
defibrination syndrome
286.7
acquired coagulation factor deficiency
286.9
other and unspecified coagulation defects
287.0-287.9
purpura and other 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
362.30-362.37 retinal vascular occlusion
362.43
hemorrhagic detachment of retinal pigment epithelium
362.81
retinal hemorrhage
363.61-363.63 choroidal hemorrhage
363.72
choroidal detachment
368.9
unspecified visual disturbances
372.72
conjunctive 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
403.01, 403.11, hypertensive chronic kidney disease, with chronic kidney disease stage v or end stage renal disease
403.91
404.02, 404.12, hypertensive heart and chronic kidney disease, without heart failure and with chronic kidney disease
404.92
stage v or end stage renal disease
410.00-410.92 acute myocardial infarction
423.0
hemopericardium
427.31
atrial fibrillation
427.9
cardiac dysrhythmias, unspecified
428.0
congestive heart failure, unspecified
429.79
mural thrombus
430-432.9
cerebral hemorrhage
433.00-433.91 occlusion and stenosis of precerebral arteries
434.00-434.91 occlusion of cerebral arteries
435.9
focal neurologic deficit
444.0-444.9
arterial embolism and thrombosis
446.6
thrombotic microangiopathy
447.2
rupture of artery
448.0
hereditary hemorrhagic telangiectasia
451.0-451.9
phlebitis and thrombophlebitis
453.0-453.9
other venous emboli and thrombosis
456.0
esophageal varices with bleeding
456.1
esophageal varices without bleeding
456.8
varices of other sites
459.89
ecchymosis
530.7
gastroesophageal laceration – hemorrhage syndrome
530.82
esophageal hemorrhage
531.00-535.61 gastric-duodenal ulcer disease
537.83
angiodysplasia of stomach and duodenum with hemorrhage
537.84
dieulafoy lesion (hemorrhagic) of stomach and duodenum
556.0-557.9
hemorrhagic bowel disease
CMS Limitations
Partial Thromboplastin Time (PTT) (con’t)
562.02-562.03
562.12
562.13
568.81
569.3
570
571.0
*571.42
573.9
576.0-576.9
577.0
578.0-578.9
579.0-579.9
581.0-581.9
583.9
584.5-584.9
585.4-585.9
586
593.81-593.89
596.7
596.8
*599.70
*599.71
*599.72
607.82
608.83
*611.89
620.7
621.4
622.8
623.6
623.8
624.5
626.6
626.7
627.0
627.1
629.0
632
634.00-634.92
635.10-635.12
636.10-636.12
637.10-637.12
638.1
639.1
639.6
640.00-640.93
641.00-641.93
642.00-642.94
646.70-646.73
diverticulosis of small intestine with hemorrhage
diverticulosis of colon with hemorrhage
diverticulitis of colon with hemorrhage
hemoperitoneum (nontraumatic)
hemorrhage of rectum and anus
acute and subacute necrosis of liver
liver disease (in place of specific codes listed)
*autoimmune hepatitis
other chronic hepatitis
biliary tract disorders
acute pancreatitis
gastrointestinal hemorrhage
malabsorption
nephrotic syndrome
nephritis, with unspecified pathological lesion in kidney
acute renal failure
chronic kidney disease
renal failure
other disorders of kidney and ureter, with hemorrhage
hemorrhage into bladder wall
other disorders of bladder, with hemorrhage
*hematuria, unspecified
*gross hematuria
*microscopic hematuria
penile hemorrhage
vascular disorders of male genital organs
*other specified disorders of breast including hematoma
hemorrhage of broad ligament
hematometra
other specified disorders of cervix, with hemorrhage
vaginal hematoma
other specified diseases of the vagina, with hemorrhage
hematoma of vulva
metrorrhagia
postcoital bleeding
premenopausal bleeding
postmenopausal bleeding
hematocele female not elsewhere classified
missed abortion
spontaneous abortion
legally induced abortion, complicated by delayed or excessive hemorrhage
illegally induced abortion, complicated by delayed or excessive hemorrhage
abortion unspecified, complicated by delayed or excessive hemorrhage
failed attempt abortion, complicated by delayed or excessive hemorrhage
delayed or excessive hemorrhage following abortion and ectopic and molar pregnancies
complications following abortion and ectopic and molar pregnancies, embolism
hemorrhage in early pregnancy
antepartum hemorrhage
hypertension complicating pregnancy, childbirth, and the puerperium
liver disorders in pregnancy
CMS Limitations
Partial Thromboplastin Time (PTT) (con’t)
649.30
649.31
649.32
649.33
649.34
649.50
649.51
649.53
656.00-656.03
658.40-658.43
666.00-666.34
671.20-671.54
673.00-673.84
674.30-674.34
710.0
713.2
713.6
719.10-719.19
729.5
729.81
733.10-733.19
762.1
764.90-764.99
767.0, 767.11
767.8
770.3
772.0-772.9
774.0-774.7
776.0-776.9
780.2
782.4
782.7
784.7
784.8
785.4
785.50
786.05
786.3
786.50
786.59
789.00-789.09
790.92
coagulation defects complicating pregnancy, childbirth, or the puerperium, unspecified as to episode
of care or not applicable
coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with or without
mention of antepartum condition
coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with mention of
postpartum complication
coagulation defects complicating pregnancy, childbirth, or the puerperium, antepartum condition or
complication
coagulation defects complicating pregnancy, childbirth, or the puerperium, postpartum condition or
complication
spotting complicating pregnancy, unspecified as to episode of care or not applicable
spotting complicating pregnancy, delivered, with or without mention of antepartum condition
spotting complicating pregnancy, antepartum condition or complication
fetal maternal hemorrhage
infection of amniotic cavity
postpartum hemorrhage
phlebitis in pregnancy
obstetrical pulmonary embolus
other complications of surgical wounds, with hemorrhage
systemic lupus erythematosus
arthropathy associated with hematologic disorders (note: may not be used without indicating
associated condition first)
arthropathy associated with henoch schonlein (note: may not be used without indicating associated
condition first)
hemarthrosis
leg pain/calf pain
swelling of limb
pathologic fracture associated with fat embolism
other forms of placental separation with hemorrhage (affecting newborn code – do not assign to
mother’s record)
fetal intrauterine growth retardation
subdural and cerebral hemorrhage
other specified birth trauma, with hemorrhage
fetal and newborn pulmonary hemorrhage
fetal and neonatal hemorrhage
other perinatal jaundice
hemorrhagic disease of the newborn
syncope
jaundice, unspecified, not of newborn
spontaneous ecchymoses petechiae
epistaxis
hemorrhage from throat
gangrene
shock
shortness of breath
hemoptysis
chest pain, unspecified
chest pain
abdominal pain
abnormal coagulation profile
CMS Limitations
Partial Thromboplastin Time (PTT) (con’t)
800.00-800.99
801.00-801.99
802.20-802.9
803.00-803.99
804.00-804.99
805.00806.9
807.00-807.09
807.10-807.19
808.8-808.9
809.0-809.1
810.00-810.13
811.00-811.19
812.00-812.59
813.10-813.18
813.30-813.33
813.50-813.54
813.90-813.93
819.0-819.1
820.00–821.39
823.00-823.92
827.0–829.1
852.00–853.19
860.0-860.5
861.00-861.32
862.0-862.9
863.0-863.99
999.2
864.00-864.19
865.00-865.19
866.00-866.13
867.0-867.9
868.00-868.19
869.0-869.1
900.00-900.9
901.0-901.9
902.0-902.9
903.00-903.9
904.0-904.9
920-924.9
925.1-929.9
958.2
959.9
964.2
964.5
964.7
980.0
989.5
995.20
995.21
fracture of vault of skull
fracture of base of skull
fracture of face bones
other fracture, skull
multiple fractures, skull
fracture, vertebral column
fractures of rib(s), closed
fracture of rib(s), open
fracture of pelvis
fracture of trunk
fracture of clavicle
fracture of scapula
fracture of humerus
fracture of radius and ulna, upper end, open
fracture of radius and ulna, shaft, open
fracture of radius and ulna, lower end, open
fracture of radius and ulna, unspecified part, open
multiple fractures
femur
tibia and fibula
other multiple lower limb
subarachnoid subdural, and extradural hemorrhage, following injury, other and specified intracranial
hemorrhage following injury
traumatic pneumothorax and hemothorax
injury to heart and lung
injury to other and unspecified intrathoracic organs
injury to gastrointestinal tract
other vascular complications of medical care
injury to liver
injury to spleen
injury to kidney
injury to pelvic organs
injury to other intra-abdominal organs
internal injury to unspecified or ill defined organs
injury to blood vessels of head and neck
injury to blood vessels of the thorax
injury to blood vessels of the abdomen and pelvis
injury to blood vessels of upper extremity
injury to blood vessels of lower extremity and unspecified sites
contusion with intact skin surface
crushing injury
secondary and recurrent hemorrhage
injury, unspecified site
poisoning by anticoagulants
poisoning by anticoagulant antagonists
poisoning by natural blood and blood products
toxic effects of alcohol
snake venom
unspecified adverse effect of unspecified drug, medicinal and biological substance
arthus phenomenon
CMS Limitations
Partial Thromboplastin Time (PTT) (con’t)
995.27
995.29
996.70-996.79
997.02
998.11
998.12
v12.3
v58.2
v58.61
v58.83
other drug allergy
unspecified adverse effect of other drug, medicinal and biological substance
other complications of internal prosthetic device
iatrogenic cerebrovascular infarction or hemorrhage
hemorrhage or hematoma complicating a procedure
hematoma complicating a procedure
personal history of diseases of blood and blood forming organs
admission for transfusion of blood products
long term (current use) of anticoagulants
encounter for therapeutic drug monitoring
LIMITATIONS: The need to repeat this test is determined by changes in the underlying medical condition and/or the
dosing of heparin.
CMS Limitations
Prostate Specific Antigen (PSA)
LCD # 190.31, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 84153
ICD-9 Codes that SUPPORT medical necessity for Prostate Specific Antigen (PSA), total (CPT 84153):
185
188.5
196.5
196.6
196.8
198.5
198.82
233.4
236.5
239.5
596.0
599.60, 599.69
*599.70
*599.71
*599.72
600.00
600.01
600.10
600.11
600.21
601.9
602.9
788.20
788.21
788.30
788.41
788.43
788.62
788.63
788.64
788.65
790.93
793.6-793.7
794.9
v10.46
malignant neoplasm of prostate
malignant neoplasm of bladder neck
secondary malignant neoplasm, lymph nodes inguinal region and lower limb
secondary malignant neoplasm, intrapelvic lymph nodes
secondary malignant neoplasm, lymph nodes of multiple sites
secondary malignant neoplasm, bone and bone marrow
secondary malignant neoplasm, genital organs
carcinoma in situ, prostate
neoplasm of uncertain behavior of prostate
neoplasm of unspecified nature, other genitourinary organs
bladder neck obstruction
urinary obstruction
*hematuria, unspecified
*gross hematuria
*microscopic hematuria
hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract (luts)
hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms
(luts)
nodular prostate without urinary obstruction
nodular prostate with urinary obstruction
benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract
symptoms (luts)
unspecified prostatitis
unspecified disorder of prostate
retention of urine, unspecified
incomplete bladder emptying
urinary incontinence, unspecified
urinary frequency
nocturia
slowing of urinary stream
urgency of urination
urinary hesitancy
straining on urination
elevated prostate specific antigen (psa)
non-specific abnormal result of radiologic examination, evidence of malignancy
bone scan evidence of malignancy
personal history of malignant neoplasm; prostate
LIMITATIONS: Generally, for patients with lower urinary tract signs or symptoms, the test is performed only once peryear unless there is a change in the patient’s medical condition.
Testing with a diagnosis of 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.
CMS Limitations
Prothrombin Time (PT)
LCD # 190.17, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 85610
ICD-9 Codes that SUPPORT medical necessity for Prothrombin Time (CPT 85610):
002.0-002.9
typhoid and paratyphoid
003.0-003.9
other salmonella infections
038.9
unspecified septicemia
042
human immunodeficiency virus (hiv) disease
060.0-060.9
yellow fever
065.0-065.9
arthropod-borne hemorrhagic fever
070.0-070.9
viral hepatitis
075
infectious mononucleosis
078.6
hemorrhagic nephrosonephritis
078.7
arenaviral hemorrhagic fever
084.8
blackwater fever
120.0
schistosomiasis
121.1
clonorchiasis
121.3
fascioliasis
124
trichinosis
134.2
hirudiniasis
135
sarcoidosis
152.0-152.9
malignant neoplasm of small intestine, including duodenum
155.0-155.2
malignant neoplasm of liver and intrahepatic bile ducts
156.0-156.9
malignant neoplasm of gallbladder and extrahepatic bile ducts
157.0-157.9
malignant neoplasm of pancreas
188.0-189.9
malignant neoplasm of bladder, kidney, and other and unspecified urinary organs
198.0
secondary malignant neoplasm, kidney
198.1
secondary malignant neoplasm, other urinary organs
200.00-200.88 lymphosarcoma and reticulosarcoma
202.00-202.98 other malignant neoplasms of lymphoid and histiocytic tissue
*209.20-209-27,*malignant carcinoid tumors of other and unspecified sites
209.29
223.0-223.9
benign neoplasm of kidney and other urinary organs
238.4
polycythemia vera
238.5
histocytic and mast cells – neoplasm of uncertain behavior
238.6
plasma cells – neoplasm of uncertain behavior
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
*238.77
*post-transplant lymphoproliferative disorder (ptld)
238.79
other lymphatic and hematopoietic tissues
239.4
neoplasm of unspecified nature, bladder
239.5
neoplasm of unspecified nature, other genitourinary organs
239.9
neoplasm of unspecified nature, site unspecified
246.3
hemorrhage and infarction of thyroid
CMS Limitations
Prothrombin Time (PT) (con’t)
250.40-250.43
263.0-263.9
269.0
269.2
273.0-273.3, 273.8-273.9
275.0
277.1
277.30
277.31
277.39
280.0
280.9
281.0
281.1
281.9
285.0
285.1
286.0-286.9
287.0-287.9
289.81
290.40-290.43
325
342.90-342.92
360.43
362.18
362.30-362.37
362.43
362.81
363.61-363.72
368.9
372.72
374.81
376.32
377.42
377.53
377.62
377.72
379.23
380.31
386.2
386.50
394.0-394.9
395.0
395.2
396.0-396.9
397.0-397.9
455.2
447.1
diabetic with renal manifestations
other and unspecified protein/calorie malnutrition
deficiency of vitamin k
unspecified vitamin deficiency
disorders of plasma protein metabolism
disorders of iron metabolism
disorders of porphyrin metabolism
amyloidosis, unspecified
familial mediterranean fever
other amyloidosis
iron deficiency anemia, secondary to blood loss – chronic
iron deficiency anemia, unspecified
pernicious anemia
other vitamin b12 deficiency anemia, nec
unspecified deficiency anemia, nos
sideroblastic anemia
acute posthemorrhagic anemia
coagulation defects
purpura and other hemorrhagic conditions
primary hypercoagulable state
vascular dementia
phlebitis and thrombophlebitis of intracranial venous sinuses
hemiplegia nos
hemophthalmos, except current injury
retinal vasculitis
retinal vascular occlusion
hemorrhagic detachment of retinal pigment epithelium
retinal hemorrhage
choroidal hemorrhage and rupture, detachment
unspecified visual disturbances
conjunctival hemorrhage
hemorrhage of eyelid
orbital hemorrhage
hemorrhage in optic nerve sheaths
disorders of optic chiasm associated with vascular disorders
disorders of visual pathways associated with vascular disorders
disorders of visual cortex associated with vascular disorders
vitreous hemorrhage
hematoma of auricle or pinna
vertigo of central origin
labyrinthine dysfunction, unspecified
diseases of the mitral valve
rheumatic aortic stenosis
rheumatic aortic stenosis with insufficiency
diseases of mitral and aortic valves
diseases of other endocardial structures
internal hemorrhoids with other complication
stricture of artery
CMS Limitations
Prothrombin Time (PT) (con’t)
447.2
447.6
448.0
448.9
451.0-451.9
452
453.0-453.9
455.5
455.8
456.0-456.1
456.8
459.0
459.10-459.19
459.2
459.81
459.89
*511.81
*511.89
514
530.7
530.82
530.86
530.87
531.00-535.61
555.0-555.9
556.0-556.9
557.0-557.9
562.02-562.03
562.10
562.11
562.12
562.13
568.81
569.3
571.0
*571.42
571.9
572.2
572.4
572.8
573.1-573.9
576.0-576.9
577.0
578.0-578.9
579.0-579.9
581.0-581.9
583.9
584.5-584.9
585.4-585.9
586
rupture of artery
arteritis, unspecified
hereditary hemorrhagic telangiectasia
other and unspecified capillary diseases
phlebitis and thrombophlebitis
portal vein thrombosis
other venous embolism and thrombosis
external hemorrhoids with other complication
unspecified hemorrhoids with other complication
esophageal varices
varices of other sites
hemorrhage, unspecified
postphlebetic syndrome
compression of vein
venous (peripheral) insufficiency, unspecified
other, other specified disorders of circulatory system
*malignant pleural effusion
*other specified forms of effusion, except tuberculosis
pulmonary congestion and hypostasis
gastroesophageal laceration
hemorrhage syndrome
esophageal hemorrhage
infection of esophagostomy
mechanical complication of esophagostomy
gastric ulcer, duodenal ulcer, peptic ulcer, gastrojejunal ulcer, gastritis and duodenitis
regional enteritis
ulcerative colitis
vascular insufficiency of intestine
diverticulosis of small intestine with hemorrhage
diverticulosis of colon w/o hemorrhage
diverticulitis of colon w/o hemorrhage
diverticulosis of colon with hemorrhage
diverticulitis of colon with hemorrhage
hemoperitoneum (nontraumatic)
hemorrhage of rectum and anus
chronic liver disease and cirrhosis
*autoimmune hepatitis
chronic liver disease and cirrhosis
hepatic coma
hepatorenal syndrome
other sequelae of chronic liver disease
hepatitis in viral diseases, other and unspecified disorder of liver
other disorders of biliary tract
acute pancreatitis
gastrointestinal hemorrhage
intestinal malabsorption
nephrotic syndrome
nephritis, with unspecified pathological lesion in kidney
acute renal failure
chronic kidney disease
renal failure, unspecified
CMS Limitations
Prothrombin Time (PT) (con’t)
593.81-593.89
596.7
596.8
*599.70
*599.71
*599.72
607.82
608.83
*611.89
620.7
621.4
622.8
623.6
623.8
624.5
626.2-626.9
627.0
627.1
629.0
632
634.10-634.12
635.10-635.12
636.10-636.12
637.10-637.12
638.1
639.1
639.6
640.00-640.93
641.00-641.93
642.00-642.94
646.70-646.73
649.30
649.31
649.32
649.33
649.34
649.50
649.51
649.53
656.00-656.03
658.40-658.43
666.00-666.34
671.20-671.94
673.00-673.84
674.30-674.34
other specified disorders of kidney and ureter
hemorrhage into bladder wall
other specified disorders of bladder
*hematuria, unspecified
*gross hematuria
*microscopic hematuria
vascular disorders of penis
vascular disorders of male genital organs
*other specified disorders of breast including hematoma
hematoma of broad ligament
hematometra
other specified noninflammatory disorders of cervix
vaginal hematoma
other specified noninflammatory disorders of the vagina
hematoma of vulva
abnormal bleeding from female genital tract
premenopausal menorrhagia
postmenopausal bleeding
hematocele female, not classified elsewhere
missed abortion
spontaneous abortion, complicated by excessive hemorrhage
legally induced abortion, complicated by delayed or excessive hemorrhage
illegally induced abortion, complicated by delayed or excessive hemorrhage
abortion unspecified, complicated by delayed or excessive hemorrhage
failed attempted abortion, complicated by delayed or excessive hemorrhage
delayed or excessive hemorrhage following abortion and ectopic and molar pregnancies
complications following abortion and ectopic and molar pregnancies with embolism
hemorrhage in early pregnancy
antepartum hemorrhage, abruptio placentae, and placenta previa
hypertension complicating pregnancy, childbirth, and the puerperium
liver disorders in pregnancy
coagulation defects complicating pregnancy, childbirth, or the puerperium, unspecified as to episode
of care or not applicable
coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with or without
mention of antepartum condition
coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with mention of
postpartum complication
coagulation defects complicating pregnancy, childbirth, or the puerperium, antepartum condition or
complication
coagulation defects complicating pregnancy, childbirth, or the puerperium, postpartum condition or
complication
spotting complicating pregnancy, unspecified as to episode of care or not applicable
spotting complicating pregnancy, delivered, with or without mention of antepartum condition
spotting complicating pregnancy, antepartum condition or complication
fetal maternal hemorrhage
infection of amniotic cavity
postpartum hemorrhage
venous complications in pregnancy and the puerperium except legs, vulva and perineum
obstetrical pulmonary embolism
other complications of obstetrical surgical wounds
CMS Limitations
Prothrombin Time (PT) (con’t)
713.2
713.6
719.15
719.16
719.19
729.5
729.81
733.10
746.00-746.9
762.1
767.0, 767.11
767.8
770.3
772.0-772.9
774.6
776.0-776.9
780.2
782.3
782.4
782.7
784.7
784.8
785.4
785.50
786.05
786.3
786.59
789.00-789.09
789.1
789.51
789.59
790.92
790.94
791.2
794.8
800.00-800.99
801.00-801.99
802.20-802.9
803.00-803.99
804.00-804.99
805.00-806.9
807.00-807.09
807.10-807.19
808.8-808.9
809.0-809.1
810.00-810.13
811.00-811.19
812.00-812.59
813.10-813.18
813.30-813.33
arthropathy associated with hematological disorders
arthropathy associated with hypersensitivity reaction
hemarthrosis pelvic region and thigh
lower leg
multiple sites
pain in limb
swelling of limb
pathologic fracture, unspecified site
other congenital anomalies of heart
other forms of placental separation and hemorrhage
birth trauma, subdural and cerebral hemorrhage and injury to scalp
other specified birth trauma
pulmonary hemorrhage
fetal and neonatal hemorrhage
unspecified fetal and neonatal jaundice
hemorrhagic disease of the newborn
syncope and collapse
edema
jaundice, unspecified, not of newborn
spontaneous ecchymosis
epistaxis
hemorrhage from throat
gangrene
shock without mention of trauma
shortness of breath
hemoptysis
chest pain, other
abdominal pain
hepatomegaly
malignant ascites
other ascites
abnormal coagulation profile
euthyroid sick syndrome
hemoglobinuria
abnormal liver function study
fracture of vault of skull
fracture of base of skull
fracture of face bones
other and unqualified skull fractures
multiple fractures involving skull or face with other bones
fracture, vertebral column
fractures of rib(s), closed
fracture of rib(s), open
unspecified fracture of pelvis
ill-defined fractures of bones of trunk
fracture of clavicle
fracture of scapula
fracture of humerus
fracture of radius and ulna, upper end, open
shaft, open
CMS Limitations
Prothrombin Time (PT) (con’t)
813.50-813.54
813.90-813.93
819.0-819.1
820.00-821.39
823.00-823.92
827.0-829.1
852.00-853.19
lower end, open
fracture unspecified part, open
multiple fractures involving both upper limbs, closed and open
fracture of neck of femur
fracture of tibia and fibula
other multiple lower limb
subarachnoid subdural, and extradural hemorrhage, following injury, other and specified intracranial
hemorrhage following injury
860.0-860.5
traumatic pneumothorax and hemothorax
861.00-861.32 injury to heart and lung
862.0-862.9
injury to other and unspecified intrathoracic organs
863.0-863.90 injury to gastrointestinal tract
863.91-863.95, adding to injury to gastrointestinal tract
863.99
864.00-864.19 injury to liver
865.00-865.19 injury to spleen
866.00-866.13 injury to kidney
867.0-867.9
injury to pelvic organs
868.00-868.19 injury to other intra-abdominal organs
869.0-869.1
internal injury to unspecified or ill defined organs
900.00-900.9 injury to blood vessels of head and neck
901.0-901.9
injury to blood vessels of the thorax
902.0-902.9
injury to blood vessels of the abdomen and pelvis
903.00-903.9 injury to blood vessels of upper extremity
904.0-904.9
injury to blood vessels of lower extremity and unspecified sites
920-924.9
contusion with intact skin surface
925.1-929.9
crushing injury
958.2
secondary and recurrent hemorrhage
959.9
injury, unspecified site
964.0-964.9
poisoning by agents primarily affecting blood constituents
980.0-980.9
toxic effect of alcohol
981
toxic effect of petroleum products
982.0-982.8
toxic effects of solvents other than petroleum-based
987.0-987.9
toxic effect of other gases, fumes or vapors
989.0-989.9
toxic effect of other substances chiefly non-medicinal 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
complication of transplanted liver
997.02
iatrogenic cerebrovascular infarction or hemorrhage
997.4
digestive system complications
998.11-998.12
hemorrhage or hematoma complicating a procedure
999.2
other vascular complications
*999.89
*other transfusion reaction
v08
asymptomatic hiv infection
v12.1
history of nutritional deficiency
v12.3
personal history of diseases of blood and blood-forming organs
v12.50-v12.54, personal history of transient ischemic attack, and cerebral infarction without residual deficits
v12.59
CMS Limitations
Prothrombin Time (PT) (con’t)
v15.1
v42.0
v42.1
v42.2
v42.6
v42.7
v42.81-v42.89
v43.21-v43.22
v43.3
v43.4
v58.2
v58.61
v58.83
personal history of surgery to heart and great vessels
kidney replaced by transplant
heart replaced by transplant
heart valve replaced by transplant
lung replaced by transplant
liver replaced by transplant
other specified organ or tissue replaced by transplant
heart replaced by other means
heart valve replaced by other means
blood vessel replaced by other means
transfusion of blood products
long-term (current) use of anticoagulants
encounter for therapeutic drug monitoring
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 or renal failure unspecified.
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. When testing is performed to evaluate a patient with signs or symptoms of abnormal bleeding or thrombosis
and the initial test result is normal, it is ordinarily not necessary to repeat testing unless there is a change in the patient’s
medical status.
CMS Limitations
Serum Iron Studies
LCD # 190.18, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 82728, CPT 83540, CPT 83550, CPT 84466
ICD-9 Codes that SUPPORT medical necessity for Ferritin (CPT 82728); Iron (CPT 83540); Iron Binding capacity (CPT
83550); Transferrin (CPT 84466):
002.0-002.9
typhoid and paratyphoid fevers
003.0-003.9
other salmonella infections
006.0-006.9
amebiasis
007.0-007.9
other protozoal intestinal diseases
008.00-008.8 intestinal infections due to other organisms
009.0-009.3
ill-defined intestinal infections
011.50-011.56
tuberculous bronchiectasis
014.00-014.86 tuberculosis of intestines, peritoneum, and mesenteric glands
015.00-015.96 tuberculosis of bones and joints
016.00-016.06 tuberculosis of kidney
016.10-016.16
tuberculosis of bladder
016.20-016.26 tuberculosis of ureter
016.30-016.36 tuberculosis of other urinary organs
042
human immunodeficiency virus (hiv) disease
070.0-070.9
viral hepatitis
140.0-149.9
malignant neoplasm of lip oral cavity and pharynx
150.0-159.9
malignant neoplasm of digestive organs and peritoneum
160.0-165.9
malignant neoplasm of respiratory and intrathoracic organs
170.0-176.9
malignant neoplasm of bone, connective tissue, skin and breast
179-189.9
malignant neoplasm of genitourinary organs
190.0-199.1
malignant neoplasm of other and unspecified sites
*199.2
*malignant neoplasm associated with transplanted organ
200.00-208.91 malignant neoplasm of lymphatic and hematopoietic tissue
*209.00-209.03*malignant carcinoid tumors of the small intestine
*209.10-209.17 *malignant carcinoid tumors of the appendix, large intestine and rectum
*209.20-209-27, *malignant carcinoid tumors of other and unspecified sites
209.29
*209.30
*malignant poorly differentiated neuroendocrine tumor, any site
*209.40-209.43 *benign carcinoid tumors of the small intestine
*209.50-209.57 *benign carcinoid tumors of the appendix, large intestine and rectum
*209.60-209.67, *benign carcinoid tumor of other and unspecified sites
209.69
210.0-229.9
benign neoplasms
230.0-233.2
carcinoma in situ (various)
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
233.4-234.9
carcinoma in situ (various)
CMS Limitations
Serum Iron Studies (con’t)
235.0-236.7, 236.90, 236.91,
236.99, 237.0237.6, 237.70237.72, 237.9238.6, 238.71238.76
*238.77
238.79, 238.8, 238.9
239.0-239.9
250.00-250.93
253.2
253.7
253.8
256.31-256.39
257.2
260
261
262
263.0-263.9
275.0
277.1
280.0-280.9
281.0-281.9
282.41-282.42, 282.49
282.60-282.63
282.64
282.68
282.69
285.0
285.1
285.21
285.9
286.0-286.9
287.0-287.9
289.52
306.4
307.1
307.50-307.59
403.01
403.11
403.91
404.02
404.03
neoplasms of uncertain behavior
*post-transplant lymphoproliferative disorder (ptld)
neoplasms of uncertain behavior
neoplasms of unspecified nature
diabetes mellitus
panhypopituitarism
iatrogenic pituitary disorders
other disorders of the pituitary and other syndromes of diencephalohypophysial origin
other ovarian failure
other testicular hypofunction
kwashiorkor
nutritional marasmus
other severe protein-calorie malnutrition
other and unspecified protein-calorie malnutrition
disorders of iron metabolism
disorders of porphyrin metabolism
iron deficiency anemias
other deficiency anemias
thalassemias
sickle-cell diseases
sickle-cell/hb-c disease with crisis
other sickle-cell disease without crisis
other sickle-cell disease with crisis
sideroblastic anemia (includes hemochromatosis with refractory anemia)
acute post-hemorrhagic anemia
anemia in chronic kidney disease
anemia, unspecified
coagulation defects (congenital factor disorders)
purpura and other hemorrhagic conditions
splenic sequestration
physiological malfunction arising from mental factors, gastrointestinal
anorexia nervosa
other and unspecified disorders of eating
hypertensive chronic kidney disease, malignant, with chronic kidney disease stage v or end stage renal
hypertensive chronic kidney disease, benign, with chronic kidney disease stage v or end stage renal
disease
hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage
renal disease
hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic
kidney disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney
disease stage v or end stage renal disease
CMS Limitations
Serum Iron Studies (con’t)
404.12
404.13
404.92
404.93
425.4
425.5
425.7
425.8
425.9
426.0-426.81, 426.89, 426.9
427.0-427.9
428.0-428.9
530.7
530.82
531.00-531.91
532.00-532.91
533.00-533.91
534.00-534.91
535.00-535.61
536.0-536.9
537.83
537.84
555.0-555.9
556.0-556.9
557.0
557.1
562.02
562.03
562.12
562.13
569.3
569.85
569.86
570
571.0-571.9
*571.42
572.0-572.8
573.0-573.9
578.0-578.9
579.0-579.3
579.8-579.9
581.0-581.9
585.4 – 585.9
586
608.3
hypertensive heart and chronic kidney disease, benign, without heart failure and with chronic kidney
disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease
stage v or end stage renal disease
hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic
kidney disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney
disease stage v or end stage renal disease
other primary cardiomyopathies
alcoholic cardiomyopathy
nutritional and metabolic cardiomyopathy
cardiomyopathy in other diseases classified elsewhere
secondary cardiomyopathy, unspecified
conduction disorders
cardiac dysrhythmias
heart failure
gastroesophageal laceration-hemorrhage syndrome
esophageal hemorrhage
gastric ulcer
duodenal ulcer
peptic ulcer, site unspecified
gastrojejunal ulcer
gastritis and duodenitis
disorders of function of stomach
angiodysplasia of stomach and duodenum with hemorrhage
dieulafoy lesion (hemorrhagic) of stomach and duodenum
regional enteritis
ulcerative colitis
acute vascular insufficiency of intestine
chronic vascular insufficiency of intestine
diverticulosis of small intestine with hemorrhage
diverticulitis of small intestine with hemorrhage
diverticulosis of colon with hemorrhage
diverticulitis of colon with hemorrhage
hemorrhage of rectum and anus
angiodysplasia of intestine with hemorrhage
dieulafoy lesion (hemorrhagic) of intestine
acute and subacute necrosis of liver
chronic liver disease and cirrhosis
*autoimmune hepatitis
liver abscess and sequelae of chronic liver disease
other disorders of liver
gastrointestinal hemorrhage
intestinal malabsorption
other specified and unspecified intestinal malabsorption
nephrotic syndrome
chronic kidney disease
renal failure, unspecified
atrophy of testis
CMS Limitations
Serum Iron Studies (con’t)
626.0-626.9
627.0
627.1
648.20-648.24
disorders of menstruation and other abnormal bleeding from female genital tract
premenopausal menorrhagia
postmenopausal bleeding
other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth,
or the puerperium: anemia
698.0-698.9
pruritus and related conditions
704.00-704.09 alopecia
709.00-709.09 dyschromia
713.0
arthropathy associated with other endocrine and metabolic disorders
716.40-716.99 other and unspecified arthropathies
719.40-719.49 pain in joint
773.2
hemolytic disease due to other and unspecified isoimmunization
773.3
hydrops fetalis due to isoimmunization
773.4
kernicterus due to isoimmunization
773.5
late anemia due to isoimmunization
783.9
other symptoms concerning nutrition, metabolism and development
790.01-790.09 abnormality of red blood cells
790.4
nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh]
790.5
other nonspecific abnormal serum enzyme levels
790.6
other abnormal blood chemistry
799.4
cachexia
964.0
poisoning by agents primarily affecting blood constituents, iron compounds
984.0-984.9
toxic effect of lead and its compounds (including fumes)
996.85
complications of transplanted organ, bone marrow
*999.89
*other transfusion reaction
v08
asymptomatic hiv infection
v12.1
personal history of nutritional deficiency
v12.3
personal history of diseases of blood and blood forming organs
v15.1
personal history of surgery to heart and great vessels
v43.21-v43.22 heart replaced by other means
v43.3
heart valve replaced by other means
v43.4
blood vessel replaced by other means
v43.60
unspecified joint replaced by other means
v56.0
extracorporeal dialysis
v56.8
other dialysis
LIMITATIONS: When an End Stage Renal Disease (ESRD) patient is tested for ferritin, testing more frequently than
every three months requires documentation of medical necessity (e.g., other than chronic renal failure or renal failure,
unspecified).
CMS Limitations
Serum Magnesium
LCD # L27375, Effective Date: 03/01/2009
CPT/HCPCS Codes: CPT 83735
ICD-9 Codes that SUPPORT medical necessity for Serum Magnesium testing (CPT 83735):
008.45
040.2
070.0
070.1
070.20-070.23 intestinal infection due to clostridium difficile
whipple’s disease
viral hepatitis a with hepatic coma
viral hepatitis a without hepatic coma
viral hepatitis b with hepatic coma acute or unspecified without hepatitis delta-chronic viral hepatitis
b with hepatic coma with hepatitis delta
070.30-070.33 viral hepatitis b without hepatic coma acute or unspecified without hepatitis delta-chronic viral
hepatitis b without hepatic coma with hepatitis delta
070.41
acute hepatitis c with hepatic coma
070.42
hepatitis delta without active hepatitis b disease with hepatic coma hepatitis delta with hepatitis b
carrier state
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
070.70-070.71 unspecified viral hepatitis c without hepatic coma-unspecified viral hepatitis c with hepatic coma
070.9
unspecified viral hepatitis without hepatic coma
203.00*
multiple myeloma, without mention of having achieved remission
203.02*
multiple myeloma, in relapse
250.00-250.03 diabetes mellitus without mention of complication, type ii or unspecified type, not stated as
uncontrolled-diabetes mellitus without mention of complication, type i [juvenile type], uncontrolled
250.10-250.13 diabetes with ketoacidosis, type ii or unspecified type, not stated as uncontrolled-diabetes with
ketoacidosis, type i [juvenile type], uncontrolled
250.20-250.23 diabetes with hyperosmolarity, type ii or unspecified type, not stated as uncontrolled-diabetes with
hyperosmolarity, type i [juvenile type], uncontrolled
250.30-250.33 diabetes with other coma, type ii or unspecified type, not stated as uncontrolled-diabetes with other
coma, type i [juvenile type], uncontrolled
250.40-250.43 diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled-diabetes
with renal manifestations, type i [juvenile type], uncontrolled
250.50-250.53 diabetes with ophthalmic manifestations, type ii or unspecified type, not stated as uncontrolleddiabetes with ophthalmic manifestations, type i [juvenile type], uncontrolled
250.60
diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled
250.70-250.73 diabetes with peripheral circulatory disorders, type ii or unspecified type, not stated as uncontrolled diabetes with peripheral circulatory disorders, type i [juvenile type], uncontrolled
250.80-250.83 diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolleddiabetes with other specified manifestations, type i [juvenile type], uncontrolled
250.90-250.93 diabetes with unspecified complication, type ii or unspecified type, not stated as uncontrolleddiabetes with unspecified complication, type i [juvenile type], uncontrolled
252.00-252.02 hyperparathyroidism, unspecified-secondary hyperparathyroidism, non-renal
CMS Limitations
Serum Magnesium (con’t)
252.08
252.1
252.8
252.9
255.10-255.14 255.41
255.42
259.3
260
261
262
263.0
263.1
263.8
263.9
268.2
269.3
269.8
275.2
275.3
275.40
275.41
275.42
275.49
275.5*
275.8
276.0
276.1
276.2
276.3
276.4
276.50
276.51
276.52
276.6
276.7
276.8
276.9
278.4
278.8
286.9
291.0-291.3 292.0
292.11-292.12 292.2
292.81-292.85 292.89
292.9
293.0
293.1
other hyperparathyroidism
hypoparathyroidism
other specified disorders of parathyroid gland
unspecified disorder of parathyroid gland
hyperaldosteronism, unspecified-other secondary aldosteronism
glucocorticoid deficiency
mineralocorticoid deficiency
ectopic hormone secretion not elsewhere classified
kwashiorkor
nutritional marasmus
other severe protein-calorie malnutrition
malnutrition of moderate degree
malnutrition of mild degree
other protein-calorie malnutrition
unspecified protein-calorie malnutrition
osteomalacia unspecified
mineral deficiency not elsewhere classified
other nutritional deficiency
disorders of magnesium metabolism
disorders of phosphorus metabolism
unspecified disorder of calcium metabolism
hypocalcemia
hypercalcemia
other disorders of calcium metabolism
hungry bone syndrome
other specified disorders of mineral metabolism
hyperosmolality and/or hypernatremia
hyposmolality and/or hyponatremia
acidosis
alkalosis
mixed acid-base balance disorder
volume depletion, unspecified
dehydration
hypovolemia
fluid overload disorder
hyperpotassemia
hypopotassemia
electrolyte and fluid disorders not elsewhere classified
hypervitaminosis d
other hyperalimentation
other and unspecified coagulation defects
alcohol withdrawal delirium-alcohol-induced psychotic disorder with hallucinations
drug withdrawal
drug-induced psychotic disorder with delusions-drug-induced psychotic disorder with hallucinations
pathological drug intoxication
drug-induced delirium-drug induced sleep disorders
other specified drug-induced mental disorders
unspecified drug-induced mental disorder
delirium due to conditions classified elsewhere
subacute delirium
CMS Limitations
Serum Magnesium (con’t)
294.0
294.10-294.11 amnestic disorder in conditions classified elsewhere
dementia in conditions classified elsewhere without behavioral disturbance-dementia in conditions
classified elsewhere with behavioral disturbance
294.8-294.9 other persistent mental disorders due to conditions classified elsewhere-unspecified persistent
mental disorders due to conditions classified elsewhere
298.9
unspecified psychosis
303.00 -303.02 acute alcoholic intoxication in alcoholism unspecified drinking behavior-acute alcoholic intoxication in
alcoholism episodic drinking behavior
303.90-303.93 other and unspecified alcohol dependence unspecified drinking behavior-other and unspecified
alcohol dependence in remission
305.90-305.93 other mixed or unspecified drug abuse unspecified use-nondependent other mixed or unspecified
drug abuse in remission
307.1
anorexia nervosa
307.20
tic disorder unspecified
307.22
chronic motor or vocal tic disorder
307.50
eating disorder unspecified
307.51
bulimia nervosa
307.52
pica
307.59
other disorders of eating
331.3
communicating hydrocephalus
331.5
idiopathic normal pressure hydrocephalus (inph)
333.0
other degenerative diseases of the basal ganglia
333.1
essential and other specified forms of tremor
333.2
myoclonus
333.3
tics of organic origin
336.1
vascular myelopathies
344.00-344.9 quadriplegia unspecified-paralysis unspecified
345.2-345.3 petit mal status epileptic-grand mal status epileptic
345.60
infantile spasms without intractable epilepsy
345.61
infantile spasms with intractable epilepsy
359.5
myopathy in endocrine diseases classified elsewhere
359.81
critical illness myopathy
359.89
other myopathies
359.9
myopathy unspecified
398.91
rheumatic heart failure (congestive)
402.01
malignant hypertensive heart disease with heart failure
402.11
benign hypertensive heart disease with heart failure
402.91
unspecified hypertensive heart disease with heart failure
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
404.01
hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage i through stage iv, or unspecified
404.03
hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney
disease stage v or end stage renal disease
404.11
hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage i through stage iv, or unspecified
CMS Limitations
Serum Magnesium (con’t)
404.13
404.91
404.93
410.00-410.02 410.10-410.12 410.20-410.22 410.30-410.32 410.40-410.42 410.50-410.52 410.60-410.62 410.70-410.72 410.80-410.82 410.90-410.92 411.81
415.11
426.10-426.13 426.2-426.4 426.50-426.54 426.6
426.7
426.81-426.82 426.89
426.9
427.0
427.1
427.2
427.31
427.32
427.41
427.42
427.5
427.60
427.61
427.69
427.81
427.89
427.9
hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease
stage v or end stage renal disease
hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney
disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage v or end stage renal disease
acute myocardial infarction of anterolateral wall episode of care unspecified-acute myocardial infarction of anterolateral wall subsequent episode of care
acute myocardial infarction of other anterior wall episode of care unspecified-acute myocardial infarction of other anterior wall subsequent episode of care
acute myocardial infarction of inferolateral wall episode of care unspecified-acute myocardial infarction of inferolateral wall subsequent episode of care
acute myocardial infarction of inferoposterior wall episode of care unspecified-acute myocardial infarction of inferoposterior wall subsequent episode of care
acute myocardial infarction of other inferior wall episode of care unspecified-acute myocardial infarction of other inferior wall subsequent episode of care
acute myocardial infarction of other lateral wall episode of care unspecified-acute myocardial infarction of other lateral wall subsequent episode of care
true posterior wall infarction episode of care unspecified-true posterior wall infarction subsequent episode of care
subendocardial infarction episode of care unspecified-subendocardial infarction subsequent episode
of care
acute myocardial infarction of other specified sites episode of care unspecified-acute myocardial infarction of other specified sites subsequent episode of care
acute myocardial infarction of unspecified site episode of care unspecified-acute myocardial infarction
of unspecified site subsequent episode of care
acute coronary occlusion without myocardial infarction
iatrogenic pulmonary embolism and infarction
atrioventricular block unspecified-other second degree atrioventricular block
left bundle branch hemiblock-right bundle branch block
bundle branch block unspecified-trifascicular block
other heart block
anomalous atrioventricular excitation
lown-ganong-levine syndrome-long qt syndrome
other specified conduction disorders
conduction disorder unspecified
paroxysmal supraventricular tachycardia
paroxysmal ventricular tachycardia
paroxysmal tachycardia unspecified
atrial fibrillation
atrial flutter
ventricular fibrillation
ventricular flutter
cardiac arrest
premature beats unspecified
supraventricular premature beats
other premature beats
sinoatrial node dysfunction
other specified cardiac dysrhythmias
cardiac dysrhythmia unspecified
CMS Limitations
Serum Magnesium (con’t)
428.0
428.20-428.23 428.30-428.33 428.40-428.43 congestive heart failure unspecified
unspecified systolic heart failure-acute on chronic systolic heart failure
unspecified diastolic heart failure-acute on chronic diastolic heart failure
unspecified combined systolic and diastolic heart failure-acute on chronic combined systolic and diastolic heart failure
428.9
heart failure unspecified
429.79
certain sequelae of myocardial infarction not elsewhere classified other
429.81
other disorders of papillary muscle
429.82
hyperkinetic heart disease
429.83
takotsubo syndrome
429.89
other ill-defined heart diseases
458.0
orthostatic hypotension
458.1
chronic hypotension
458.21
hypotension of hemodialysis
458.29
other iatrogenic hypotension
458.8
other specified hypotension
458.9
hypotension unspecified
493.00-493.02 extrinsic asthma unspecified-extrinsic asthma with (acute) exacerbation
493.10-493.12 intrinsic asthma unspecified-intrinsic asthma with (acute) exacerbation
493.20-493.22 chronic obstructive asthma unspecified-chronic obstructive asthma with (acute) exacerbation
493.81-493.82 exercise-induced bronchospasm-cough variant asthma
493.90-493.92 asthma unspecified-asthma unspecified with (acute) exacerbation
536.2
persistent vomiting
555.0
regional enteritis of small intestine
555.1
regional enteritis of large intestine
555.2
regional enteritis of small intestine with large intestine
555.9
regional enteritis of 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
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 impaction of intestine
560.81
intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)
560.89
other specified intestinal obstruction
CMS Limitations
Serum Magnesium (con’t)
560.9
564.2
564.3
564.4
569.81
571.0
571.1
571.2
571.3
571.40
571.41
571.42*
571.49
571.5
571.6
571.8
571.9
572.0
572.1
572.2
572.3
572.4
572.8
573.0
576.4
577.0
577.1
579.0
579.1
579.2
579.3
579.4
579.8
579.9
584.5
584.6
584.7
584.8
584.9
585.1
585.2
585.3
585.4
585.5
585.6
585.9
586
588.0
588.1
588.81
unspecified intestinal obstruction
postgastric surgery syndromes
vomiting following gastrointestinal surgery
other postoperative functional disorders
fistula of intestine excluding rectum and anus
alcoholic fatty liver
acute alcoholic hepatitis
alcoholic cirrhosis of liver
alcoholic liver damage unspecified
chronic hepatitis unspecified
chronic persistent hepatitis
autoimmune hepatitis
other chronic hepatitis
cirrhosis of liver without alcohol
biliary cirrhosis
other chronic nonalcoholic liver disease
unspecified chronic liver disease without alcohol
abscess of liver
portal pyemia
hepatic coma
portal hypertension
hepatorenal syndrome
other sequelae of chronic liver disease
chronic passive congestion of liver
fistula of bile duct
acute pancreatitis
chronic pancreatitis
celiac disease
tropical sprue
blind loop syndrome
other and unspecified postsurgical nonabsorption
pancreatic steatorrhea
other specified intestinal malabsorption
unspecified intestinal malabsorption
acute renal failure with lesion of tubular necrosis
acute renal failure with lesion of renal cortical necrosis
acute renal failure with lesion of renal medullary (papillary) necrosis
acute renal failure with other specified pathological lesion in kidney
acute renal failure unspecified
chronic kidney disease, stage i
chronic kidney disease, stage ii (mild)
chronic kidney disease, stage iii (moderate)
chronic kidney disease, stage iv (severe)
chronic kidney disease, stage v
end stage renal disease
chronic kidney disease, unspecified
renal failure unspecified
renal osteodystrophy
nephrogenic diabetes insipidus
secondary hyperparathyroidism (of renal origin)
CMS Limitations
Serum Magnesium (con’t)
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 necrosis
590.10
acute pyelonephritis without lesion of renal medullary necrosis
590.11
acute pyelonephritis 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
593.81
vascular disorders of kidney
593.89
other specified disorders of kidney and ureter
593.9
unspecified disorder of kidney and ureter
632
missed abortion
634.00-634.02 spontaneous abortion unspecified complicated by genital tract and pelvic infection-spontaneous abortion complete complicated by genital tract and pelvic infection
634.10-634.12 spontaneous abortion unspecified complicated by delayed or excessive hemorrhage-spontaneous
abortion complete complicated by delayed or excessive hemorrhage
634.20-634.22 spontaneous abortion unspecified complicated by damage to pelvic organs or tissues-spontaneous
abortion complete complicated by damage to pelvic organs or tissues
634.30-634.32 spontaneous abortion unspecified complicated by renal failure-spontaneous abortion complete complicated by renal failure
634.40-634.42 spontaneous abortion unspecified complicated by metabolic disorder-spontaneous abortion complete
complicated by metabolic disorder
634.50-634.52 spontaneous abortion unspecified complicated by shock-spontaneous abortion complete complicated
by shock
634.60-634.62 spontaneous abortion unspecified complicated by embolism-spontaneous abortion complete complicated by embolism
634.70-634.72 spontaneous abortion unspecified with other specified complications-spontaneous abortion complete
with other specified complications
634.80-634.82 spontaneous abortion unspecified with unspecified complication-spontaneous abortion complete with
unspecified complication
634.90-634.92 spontaneous abortion unspecified without complication-spontaneous abortion complete without
complication
635.00-635.02 legally induced abortion unspecified complicated by genital tract and pelvic infection-legally induced
abortion complete complicated by genital tract and pelvic infection
635.10-635.12 legally induced abortion unspecified complicated by delayed or excessive hemorrhage-legally induced
abortion complete complicated by delayed or excessive hemorrhage
635.20-635.22 legally induced abortion unspecified complicated by damage to pelvic organs or tissues-legally induced abortion complete complicated by damage to pelvic organs or tissues
635.30-635.32 legally induced abortion unspecified complicated by renal failure-legally induced abortion complete
complicated by renal failure
635.40-635.42 legally induced abortion unspecified complicated by metabolic disorder-legally induced abortion complete complicated by metabolic disorder
635.50-635.52 legally induced abortion unspecified complicated by shock-legally induced abortion complete complicated by shock
635.60-635.62 legally induced abortion unspecified complicated by embolism-legally induced abortion complete
complicated by embolism
CMS Limitations
Serum Magnesium (con’t)
635.70-635.72 legally induced abortion unspecified with other specified complications-legally induced abortion complete with other specified complications
635.80-635.82 legally induced abortion unspecified with unspecified complication-legally induced abortion complete
with unspecified complication
635.90-635.92 legally induced abortion unspecified without complication-legally induced abortion complete without
complication
636.00-636.02 illegal abortion unspecified complicated by genital tract and pelvic infection-illegal abortion complete
complicated by genital tract and pelvic infection
636.10-636.12 illegal abortion unspecified complicated by delayed or excessive hemorrhage-illegal abortion complete
complicated by delayed or excessive hemorrhage
636.20-636.22 illegal abortion unspecified complicated by damage to pelvic organs or tissues-illegal abortion complete complicated by damage to pelvic organs or tissues
636.30-636.32 illegal abortion unspecified complicated by renal failure-illegal abortion complete complicated by renal
failure
636.40-636.42 illegal abortion unspecified complicated by metabolic disorder-illegal abortion complete complicated
by metabolic disorder
636.50-636.52 illegal abortion unspecified complicated by shock-illegal abortion complete complicated by shock
636.60-636.62 illegal abortion unspecified complicated by embolism-illegal abortion complete complicated by embolism
636.70-636.72 illegal abortion unspecified with other specified complications-illegal abortion complete with other
specified complications
636.80-636.82 illegal abortion unspecified with unspecified complication-illegal abortion complete with unspecified
complication
636.90-636.92 illegal abortion unspecified without complication-illegal abortion complete without complication
637.00-637.02 unspecified type of abortion unspecified complicated by genital tract and pelvic infection-unspecified
abortion complete complicated by genital tract and pelvic infection
637.10-637.12 unspecified type of abortion unspecified complicated by delayed or excessive hemorrhage-legally
unspecified abortion complete complicated by delayed or excessive hemorrhage
637.20-637.22 legally unspecified type of abortion unspecified complicated by damage to pelvic organs or tissues-legally unspecified abortion complete complicated by damage to pelvic organs or tissues
637.30-637.32 legally unspecified type of abortion unspecified complicated by renal failure-legally unspecified abortion complete complicated by renal failure
637.40-637.42 legally unspecified type of abortion unspecified complicated by metabolic disorder-legally unspecified
abortion complete complicated by metabolic disorder
637.50-637.52 legally unspecified type of abortion unspecified complicated by shock-legally unspecified abortion
complete complicated by shock
637.60-637.62 legally unspecified type of abortion unspecified complicated by embolism-legally unspecified abortion
complete complicated by embolism
637.70-637.72 legally unspecified type of abortion unspecified with other specified complications-legally unspecified
abortion complete with other specified complications
637.80-637.82 legally unspecified type of abortion unspecified with unspecified complication-legally unspecified
abortion complete with unspecified complication
637.90-637.92 legally unspecified type of abortion unspecified without complication-legally unspecified abortion
complete without complication
638.0
failed attempted abortion complicated by genital tract and pelvic infection
638.1-638.9 failed attempted abortion complicated by delayed or excessive hemorrhage-failed attempted abortion
without complication
639.0
genital tract and pelvic infection following abortion or ectopic and molar pregnancies
639.1
delayed or excessive hemorrhage following abortion or ectopic and molar pregnancies
639.3
renal failure following abortion or ectopic and molar pregnancies
CMS Limitations
Serum Magnesium (con’t)
639.4
metabolic disorders following abortion or ectopic and molar pregnancies
639.5
shock following abortion or ectopic and molar pregnancies
639.6
embolism following abortion or ectopic and molar pregnancies
639.8
other specified complications following abortion or ectopic and molar pregnancies
639.9
unspecified complication following abortion or ectopic and molar pregnancies
640.00-640.03 threatened abortion unspecified as to episode of care-threatened abortion antepartum
640.80
other specified hemorrhage in early pregnancy unspecified as to episode of care
640.81
other specified hemorrhage in early pregnancy delivered
640.83
other specified hemorrhage in early pregnancy antepartum
640.90
unspecified hemorrhage in early pregnancy unspecified as to episode of care
640.91
unspecified hemorrhage in early pregnancy delivered
640.93
unspecified hemorrhage in early pregnancy antepartum
641.00
placenta previa without hemorrhage unspecified as to episode of care
641.01
placenta previa without hemorrhage with delivery
641.03
placenta previa without hemorrhage antepartum
641.10
hemorrhage from placenta previa unspecified as to episode of care
641.11
hemorrhage from placenta previa with delivery
641.13
hemorrhage from placenta previa antepartum
641.20
premature separation of placenta unspecified as to episode of care
641.21
premature separation of placenta with delivery
641.23
premature separation of placenta antepartum
641.30
antepartum hemorrhage associated with coagulation defects unspecified as to episode of care
641.31
antepartum hemorrhage associated with coagulation defects with delivery
641.33
antepartum hemorrhage associated with coagulation defects
641.80
other antepartum hemorrhage unspecified as to episode of care
641.81
other antepartum hemorrhage with delivery
641.83
other antepartum hemorrhage
641.90
unspecified antepartum hemorrhage unspecified as to episode of care
641.91
unspecified antepartum hemorrhage with delivery
641.93
unspecified antepartum hemorrhage
642.00-642.04 benign essential hypertension complicating pregnancy childbirth and the puerperium unspecified as to
episode of care-postpartum benign essential hypertension
642.10-642.14 hypertension secondary to renal disease complicating pregnancy childbirth and the puerperium unspecified as to episode of care-hypertension secondary to renal disease postpartum
642.20-642.24 other pre-existing hypertension complicating pregnancy childbirth and the puerperium unspecified as
to episode of care-other pre-existing hypertension postpartum
642.30-642.34 transient hypertension of pregnancy unspecified as to episode of care-postpartum transient hypertension
642.40-642.44 mild or unspecified pre-eclampsia unspecified as to episode of care-mild or unspecified pre-eclampsia
postpartum
642.50-642.54 severe pre-eclampsia unspecified as to episode of care-severe pre-eclampsia postpartum
642.60-642.64 eclampsia complicating pregnancy childbirth or the puerperium unspecified as to episode of care-eclampsia postpartum
642.70-642.74 pre-eclampsia or eclampsia superimposed on pre-existing hypertension complicating pregnancy childbirth or the puerperium unspecified as to episode of care-pre-eclampsia or eclampsia superimposed
on pre-existing hypertension postpartum
642.90-642.94 unspecified hypertension complicating pregnancy childbirth or the puerperium unspecified as to episode of care-unspecified postpartum hypertension
643.10
hyperemesis gravidarum with metabolic disturbance unspecified as to episode of care
643.11
hyperemesis gravidarum with metabolic disturbance delivered
CMS Limitations
Serum Magnesium (con’t)
643.13
hyperemesis gravidarum with metabolic disturbance antepartum
643.20
late vomiting of pregnancy unspecified as to episode of care
643.21
late vomiting of pregnancy delivered
643.23
late vomiting of pregnancy antepartum
643.80
other vomiting complicating pregnancy unspecified as to episode of care
643.81
other vomiting complicating pregnancy delivered
643.83
other vomiting complicating pregnancy antepartum
643.90
unspecified vomiting of pregnancy unspecified as to episode of care
643.91
unspecified vomiting of pregnancy delivered
643.93
unspecified vomiting of pregnancy antepartum
646.20- 646.24 unspecified renal disease in pregnancy unspecified as to episode of care-unspecified postpartum renal
disease
646.80-646.84 other specified complications of pregnancy unspecified as to episode of care-other specified postpartum complications
646.90
unspecified complication of pregnancy unspecified as to episode of care
646.91
unspecified complication of pregnancy with delivery
646.93
unspecified antepartum complication
648.00-648.04 diabetes mellitus of mother complicating pregnancy childbirth or the puerperium unspecified as to
episode of care-postpartum diabetes mellitus
648.90-648.94 other current conditions classifiable elsewhere of mother complicating pregnancy childbirth or the puerperium unspecified as to episode of care-other current conditions classifiable elsewhere of mother
postpartum
655.80
other known or suspected fetal abnormality not elsewhere classified affecting management of mother
unspecified as to episode of care
655.81
other known or suspected fetal abnormality not elsewhere classified affecting management of mother
with delivered
655.83
other known or suspected fetal abnormality not elsewhere classified affecting management of mother
antepartum condition or complication
655.90
unspecified suspected fetal abnormality affecting management of mother unspecified as to episode of
care
655.91
unspecified suspected fetal abnormality affecting management of mother delivered
655.93
unspecified suspected fetal abnormality affecting management of mother antepartum condition or
complication
656.00
fetal-maternal hemorrhage unspecified as to episode of care in pregnancy
656.01
fetal-maternal hemorrhage with delivery
656.03
fetal-maternal hemorrhage antepartum condition or complication
656.30
fetal distress affecting management of mother unspecified as to episode of care
656.31
fetal distress affecting management of mother delivered
656.33
fetal distress affecting management of mother antepartum
656.40
intrauterine death affecting management of mother unspecified as to episode of care
656.41
intrauterine death affecting management of mother delivered
656.43
intrauterine death affecting management of mother antepartum
659.70
abnormality in fetal heart rate or rhythm unspecified as to episode of care or not applicable
659.71
abnormality in fetal heart rate or rhythm delivered with or without antepartum condition
659.73
abnormality in fetal heart rate or rhythm antepartum condition or complication
666.00
third-stage postpartum hemorrhage unspecified as to episode of care
666.02
third-stage postpartum hemorrhage with delivery
666.04
third-stage postpartum hemorrhage
666.10
other immediate postpartum hemorrhage unspecified as to episode of care
666.12
other immediate postpartum hemorrhage with delivery
CMS Limitations
Serum Magnesium (con’t)
666.14
other immediate postpartum hemorrhage
666.20
delayed and secondary postpartum hemorrhage unspecified as to episode of care
666.22
delayed and secondary postpartum hemorrhage with delivery
666.24
delayed and secondary postpartum hemorrhage
668.00-668.04 pulmonary complications of anesthesia or other sedation in labor and delivery unspecified as to episode of care-pulmonary complications of anesthesia or other sedation in labor and delivery postpartum
668.10-668.14 cardiac complications of anesthesia or other sedation in labor and delivery unspecified as to episode
of care-cardiac complications of anesthesia or other sedation in labor and delivery postpartum
668.80-668.84 other complications of anesthesia or other sedation in labor and delivery unspecified as to episode of
care-other complications of anesthesia or other sedation in labor and delivery postpartum
668.90-668.94 unspecified complication of anesthesia or other sedation in labor and delivery unspecified as to episode of care-unspecified complication of anesthesia or other sedation in labor and delivery postpartum
669.01-669.04 maternal distress with delivery with or without antepartum condition-maternal distress complicating
labor and delivery postpartum condition or complication
669.10-669.14 obstetric shock unspecified as to episode of care-postpartum obstetric shock
669.20-669.24 maternal hypotension syndrome complicating labor and delivery unspecified as to episode of carematernal hypotension syndrome postpartum
669.30
acute renal failure following labor and delivery unspecified as to episode of care
669.32
acute renal failure with delivery with postpartum complication
669.34
acute renal failure following labor and delivery postpartum condition or complication
669.40-669.44 other complications of obstetrical surgery and procedures unspecified as to episode of care-other
complications of obstetrical surgery and procedures postpartum condition or complication
669.80-669.84 other complications of labor and delivery unspecified as to episode of care-other complications of
labor and delivery postpartum condition or complication
669.90-669.94 unspecified complication of labor and delivery unspecified as to episode of care-unspecified complication of labor and delivery postpartum condition or complication
673.20-673.24 obstetrical blood-clot embolism unspecified as to episode of care-obstetrical blood-clot embolism
postpartum
710.1
systemic sclerosis
728.5
hypermobility syndrome
728.85
spasm of muscle
728.86
necrotizing fasciitis
728.9
unspecified disorder of muscle ligament and fascia
729.82
cramp of limb
731.0
osteitis deformans without bone tumor
733.00
osteoporosis unspecified
760.0
maternal hypertensive disorders affecting fetus or newborn
760.1
maternal renal and urinary tract diseases affecting fetus or newborn
760.4
maternal nutritional disorders affecting fetus or newborn
760.71
noxious influences affecting fetus or newborn via placenta or breast milk, alcohol
760.8
other specified maternal conditions affecting fetus or newborn
763.81
abnormality in fetal heart rate or rhythm before the onset of labor
763.82
abnormality in fetal heart rate or rhythm during labor
763.83
abnormality in fetal heart rate or rhythm unspecified as to time of onset
763.89
other specified complications of labor and delivery affecting fetus or newborn
763.9
unspecified complication of labor and delivery affecting fetus or newborn
764.10-764.19 light-for-dates infant with signs of fetal malnutrition unspecified weight-light-for-dates infant with
signs of fetal malnutrition 2500 grams and over
CMS Limitations
Serum Magnesium (con’t)
764.20-764.29 fetal malnutrition without light-for-dates unspecified weight-fetal malnutrition without light-for-dates
2500 grams and over
775.4
hypocalcemia and hypomagnesemia of newborn
775.7
late metabolic acidosis of newborn
775.9
unspecified endocrine and metabolic disturbances specific to the fetus and newborn
780.01
coma
780.02
transient alteration of awareness
780.03
persistent vegetative state
780.09
alteration of consciousness other
780.2
syncope and collapse
780.31
febrile convulsions (simple), unspecified
780.32
complex febrile convulsions
780.39
other convulsions
780.71
chronic fatigue syndrome
780.79
other malaise and fatigue
781.0
abnormal involuntary movements
781.1
disturbances of sensation of smell and taste
781.2
abnormality of gait
781.3
lack of coordination
781.4
transient paralysis of limb
781.6
meningismus
781.7
tetany
781.99
other symptoms involving nervous and musculoskeletal systems
783.0
anorexia
783.21
loss of weight
783.22
underweight
783.3
feeding difficulties and mismanagement
783.41
failure to thrive
783.7
adult failure to thrive
783.9
other symptoms concerning nutrition metabolism and development
785.0
tachycardia unspecified
785.50
shock unspecified
785.51
cardiogenic shock
785.59
other shock without trauma
787.01
nausea with vomiting
787.02
nausea alone
787.03
vomiting alone
787.91
diarrhea
790.6
other abnormal blood chemistry
794.31
nonspecific abnormal electrocardiogram (ecg) (ekg)
794.4
nonspecific abnormal results of function study of kidney
796.0
nonspecific abnormal toxicological findings
796.1
abnormal reflex
796.2
elevated blood pressure reading without diagnosis of hypertension
799.4
cachexia
958.4
traumatic shock
958.5
traumatic anuria
960.8
poisoning by other specified antibiotics
962.0-962.9 poisoning by adrenal cortical steroids-poisoning by other and unspecified hormones and synthetic
substitutes
CMS Limitations
Serum Magnesium (con’t)
963.1
972.1
973.0-973.6 973.8-973.9 974.0-974.7 989.5
990
995.20
995.22
995.27
995.29
995.4
995.51
995.52
995.55
996.81
996.83
997.1
998.0
v42.0
v42.1
v45.11*
v45.12*
v56.0
v56.31
v56.32
v56.8
v58.11
v58.12
v58.2
v58.62
v58.63
v58.64
v58.65
v58.69
v67.2
v67.51
v71.82
v71.83
poisoning by antineoplastic and immunosuppressive drugs
poisoning by cardiotonic glycosides and drugs of similar action
poisoning by antacids and antigastric secretion drugs-poisoning by emetics
poisoning by other specified agents primarily affecting the gastrointestinal system-poisoning by unspecified agent primarily affecting the gastrointestinal system
poisoning by mercurial diuretics-poisoning by uric acid metabolism drugs
toxic effect of venom
effects of radiation unspecified
unspecified adverse effect of unspecified drug, medicinal and biological substance
unspecified adverse effect of anesthesia
other drug allergy
unspecified adverse effect of other drug, medicinal and biological substance
shock due to anesthesia not elsewhere classified
child emotional/psychological abuse
child neglect (nutritional)
shaken baby syndrome
complications of transplanted kidney
complications of transplanted heart
cardiac complications not elsewhere classified
postoperative shock not elsewhere classified
kidney replaced by transplant
heart replaced by transplant
renal dialysis status
noncompliance with renal dialysis
aftercare involving extracorporeal dialysis
encounter for adequacy testing for hemodialysis
encounter for adequacy testing for peritoneal dialysis
aftercare involving other dialysis
encounter for antineoplastic chemotherapy
encounter for immunotherapy for neoplastic condition
blood transfusion without reported diagnosis
long-term (current) use of antibiotics
long-term (current) use of antiplatelets/antithrombotics
long-term (current) use of nonsteroidal anti-inflammatories
long-term (current) use of steroids
long-term (current) use of other medications
follow-up examination following chemotherapy
follow-up examination following completed treatment with high-risk medication not elsewhere classified
observation and evaluation for suspected exposure to anthrax
observation and evaluation for suspected exposure to other biological agent
* Effective for services rendered on or after 10/01/2008 the following ICD-9-CM codes were revised/deleted/added:
• ICD-9-CM code 203.00 was revised.
• ICD-9-CM codes 203.02, 275.5, 571.42, V45.11 and V45.12 were added.
• ICD-9-CM code V45.1 was deleted.
CMS Limitations
Syphilis Tests
LCD # L28535; Effective Date 01/01/2009
CPT/HCPCS Codes: CPT 86592, CPT 86593, CPT 86781, CPT 87164, CPT 87166, CPT 87285
ICD-9 codes that SUPPORT medical necessity for syphilis test; qualitative (eg, vdrl, rpr, art) (CPT 86592); syphilis test;
quantitative (CPT 86593); antibody; treponema pallidum, confirmatory test (eg, fta-abs) (CPT 86781); dark field examination, any source (eg, penile, vaginal, oral, skin); includes specimen collection (CPT 87164); dark field examination, any
source (eg, penile, vaginal, oral, skin); without collection (CPT 87166); and infectious agent antigen detection by immunofluorescent technique; treponema pallidum (CPT 87285):
042
054.10
054.11
054.12
054.13
054.19
058.21
058.29
058.81
058.82
058.89
078.0
078.10
078.11
078.19
090.0
090.1
090.2
090.3
090.40
090.41
090.42
090.49
090.5
090.6
090.7
090.9
091.0
091.1
091.2
091.3
091.4
091.50
091.51
091.52
091.61
091.62
091.69
091.7
091.81
human immunodeficiency virus (hiv) disease
genital herpes unspecified
herpetic vulvovaginitis
herpetic ulceration of vulva
herpetic infection of penis
other genital herpes
human herpesvirus 6 encephalitis
other human herpesvirus encephalitis
human herpesvirus 6 infection
human herpesvirus 7 infection
other human herpesvirus infection
molluscum contagiosum
viral warts unspecified
condyloma acuminatum
other specified viral warts
early congenital syphilis symptomatic
early congenital syphilis latent
early congenital syphilis unspecified
syphilitic interstitial keratitis
juvenile neurosyphilis unspecified
congenital syphilitic encephalitis
congenital syphilitic meningitis
other juvenile neurosyphilis
other late congenital syphilis symptomatic
late congenital syphilis latent
late congenital syphilis unspecified
congenital syphilis unspecified
genital syphilis (primary)
primary anal syphilis
other primary syphilis
secondary syphilis of skin or mucous membranes
adenopathy due to secondary syphilis
syphilitic uveitis unspecified
syphilitic chorioretinitis (secondary)
syphilitic iridocyclitis (secondary)
secondary syphilitic periostitis
secondary syphilitic hepatitis
secondary syphilis of other viscera
secondary syphilis relapse
acute syphilitic meningitis (secondary)
CMS Limitations
Syphilis Tests (con’t)
091.82
091.89
091.9
092.0
092.9
093.0
093.1
093.20
093.21
093.22
093.23
093.24
093.81
093.82
093.89
093.9
094.0
094.1
094.2
094.3
094.81
094.82
094.83
094.84
094.85
094.86
094.87
094.89
094.9
095.0
095.1
095.2
095.3
095.4
095.5
095.6
095.7
095.8
095.9
096
097.0
097.1
097.9
098.0
098.10
098.11
098.12
098.13
098.14
098.15
syphilitic alopecia
other forms of secondary syphilis
unspecified secondary syphilis
early syphilis latent serological relapse after treatment
early syphilis latent unspecified
aneurysm of aorta specified as syphilitic
syphilitic aortitis
syphilitic endocarditis of valve unspecified
syphilitic endocarditis of mitral valve
syphilitic endocarditis of aortic valve
syphilitic endocarditis of tricuspid valve
syphilitic endocarditis of pulmonary valve
syphilitic pericarditis
syphilitic myocarditis
other specified cardiovascular syphilis
cardiovascular syphilis unspecified
tabes dorsalis
general paresis
syphilitic meningitis
asymptomatic neurosyphilis
syphilitic encephalitis
syphilitic parkinsonism
syphilitic disseminated retinochoroiditis
syphilitic optic atrophy
syphilitic retrobulbar neuritis
syphilitic acoustic neuritis
syphilitic ruptured cerebral aneurysm
other specified neurosyphilis
neurosyphilis unspecified
syphilitic episcleritis
syphilis of lung
syphilitic peritonitis
syphilis of liver
syphilis of kidney
syphilis of bone
syphilis of muscle
syphilis of synovium tendon and bursa
other specified forms of late symptomatic syphilis
late symptomatic syphilis unspecified
late syphilis latent
late syphilis unspecified
latent syphilis unspecified
syphilis unspecified
gonococcal infection (acute) of lower genitourinary tract
gonococcal infection (acute) of upper genitourinary tract site unspecified
gonococcal cystitis (acute)
gonococcal prostatitis (acute)
gonococcal epididymo-orchitis (acute)
gonococcal seminal vesiculitis (acute)
gonococcal cervicitis (acute)
CMS Limitations
Syphilis Tests (con’t)
098.16
098.17
098.19
098.2
098.30
098.31
098.32
098.33
098.34
098.35
098.36
098.37
098.39
098.40
098.41
098.42
098.43
098.49
098.50
098.51
098.52
098.53
098.59
098.6
098.7
098.81
098.82
098.83
098.84
098.85
098.86
098.89
099.0
099.1
099.2
099.3
099.40
099.41
099.49
099.50
099.51
099.52
099.53
099.54
099.55
099.56
099.8
099.9
104.0
131.00
gonococcal endometritis (acute)
gonococcal salpingitis specified as acute
other gonococcal infection (acute) of upper genitourinary tract
gonococcal infection chronic of lower genitourinary tract
chronic gonococcal infection of upper genitourinary tract site unspecified
gonococcal cystitis chronic
gonococcal prostatitis chronic
gonococcal epididymo-orchitis chronic
gonococcal seminal vesiculitis chronic
gonococcal cervicitis chronic
gonococcal endometritis chronic
gonococcal salpingitis (chronic)
other chronic gonococcal infection of upper genitourinary tract
gonococcal conjunctivitis (neonatorum)
gonococcal iridocyclitis
gonococcal endophthalmia
gonococcal keratitis
other gonococcal infection of eye
gonococcal arthritis
gonococcal synovitis and tenosynovitis
gonococcal bursitis
gonococcal spondylitis
other gonococcal infection of joint
gonococcal infection of pharynx
gonococcal infection of anus and rectum
gonococcal keratosis (blennorrhagica)
gonococcal meningitis
gonococcal pericarditis
gonococcal endocarditis
other gonococcal heart disease
gonococcal peritonitis
gonococcal infection of other specified sites
chancroid
lymphogranuloma venereum
granuloma inguinale
reiter’s disease
other nongonococcal urethritis unspecified
other nongonococcal urethritis chlamydia trachomatis
other nongonococcal urethritis other specified organism
other venereal diseases due to chlamydia trachomatis unspecified site
other venereal diseases due to chlamydia trachomatis pharynx
other venereal diseases due to chlamydia trachomatis anus and rectum
other venereal diseases due to chlamydia trachomatis lower genitourinary sites
other venereal diseases due to chlamydia trachomatis other genitourinary sites
other venereal diseases due to chlamydia trachomatis unspecified genitourinary site
other venereal diseases due to chlamydia trachomatis peritoneum
other specified venereal diseases
venereal disease unspecified
nonvenereal endemic syphilis
urogenital trichomoniasis unspecified
CMS Limitations
Syphilis Tests (con’t)
131.01
131.02
131.03
131.09
131.8
131.9
290.10
290.11
290.12
290.13
294.9
331.0
331.2
331.9
356.9
364.00
364.01
364.02
364.03
364.04
364.05
370.8
389.10
389.11
389.12
389.13
389.14
389.15
389.16
389.17
424.1
441.01
441.1
441.2
614.0
614.1
614.2
614.3
614.4
614.5
614.6
614.7
614.8
614.9
615.0
615.1
615.9
616.0
616.10
616.11
trichomonal vulvovaginitis
trichomonal urethritis
trichomonal prostatitis
other urogenital trichomoniasis
trichomoniasis of other specified sites
trichomoniasis unspecified
presenile dementia uncomplicated
presenile dementia with delirium
presenile dementia with delusional features
presenile dementia with depressive features
unspecified persistent mental disorders due to conditions classified elsewhere
alzheimer’s disease
senile degeneration of brain
cerebral degeneration unspecified
unspecified idiopathic peripheral neuropathy
acute and subacute iridocyclitis unspecified
primary iridocyclitis
recurrent iridocyclitis
secondary iridocyclitis infectious
secondary iridocyclitis noninfectious
hypopyon
other forms of keratitis
sensorineural hearing loss unspecified
sensory hearing loss, bilateral
neural hearing loss, bilateral
neural hearing loss, unilateral
central hearing loss
sensorineural hearing loss, unilateral
sensorineural hearing loss, asymmetrical
sensory hearing loss, unilateral
aortic valve disorders
dissection of aorta thoracic
thoracic aneurysm ruptured
thoracic aneurysm without rupture
acute salpingitis and oophoritis
chronic salpingitis and oophoritis
salpingitis and oophoritis not specified as acute subacute or chronic
acute parametritis and pelvic cellulitis
chronic or unspecified parametritis and pelvic cellulitis
acute or unspecified pelvic peritonitis female
pelvic peritoneal adhesions female (postoperative) (postinfection)
other chronic pelvic peritonitis female
other specified inflammatory disease of female pelvic organs and tissues
unspecified inflammatory disease of female pelvic organs and tissues
acute inflammatory diseases of uterus except cervix
chronic inflammatory diseases of uterus except cervix
unspecified inflammatory disease of uterus
cervicitis and endocervicitis
vaginitis and vulvovaginitis unspecified
vaginitis and vulvovaginitis in diseases classified elsewhere
CMS Limitations
Syphilis Tests (con’t)
616.2
616.3
616.4
616.50
616.51
616.81
616.89
616.9
704.01
760.2
781.2
782.1
785.6
790.99
v01.6
v71.5
cyst of bartholin’s gland
abscess of bartholin’s gland
other abscess of vulva
ulceration of vulva unspecified
ulceration of vulva in diseases classified elsewhere
mucositis (ulcerative) of cervix, vagina, and vulva
other inflammatory disease of cervix, vagina and vulva
unspecified inflammatory disease of cervix vagina and vulva
alopecia areata
maternal infections affecting fetus or newborn
abnormality of gait
rash and other nonspecific skin eruption
enlargement of lymph nodes
other abnormal findings on examination of blood
contact with or exposure to venereal diseases
observation following alleged rape or seduction
LIMITATIONS:
• Quantitative syphilis testing (86593) is never covered when 86592, 86781, 87164, 87166, or 87285 testing is
negative.
• Rapid Plasma Reagin (RPR), Fluorescent Treponemal Antibody-Absorption (FTA-ABS), and/or Microhemaggluntination -Treponema pallidum test (MHA-TP) testing of cerebrospinal fluid will be denied as not medically necessary.
• Repeat automatic reflex testing of FTA-ABS or TPI (CPT 86781) to confirm the positive qualitative test result
will not be covered once the FTA-ABS or TPI has previously been reported positive.
• Screening tests, in the absence of associated signs, symptoms, or complaints are denied under SSA
1862(a)(7).
CMS Limitations
Thyroid Testing
LCD # 190.22, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 84436, CPT 84439, CPT 84443, CPT 84479
ICD-9 Codes that SUPPORT medical necessity for Thyroxine; total (CPT 84436); Thyroxine; free (CPT 84439); Thyroid
stimulating hormone (TSH) (CPT 84443); Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR)
(CPT 84479):
017.50-017.56
183.0
193
194.8
198.89
220
226
227.3
234.8
263.0-263.9
237.4
239.7
240.0-240.9
241.0-241.9
242.00-242.91
243
244.0-244.9
245.0-245.9
246.0-246.9
250.00-250.93
252.1
253.1
253.2
253.3
253.4
253.7
255.2
255.41
255.42
256.31-256.39
257.2
258.01
258.02
258.03
258.9
262
266.0
272.0
272.2
272.4
275.40-275.49
*275.5
tuberculosis of the thyroid gland
malignant neoplasm of ovary
malignant neoplasm of thyroid gland
malignant neoplasm of other endocrine glands and related structures
secondary malignant neoplasm of the thyroid
benign neoplasm of ovary
benign neoplasm of thyroid gland
benign neoplasm of pituitary gland and craniopharyngeal duct
carcinoma in situ of other and unspecified sites
malnutrition, other and unspecified
neoplasm of uncertain behavior of other and unspecified endocrine glands
neoplasm of unspecified nature, thyroid gland
goiter specified and unspecified
nontoxic nodular goiter
thyrotoxicosis with or without goiter
congenital hypothyroidism
acquired hypothyroidism
thyroiditis
other disorders of thyroid
diabetes mellitus
hypoparathyroidism
other and unspecified anterior pituitary hyper function
panhypopituitarism
pituitary dwarfism
other anterior pituitary disorders
iatrogenic pituitary disorders
adrenogenital disorders
glucocorticoid deficiency
mineralocorticoid deficiency
ovarian failure
testicular hypofunction
multiple endocrine neoplasia (men) type i
multiple endocrine neoplasia (men) type ii a
multiple endocrine neoplasia (men) type ii b
polyglandular dysfunction
malnutrition, severe
ariboflavinosis
pure hypercholesterolemia
mixed hyperlipidemia
other and unspecified hyperlipidemia
calcium disorders
*hungry bone syndrome
CMS Limitations
Thyroid Testing (con’t)
276.0
276.1
278.3
279.4
281.0
281.9
283.0
285.9
290.0
290.10-290.13
290.20-290.21
290.3
293.0-293.1
293.81-293.89
294.8
296.00-296.99
297.0
297.1
297.9
298.3
300.00-300.09
307.9
310.1
311
327.00
327.01
327.09
327.29
327.52
327.8
331.0, 331.11, 331.19, 331.2
331.83
333.1
333.99
354.0
356.9
358.1
359.5
359.9
368.2
372.71
372.73
374.41
374.82
376.21
376.22
376.30-376.31
376.33-376.34
378.50-378.55
hyposmolality and/or hypernatremia
hyposmolality and/or hyponatremia
hypercarotenemia
autoimmune disorder, not classified elsewhere
pernicious anemia
unspecified deficiency anemia
autoimmune hemolytic anemia
anemia, unspecified
senile dementia, uncomplicated
presenile dementia
senile dementia with delusional or depressive features
senile dementia with delirium
delirium
other specified transient mental disorders due to conditions classified elsewhere
other persistent mental disorders due to conditions classified elsewhere
episodic mood disorders
paranoid state, simple
delusional disorder
unspecified paranoid state
acute paranoid reaction
anxiety states
other and unspecified special symptoms or syndromes, not elsewhere classified
personality change due to conditions classified elsewhere
depressive disorder, not elsewhere classified
organic insomnia, unspecified
insomnia due to medical condition classified elsewhere
other organic insomnia
other organic sleep apnea
sleep related leg cramps
other organic sleep disorders
alzheimer’s, pick’s disease, senile degeneration of brain
mild cognitive impairment, so stated
essential and other specified forms of tremor
other extrapyramidal diseases and abnormal movement disorders
carpal tunnel syndrome
idiopathic peripheral neuropathy, unspecified polyneuropathy
myasthenic syndromes in diseases classified elsewhere
myopathy in endocrine diseases classified elsewhere
myopathy, unspecified
diplopia
conjunctival hyperemia
conjunctival edema
lid retraction or lag
eyelid edema
thyrotoxic exophthalmos
exophthalmic ophthalmoplegia
exophthalmic conditions, unspecified and constant
orbital edema or congestion, intermittent exophthalmos
paralytic strabismus
CMS Limitations
Thyroid Testing (con’t)
401.0-401.9
403.00-403.91
404.00-404.93
423.9
425.7
427.0
427.2
427.31
427.89
427.9
428.0
428.1
429.3
511.9
518.81
529.8
560.1
564.00-564.09
564.7
568.82
625.3
626.0-626.2
626.4
648.10-648.14
essential hypertension
hypertensive chronic kidney disease
hypertensive heart and chronic kidney disease
unspecified disease of pericardium
nutritional and metabolic cardiomyopathy
paroxysmal supraventricular tachycardia
paroxysmal tachycardia, unspecified
atrial fibrillation
other specified cardiac dysrhythmia
cardiac dysrhythmia, unspecified
congestive heart failure, unspecified
left heart failure
cardiomegaly
unspecified pleural effusion
acute respiratory failure
other specified conditions of the tongue
paralytic ileus
constipation
megacolon, other than hirschsprung’s
peritoneal effusion (chronic)
dysmenorrhea
disorders of menstruation
irregular menstrual cycle
other current conditions in mother, classifiable elsewhere, but complicating pregnancy, childbirth, or
puerperium, thyroid dysfunction
676.20-676.24 engorgement of breast associated with childbirth and disorders of lactation
698.9
unspecified pruritic disorder
701.1
keratoderma, acquired (dry skin)
703.8
other specified diseases of nail (brittle nails)
704.00-704.09 alopecia
709.01
vitiligo
710.0-710.9
diffuse disease of connective tissue
728.2
muscle wasting
728.87
muscle weakness (generalized)
728.9
unspecified disorder of muscle, ligament, and fascia
729.1
myalgia and myositis, unspecified
729.82
musculoskeletal cramp
730.30-730.39 periostitis without osteomyelitis
733.02
idiopathic osteoporosis
733.09
osteoporosis, drug induced
750.15
macroglossia, congenital
759.2
anomaly of other endocrine glands
780.01
coma
780.02
transient alteration of awareness
780.09
alteration of consciousness, other
780.50
insomnia
780.51
insomnia with sleep apnea, unspecified
780.52
insomnia, unspecified
780.60
*fever, unspecified
780.61
*fever presenting with conditions classified elsewhere
CMS Limitations
Thyroid Testing (con’t)
780.62
780.63
780.64
780.65
780.71
780.72
780.97
780.99
781.0
781.3
782.0
782.3
782.8
782.9
783.0
783.1
783.21
783.6
784.1
784.49
784.5
785.0
785.1
787.21
785.9
786.09
786.1
787.20
787.22
787.23
787.24
787.29
787.91-787.99
789.51
789.59
793.99
794.5
796.1
799.2
990
v10.87
v10.88
v12.2
v58.69
v67.00-v67.9
*postprocedural fever
*postvaccination fever
*chills (without fever)
*hypothermia not associated with low environmental temperature
chronic fatigue syndrome
*functional quadriplegia
altered mental status
other general symptoms
abnormal involuntary movements
lack of coordination, ataxia
disturbance of skin sensation
localized edema
changes in skin texture
other symptoms involving skin and integumentary tissues
anorexia
abnormal weight gain
abnormal loss of weight
polyphagia
throat pain
voice disturbance
other speech disturbance
tachycardia, unspecified
palpitations
dysphagia, oral phase
other symptoms involving cardiovascular system
other symptoms involving respiratory system
stridor
dysphagia, unspecified
dysphagia, oropharyngeal phase
dysphagia, pharyngeal phase
dysphagia, pharyngo-esophageal phase
other dysphagia
other symptoms involving digestive system
malignant ascites
other ascites
other nonspecific abnormal findings on radiological and other examinations of body structure
thyroid, abnormal scan or uptake
other nonspecific abnormal findings, abnormal reflex
nervousness
effects of radiation, unspecified
personal history of malignant neoplasm of the thyroid
personal history of malignant neoplasm of other endocrine gland
personal history of endocrine, metabolic and immunity disorders
long term (current) use of other medications
follow-up examination
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 hyperthyroidism or hypothyroidism are noted.
CMS Limitations
Tumor Antigen by Immunoassay CA 125
LCD # 190.28, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 86304
ICD-9 Codes that SUPPORT medical necessity for Immunoassay for tumor antigen, quantitative, CA 125 (CPT 86304):
158.8
158.9
180.0
182.0
183.0
183.2
183.8
184.8
198.6
198.82
236.0-236.3
338.3
789.39
795.82
795.89
v10.41
v10.42
v10.43-v10.44
malignant neoplasm, specified parts of peritoneum
malignant neoplasm, peritoneum, unspecified
malignant neoplasm, endocervix
malignant neoplasm of corpus uteri, except isthmus
malignant neoplasm,ovary
malignant neoplasm, fallopian tube
malignant neoplasm, other specified sites of uterine adnexa
malignant neoplasm, other specified sites of female genital organs
secondary malignant neoplasm, ovary
secondary malignancy of genital organs
neoplasm of uncertain behavior of female genital organs
neoplasm related pain (acute) (chronic)
abdominal or pelvic swelling, mass or lump of other specified site
elevated cancer antigen 125 [ca 125]
other abnormal tumor markers
personal history of malignant neoplasm, cervix uteri
personal history of malignant neoplasm, other parts of the uterus
personal history of malignant neoplasm of female genital organs
CMS Limitations
Tumor Antigen by Immunoassay CA 15-3/CA 27.29
LCD #190.29, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 86300
ICD-9 Codes that SUPPORT medical necessity Immunoassay for tumor antigen, quantitative; CA 15-3 (27.29) (CPT
85730):
174.0-174.9
175.0-175.9
198.2
198.81
338.3
795.89
v10.3
breast, primary (female)-malignant neoplasm of female breast
breast, primary (male)-malignant neoplasm of male breast
secondary malignant neoplasm (breast)
secondary malignant neoplasm (breast)
neoplasm related pain (acute) (chronic)
other abnormal tumor markers
personal history of malignant neoplasm, breast
CMS Limitations
Tumor Antigen by Immunoassay CA 19-9
LCD #190.30, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 86301
ICD-9 Codes that SUPPORT medical necessity for Immunoassay for tumor antigen, quantitative; CA 19-9 (CPT 86301):
155.1
156.0
156.1
156.2
156.8
156.9
157.0-157.9
197.8
235.3
235.5
338.3
795.89
v10.09
malignant neoplasm, intrahepatic bile ducts
malignant neoplasm of the gallbladder
malignant neoplasm, extrahepatic bile ducts
malignant neoplasm of the ampulla of vater
malignant neoplasm, other specified sites of gallbladder and extrahepatic bile ducts
malignant neoplasm, unspecified part of biliary tract
malignant neoplasm, pancreas
secondary malignant neoplasm, other digestive organs and spleen
neoplasm of uncertain behavior, liver and biliary passages
neoplasm of uncertain behavior, other and unspecified digestive organs
neoplasm related pain (acute) (chronic)
other abnormal tumor markers
other personal history of cancer
CMS Limitations
Urine Culture, Bacterial
LCD # 190.12, Effective Date: 01/01/2009
CPT/HCPCS Codes: CPT 87086, CPT 87088, CPT 87184, CPT 87186
ICD-9 Codes that SUPPORT medical necessity for Culture, bacterial; quantitative, colony count, urine (CPT 87086); Culture, bacterial; with isolation and presumptive identification of each isolates, urine (CPT 87088); Susceptibility studies,
antimicrobial agent; disk method, per plate (12 or fewer agents) (CPT 87184-Listed in manual only); Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration (MIC) or breakpoint), each
multi-antimicrobial, per plate (CPT 87186-Listed in manual only):
003.1
038.0-038.9
276.2
276.4
286.6
288.00
288.01
288.02
288.03
288.04
288.09
288.8
306.53
306.59
518.82
570
580.0-580.9
583.0-583.9
585.6
590.00-590.9
592.0-592.9
593.0-593.9
594.0-594.9
595.0-595.9
597.0
597.80-597.89
598.00-598.01
599.0
*599.70
*599.71
*599.72
600.00-600.91
601.0-601.9
602.0-602.9
604.0-604.99
608.0-608.1, 608.20-608.24,
608.3-608.9
614.0-614.9
615.0-615.9
salmonella septicemia
septicemia
acidosis
metabolic acidosis/alkalosis
defibrination syndrome/disseminated intravascular coagulation
neutropenia, unspecified
congenital neutropenia
cyclic neutropenia
drug induced neutropenia
neutropenia due to infection
other neutropenia
other specified disease of white blood cells including leukemoid reaction/leukocytosis
psychogenic dysuria
other psychogenic genitourinary malfunction
other pulmonary insufficiency, not elsewhere classified
acute and subacute necrosis of liver
acute glomerulonephritis
nephritis and nephropathy, not specified as acute or chronic
end stage renal disease
infections of kidney/pyelonephritis acute and chronic
calculus of kidney and ureter
other disorders of kidney and ureter (cyst, stricture, obstruction, reflux, etc.)
calculus of lower urinary tract
cystitis
urethritis, not sexually transmitted and urethral syndrome
other urethritis
urethral stricture due to infection
urinary tract infection, site not specified
*hematuria, unspecified
*gross hematuria
*microscopic hematuria
hyperplasia of prostate
inflammatory diseases of prostate
other disorders of prostate (calculus, congestion, atrophy, etc.)
orchitis and epididymitis
other disorders of male genital organs (seminal vesiculitis, spermatocele, etc.)
inflammatory disease of ovary, fallopian tube, pelvic cellular tissue, and peritoneum
inflammatory disease of uterus, except cervix
CMS Limitations
Urine Culture, Bacterial (con’t)
616.0
cervicitis and endocervicitis
616.10-616.11
vaginitis and vulvovaginitis
616.2-616.4, other inflammatory conditions of cervix, vagina and vulva
616.50, 616.51,
616.81, 616.89,
616.9
619.0-619.9
fistula involving female genital tract
625.6
stress incontinence, female
639.0
genital tract and pelvic infection complicating abortion, ectopic or molar pregnancies
639.5
shock complicating abortion, ectopic or molar pregnancies
646.60-646.64 infections of genitourinary tract in pregnancy
670.00-670.04 major puerperal infection
672.00-672.04 pyrexia of unknown origin during the puerperium
724.5
backache, unspecified
771.81
septicemia (sepsis) of newborn
771.82
urinary tract infection of newborn
771.83
bacteremia of newborn
780.02
general symptoms, transient alteration of awareness
*780.60
*fever, unspecified
*780.61
*fever presenting with conditions classified elsewhere
*780.62
*postprocedural fever
*780.63
*postvaccination fever
*780.64
*chills (without fever)
*780.65
*hypothermia not associated with low environmental temperature
780.79
other malaise and fatigue
780.93
memory loss
780.94
early satiety
780.96
generalized pain
780.97
altered mental status
780.99
other general symptoms
785.0
tachycardia, unspecified
785.50-785.59 shock without mention of trauma
788.0-788.63, symptoms involving urinary system (renal colic, dysuria, retention of urine, incontinence of urine,
788.64, 788.65, frequency, polyuria, nocturia, oliguria, anuria, other abnormality of urination, urethral discharge,
788.69, 788.7- extravasation of urine, other symptoms of urinary system)
788.9
*788.91
*functional urinary incontinence
*788.99
*other symptoms involving urinary system
789.00-789.09 abdominal pain
789.60-789.69 abdominal tenderness
790.7
bacteremia
791.0-791.9
nonspecific findings on examination of urine (proteinuria, chyluria, hemoglobinuria, myoglobinuria,
biliuria, glycosuria, acetonuria, other cells and casts in urine, other nonspecific findings on examination
of urine)
799.3
debility, unspecified (only for declining functional status)
939.0
foreign body in genitourinary tract, bladder and urethra
939.3
foreign body in genitourinary tract, penis
v44.50-v44.6 artificial cystostomy or other artificial opening of urinary tract status
v55.5-v55.6
attention to cystostomy or other artificial opening of urinary tract
v58.69
long-term (current) use of other medications
CMS Limitations
Urine Culture, Bacterial (con’t)
LIMITATIONS
• CPT 87086 may be used one time per encounter.
• Colony count restrictions on coverage of CPT 87088 do not apply, as they may be highly variable according
to syndrome or other clinical circumstances (for example, antecedent therapy, collection time, degree of
hydration).
• CPT 87088, 87184, and 87186 may be used multiple times in association with or independent of 87086, as
urinary tract infections may be polymicrobial.
• Testing for asymptomatic bacteriuria as part of a prenatal evaluation may be medically appropriate but
is considered screening and therefore not covered by Medicare. The U.S. Preventive Services Task Force
has concluded that screening for asymptomatic bacteriuria outside of the narrow indication for pregnant
women is generally not indicated. There are insufficient data to recommend screening in ambulatory elderly
patients including those with diabetes. Testing may be clinically indicated on other grounds including likelihood of recurrence or potential adverse effects of antibiotics, but is considered screening in the absence of
clinical or laboratory evidence of infection.
CMS Limitations
Viral Hepatitis Serology Tests
LCD # L28427, Effective Date: 01/01/09
CPT/HCPCS Codes: CPT 86692, CPT 86704, CPT 86705, CPT 86706, CPT 86707, CPT 86708, CPT 86709, CPT 86803,
CPT 86804, CPT 87340, CPT 87341, CPT 87350, CPT 87380
ICD-9 codes that SUPPORT medical necessity for antibody; hepatitis, delta agent (CPT 86692); hepatitis b core antibody (hbcab); total (CPT 86704); hepatitis b core antibody (hbcab); igm antibody (CPT 86705); hepatitis b surface
antibody (hbsab) (CPT 86706); hepatitis be antibody (hbeab) (CPT 86707); hepatitis a antibody (haab); total (CPT
86708); hepatitis a antibody (haab); igm antibody (CPT 86709); hepatitis c antibody; (CPT 86803); hepatitis c antibody; confirmatory test (eg, immunoblot) (CPT 86804); infectious agent antigen detection by enzyme immunoassay
technique, qualitative or semiquantitative, multiple-step method; hepatitis b surface antigen (hbsag) (CPT 87340);
infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step
method; hepatitis b surface antigen (hbsag) neutralization (CPT 87341); infectious agent antigen detection by enzyme
immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis be antigen (hbeag) (CPT
87350); and infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative,
multiple-step method; hepatitis, delta agent (CPT 87380):
042
070.0
070.1
070.20
070.21
070.22
070.23
070.30
070.31
070.32
070.33
070.41
070.42
070.43
070.44
070.49
070.51
070.52
070.53
070.54
070.59
070.6
070.70
070.71
070.9
273.2
275.0
275.1
277.1
277.30
277.31
277.39
human immunodeficiency virus (hiv) disease
viral hepatitis a with hepatic coma
viral hepatitis a without hepatic coma
viral hepatitis b with hepatic coma acute or unspecified without hepatitis delta
viral hepatitis b with hepatic coma acute or unspecified with hepatitis delta
chronic viral hepatitis b with hepatic coma without hepatitis delta
chronic viral hepatitis b with hepatic coma with hepatitis delta
viral hepatitis b without hepatic coma acute or unspecified without hepatitis delta
viral hepatitis b without hepatic coma acute or unspecified with hepatitis delta
chronic viral hepatitis b without hepatic coma without hepatitis delta
chronic viral hepatitis b without hepatic coma with hepatitis delta
acute hepatitis c with hepatic coma
hepatitis delta without active hepatitis b disease with hepatic coma hepatitis delta with hepatitis b carrier state
hepatitis e with hepatic coma
chronic hepatitis c with hepatic coma
other specified viral hepatitis with hepatic coma
acute hepatitis c without mention of hepatic coma
hepatitis delta without active hepatitis b disease or hepatic coma
hepatitis e without hepatic coma
chronic hepatitis c without hepatic coma
other specified viral hepatitis without hepatic coma
unspecified viral hepatitis with hepatic coma
unspecified viral hepatitis c without hepatic coma
unspecified viral hepatitis c with hepatic coma
unspecified viral hepatitis without hepatic coma
other paraproteinemias
disorders of iron metabolism
disorders of copper metabolism
disorders of porphyrin metabolism
amyloidosis, unspecified
familial mediterranean fever
other amyloidosis
CMS Limitations
Viral Hepatitis Serology Tests (con’t)
354.5
370.00*
446.0
452
453.0
456.0
456.1
456.20
456.21
516.3
570
571.0
571.1
571.2
571.3
571.40
571.41
571.42
571.49
571.5
571.6
571.8
571.9
572.0
572.1
572.2
572.3
572.4
572.8
573.1
573.2
573.3
573.8
573.9
583.1
584.9
585.3
585.4
585.5
585.6
686.8
697.0
780.31
780.32
780.71
780.79
782.4
783.0
783.1
mononeuritis multiplex
corneal ulcer unspecified
polyarteritis nodosa
portal vein thrombosis
budd-chiari syndrome
esophageal varices with bleeding
esophageal varices without bleeding
esophageal varices in diseases classified elsewhere with bleeding
esophageal varices in diseases classified elsewhere without bleeding
idiopathic fibrosing alveolitis
acute and subacute necrosis of liver
alcoholic fatty liver
acute alcoholic hepatitis
alcoholic cirrhosis of liver
alcoholic liver damage unspecified
chronic hepatitis unspecified
chronic persistent hepatitis
autoimmune hepatitis
other chronic hepatitis
cirrhosis of liver without alcohol
biliary cirrhosis
other chronic nonalcoholic liver disease
unspecified chronic liver disease without alcohol
abscess of liver
portal pyemia
hepatic coma
portal hypertension
hepatorenal syndrome
other sequelae of chronic liver disease
hepatitis in viral diseases classified elsewhere
hepatitis in other infectious diseases classified elsewhere
hepatitis unspecified
other specified disorders of liver
unspecified disorder of liver
nephritis and nephropathy not specified as acute or chronic with lesion of membranous glomerulonephritis
acute renal failure unspecified
chronic kidney disease, stage iii (moderate)
chronic kidney disease, stage iv (severe)
chronic kidney disease, stage v
end stage renal disease
other specified local infections of skin and subcutaneous tissue
lichen planus
febrile convulsions (simple), unspecified
complex febrile convulsions
chronic fatigue syndrome
other malaise and fatigue
jaundice unspecified not of newborn
anorexia
abnormal weight gain
CMS Limitations
Viral Hepatitis Serology Tests (con’t)
783.21
783.22
783.3
783.40
783.41
783.42
783.43
783.5
783.6
784.69
787.01
787.02
787.03
789.00
789.01
789.02
789.03
789.04
789.05
789.06
789.07
789.09
790.4
794.8
996.82
999.5
v01.79
v02.60
v02.61
v02.62
v02.69
v10.07
v15.85
v45.11
v56.0
v56.8
v71.83*
v72.85*
loss of weight
underweight
feeding difficulties and mismanagement
unspecified lack of normal physiological development
failure to thrive
delayed milestones
short stature
polydipsia
polyphagia
other symbolic dysfunction
nausea with vomiting
nausea alone
vomiting alone
abdominal pain unspecified site
abdominal pain right upper quadrant
abdominal pain left upper quadrant
abdominal pain right lower quadrant
abdominal pain left lower quadrant
abdominal pain periumbilic
abdominal pain epigastric
abdominal pain generalized
abdominal pain other specified site
nonspecific elevation of levels of transaminase or lactic acid dehydrogenase (ldh)
nonspecific abnormal results of function study of liver
complications of transplanted liver
other serum reaction not elsewhere classified
contact or exposure to other viral diseases
carrier or suspected carrier of viral hepatitis unspecified
carrier or suspected carrier of hepatitis b
carrier or suspected carrier of hepatitis c
carrier or suspected carrier of other viral hepatitis
personal history of malignant neoplasm of liver
personal history of exposure to potentially hazardous body fluids
renal dialysis status
aftercare involving extracorporeal dialysis
aftercare involving other dialysis
observation and evaluation for suspected exposure to other biological agent
other specified examination
*Use ICD-9-CM code 370.00 to report Mooren’s corneal ulcer.’
*Use v71.83 when testing patients with B-cell lymphoma for hepatitis C. The appropriate B-cell lymphoma ICD-9-CM
code should also be submitted.
*Use v72.85 when viral hepatitis serologies are necessary prior to chemotherapy or other immunosuppressive therapy.
LIMITATIONS:
• Hepatitis B core antibody testing (CPT codes 86704, 86705) - should not be utilized in the presence of a
recently positive hepatitis B surface antigen test. There is no need to repeat unless there is clinical evidence
of reactivation of hepatitis B.
CMS Limitations
Viral Hepatitis Serology Tests (con’t)
•
•
•
•
Hepatitis C antibody testing (CPT code 86803) – should not be repeated if positive unless the patient is
treated with interferon. In such cases, documentation should be present to verify the medical necessity of
additional testing.
These tests are only payable for exposure to hepatitis, jaundice and conditions when viral hepatitis is considered as a diagnosis.
After a hepatitis diagnosis has been established, only individual tests, rather than the entire panel, are
needed.
Hepatitis testing will not be covered for the purpose of routine screening.
CMS Limitations Guide - Pulmonary Services
Starting July 1, 2008, CMS has placed numerous medical necessity limits on tests and procedures. This reference guide provides you with all of the latest changes.
This guide is not an all-inclusive list of National Coverage
Documents (NCD) and Local Coverage Documents (LCD).
Please consult the CMS website for additional information
at cms.hhs.gov/mcd/search.asp?clickon=search. You can
search by LCD or NCD or keyword and region.
CMS will deny payment if the correct diagnosis codes are
not entered on the order form, and your patient’s test or
procedure will not be covered. We compiled this information in one location to make it easier for you to find the
proper codes for medically necessary diagnoses.
It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g. to the fourth or
fifth digit). The correct use of an ICD-9-CM code listed
below does not assure coverage of a service. The service
must be reasonable and necessary in the specific case and
must meet the criteria specified in this determination.
We will continue to update this list as new CMS limitations
are announced. You can always find the most current list
on mymunson.org.
If you have any questions, please contact Kari Smith,
Office Coordinator, at (231) 935-2296, or Karen Popa,
Director, Patient Access Services, at (231) 935-7493.
CMS Limitations
Pulmonary Rehab
LCD # L28424, Effective Date: 01/01/2009
Effective January 1st, 2009, Medicare issued Medical Necessity rules for Pulmonary Rehab services. Only the following
diagnoses will be paid for by Medicare or any Medicare Advantage Plan:
135
277.00
277.02
491.0
491.1
491.20
491.21
491.22
491.8
491.9
492.0
492.8
493.20
493.82
494.0
494.1
496
500
501
502
503
504
505
506.4
506.9
508.1
515
516.0
516.2
516.3
516.8
516.9
518.89
sarcoidosis
cystic fibrosis without meconium ileus
cystic fibrosis with pulmonary manifestations
simple chronic bronchitis
mucopurulent chronic bronchitis
obstructive chronic bronchitis without exacerbation
obstructive chronic bronchitis with (acute) exacerbation
obstructive chronic bronchitis with acute bronchitis
other chronic bronchitis
unspecified chronic bronchitis
emphysematous bleb
other emphysema
chronic obstructive asthma unspecified
cough variant asthma
bronchiectasis without acute exacerbation
bronchiectasis with acute exacerbation
chronic airway obstruction not elsewhere classified
coal workers’ pneumoconiosis
asbestosis
pneumoconiosis due to other silica or silicates
pneumoconiosis due to other inorganic dust
pneumonopathy due to inhalation of other dust
pneumoconiosis unspecified
chronic respiratory conditions due to fumes and vapors
unspecified respiratory conditions due to fumes and vapors
chronic and other pulmonary manifestations due to radiation
postinflammatory pulmonary fibrosis
pulmonary alveolar proteinosis
pulmonary alveolar microlithiasis
idiopathic fibrosing alveolitis
other specified alveolar and parietoalveolar pneumonopathies
unspecified alveolar and parietoalveolar pneumonopathy
other diseases of lung not elsewhere classified
CMS Limitations Guide - Radiology Services
Starting July 1, 2008, CMS has placed numerous medical necessity limits on tests and procedures. This reference guide provides you with all of the latest changes.
This guide is not an all-inclusive list of National Coverage
Documents (NCD) and Local Coverage Documents (LCD).
Please consult the CMS website for additional information
at cms.hhs.gov/mcd/search.asp?clickon=search. You can
search by LCD or NCD or keyword and region.
CMS will deny payment if the correct diagnosis codes are
not entered on the order form, and your patient’s test or
procedure will not be covered. We compiled this information in one location to make it easier for you to find the
proper codes for medically necessary diagnoses.
It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g. to the fourth or
fifth digit). The correct use of an ICD-9-CM code listed
below does not assure coverage of a service. The service
must be reasonable and necessary in the specific case and
must meet the criteria specified in this determination.
We will continue to update this list as new CMS limitations
are announced. You can always find the most current list
on mymunson.org.
If you have any questions, please contact Kari Smith,
Office Coordinator, at (231) 935-2296, or Karen Popa,
Director, Patient Access Services, at (231) 935-7493.
CMS Limitations
Breast Imaging: Breast Ultrasound, Breast MRI, Ductography
LCD # L26890, Effective date: 12/01/2008
CPT/HCPCS Codes: CPT 19030, CPT 77053, CPT 77054, CPT 77058, CPT 77059, CPT 77645
ICD-9 codes that SUPPORT medical necessity for Breast Ultrasound (CPT 77645) and Breast MRI (CPT 77058 Unilateral, CPT 77059 Bilateral):
174.0
malignant neoplasm of nipple and areola of female breast
174.1
malignant neoplasm of central portion of female breast
174.2
malignant neoplasm of upper-inner quadrant of female breast
174.3
malignant neoplasm of lower-inner quadrant of female breast
174.4
malignant neoplasm of upper-outer quadrant of female breast
174.5
malignant neoplasm of lower-outer quadrant of female breast
174.6
malignant neoplasm of auxiliary tail of female breast
174.8
malignant neoplasm of other specified sites of female breast
174.9
malignant neoplasm of breast (female) unspecified site
175.0
malignant neoplasm of nipple and areola of male breast
175.9
malignant neoplasm of other and unspecified sites of the male breast
198.2
secondary malignant neoplasm of skin
198.81
secondary malignant neoplasm of breast
217
benign neoplasm of breast
233.0
carcinoma in situ of breast
238.3
neoplasm of uncertain behavior of breast
239.2
neoplasm of unspecified nature of bone soft tissue and skin
239.3
neoplasm of unspecified nature of breast
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
611.0
inflammatory disease of breast
611.1
hypertrophy of breast
611.2*
fissure of nipple
611.3*
fat necrosis of breast
611.4*
atrophy of breast
611.5*
galactocele
611.6*
galactorrhea not associated with childbirth
611.72
lump or mass in breast
611.79
other signs and symptoms in breast
611.8*
other specified disorders of breast
611.9*
unspecified breast disorder
793.80
unspecified abnormal mammogram
793.81
mammographic microcalcification
793.89
other abnormal findings on radiological examination of breast
996.54
mechanical complication of breast prosthesis
*ICD-9-CM codes 610.1-610.4, 610.8-610.9, 611.2-611.6, 611.8-611.9 should be reported only after mammography and focal
findings.
CMS Limitations
Breast Imaging: Breast Ultrasound, Breast MRI, Ductography (con’t)
ICD-9 codes that SUPPORT medical necessity for Ductography (Galactography) (CPT 77053), Single Duct (CPT
77054), Multiple Ducts (CPT 19030) injection procedure:
611.79
other signs and symptoms in breast
CMS Limitations
Breast Imaging: Diagnostic Mammography
LCD # L20061, Effective date: 10/01/2008
CPT/HCPCS Codes: CPT 77051, CPT 77055, CPT 77056, HCPCS G0204, HCPCS G0206
ICD-9 codes that SUPPORT medical necessity for Diagnostic Mammography (CPT 77051) and Screening Mammography
(CPT 77055, HCPCS G0206) Unilateral (CPT 77056, HCPCS G0204) Bilateral that converts to Diagnostic Mammography:
174.0-174.6
174.8-174.9
175.0
175.9
183.0
196.3
197.0
197.1
197.2
197.7
198.2
198.3
198.5
198.81
199.0
199.1
217
232.5
233.0
238.3
239.2
239.3
451.89
610.0
610.1
610.2
610.3
610.4
610.8
610.9
611.0
611.1
611.2
611.3
611.4
611.5
611.6
611.71
611.72
611.79
611.8*
611.9
785.6
malignant neoplasm of female breast
malignant neoplasm of other specified or unspecified sites of female breast
malignant neoplasm of nipple and areola of male breast
malignant neoplasm of other and unspecified sites of male breast
malignant neoplasm of ovary
secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb
secondary malignant neoplasm of lung
secondary malignant neoplasm of mediastinum
secondary malignant neoplasm of pleura
malignant neoplasm of liver secondary
secondary malignant neoplasm of skin
secondary malignant neoplasm of brain and spinal cord
secondary malignant neoplasm of bone and bone marrow
secondary malignant neoplasm of breast
disseminated malignant neoplasm
other malignant neoplasm of unspecified site
benign neoplasm of breast
carcinoma in situ of skin of trunk except scrotum
carcinoma in situ of breast
neoplasm of uncertain behavior of breast
neoplasm of unspecified nature of bone soft tissue and skin
neoplasm of unspecified nature of breast
phlebitis and thrombophlebitis of other sites
solitary cyst of breast
diffuse cystic mastopathy
fibroadenosis of breast
fibrosclerosis of breast
mammary duct ectasia
other specified benign mammary dysplasias
benign mammary dysplasia unspecified
inflammatory disease of breast
hypertrophy of breast
fissure of nipple
fat necrosis of breast
atrophy of breast
galactocele
galactorrhea not associated with childbirth
mastodynia
lump or mass in breast
other signs and symptoms in breast
other specified disorders of breast
unspecified breast disorder
enlargement of lymph nodes
CMS Limitations
Breast Imaging: Diagnostic Mammography (con’t)
793.80
793.81
793.89
879.0
879.1
922.0
996.54
996.69
V10.3
V10.89**
V45.83**
V67.1
V67.2
V71.1
unspecified abnormal mammogram
mammographic microcalcification
other abnormal findings on radiological examination of breast
open wound of breast without complication
open wound of breast complicated
contusion of breast
mechanical complication of breast prosthesis
infection and inflammatory reaction due to other internal prosthetic device implant and graft
personal history of malignant neoplasm of breast
personal history of malignant neoplasm of other sites
breast implant removal status
follow-up examination following radiotherapy
follow-up examination following chemotherapy
observation for suspected malignant neoplasm
*Use ICD-9-CM 611.8 for Hematoma.
**ICD-9-CM V10.89 and V45.83 may be reported only until clinical stability has been established.
CMS Limitations
Breast Imaging: Screening Mammography
CPT/HCPCS Codes: CPT 77052, CPT 77057, HCPCS G0202
The following limitations apply to Screening Mammography:
• The service must be, at a minimum, a two-view exposure (cranio-caudal and a medial-lateral oblique view)
of each breast.
• Payment may not be made for screening mammography performed on a woman under age 35.
• Payment may only be made for a screening mammography when performed after at least 11 months have
passed following the month in which the last screening mammography service was rendered.
• Mammography facilities that perform screening mammography services may not release screening mammography x-rays for interpretation to physicians who are not approved under the facilities certification
number unless: The patient has requested a transfer of the films from one facility to another for a second
opinion OR the patient has moved to another part of the country where the next screening mammography
will be performed.
• Only one type of screening mammography will be allowed in a calendar year. Either a screening mammography – film (CPT 77057) OR a screening mammography – digital (HCPCS G0202) will be paid.
• A screening mammography is not payable for a male beneficiary.
ICD-9 codes that SUPPORT medical necessity for Screening Mammography (CPT 77052, CPT 77057, and HCPCS
G0202), all views:
V76.11
V76.12
screening mammogram for high-risk patient
other screening mammogram
The following code is necessary to SUPPORT medical necessity for patients having Screening Mammography on only
one breast:
V103
history of malignant neoplasm of female breast
CMS Limitations
CT Abdomen and Pelvis
LCD # L28544, Effective Date: 03/25/2009
CPT/HCPCS Codes: CPT 72192, CPT 72193, CPT 72194, CPT 74150, CPT 74160, CPT 74170, CPT 76376*, CPT 76377*
ICD-9 codes that SUPPORT medical necessity for computed tomography, pelvis; without contrast material (CPT 72192);
computed tomography, pelvis; with contrast material(s) (CPT 72193); computed tomography, pelvis; without contrast
material, followed by contrast material(s) and further sections (CPT 72194); computed tomography, abdomen; without
contrast material (CPT 74150); computed tomography, abdomen; with contrast material(s) (CPT 74160); computed
tomography, abdomen; without contrast material, followed by contrast material(s) and further sections (CPT 74170);
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or
other tomographic modality; not requiring image post-processing on an independent workstation (CPT 76376*); and
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or
other tomographic modality; requiring image post-processing on an independent workstation (CPT 76377*):
*Note: For the purposes of this LCD, CPT code 76376 or 76377 is allowed only when billed in conjunction with another
computed tomography procedure code.
006.0 - 006.9 acute amebic dysentery without abscess - amebiasis unspecified
014.00 - 014.86 tuberculous peritonitis unspecified examination - other tuberculosis of intestines and mesenteric
glands tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
016.00 - 016.96 tuberculosis of kidney unspecified examination - unspecified genitourinary tuberculosis tubercle bacilli
not found by bacteriological or histological examination but tuberculosis confirmed by other methods
(inoculation of animals)
017.60 - 017.76 tuberculosis of adrenal glands unspecified examination - tuberculosis of spleen tubercle bacilli not
found by bacteriological or histological examination but tuberculosis confirmed by other methods
(inoculation of animals)
038.0 - 038.9 streptococcal septicemia - unspecified septicemia
039.0 - 039.9 cutaneous actinomycotic infection - actinomycotic infection of unspecified site
042
human immunodeficiency virus (hiv) disease
070.0 - 070.9 viral hepatitis a with hepatic coma - unspecified viral hepatitis without hepatic coma
090.0
early congenital syphilis symptomatic
095.0 - 095.9 syphilitic episcleritis - late symptomatic syphilis unspecified
150.0 - 150.9 malignant neoplasm of cervical esophagus - malignant neoplasm of esophagus unspecified site
151.0 - 151.9 malignant neoplasm of cardia - malignant neoplasm of stomach unspecified site
152.0 - 152.9 malignant neoplasm of duodenum - malignant neoplasm of small intestine unspecified site
153.0 - 153.9 malignant neoplasm of hepatic flexure - malignant neoplasm of colon unspecified site
154.0 - 154.8 malignant neoplasm of rectosigmoid junction - malignant neoplasm of other sites of rectum rectosigmoid junction and anus
155.0 - 155.2 malignant neoplasm of liver primary - malignant neoplasm of liver not specified as primary or secondary
156.0 - 156.9 malignant neoplasm of gallbladder - malignant neoplasm of biliary tract part unspecified site
157.0 - 157.9 malignant neoplasm of head of pancreas - malignant neoplasm of pancreas part unspecified
158.0 - 158.9 malignant neoplasm of retroperitoneum - malignant neoplasm of peritoneum unspecified
159.0 - 159.9 malignant neoplasm of intestinal tract part unspecified - malignant neoplasm of ill-defined sites within
the digestive organs and peritoneum
162.0 - 162.9 malignant neoplasm of trachea - malignant neoplasm of bronchus and lung unspecified
170.6
malignant neoplasm of pelvic bones sacrum and coccyx
171.5 - 171.9 malignant neoplasm of connective and other soft tissue of abdomen - malignant neoplasm of connective and other soft tissue site unspecified
CMS Limitations
CT Abdomen and Pelvis (con’t)
174.0 - 174.9 malignant neoplasm of nipple and areola of female breast - malignant neoplasm of breast (female)
unspecified site
175.0
malignant neoplasm of nipple and areola of male breast
175.9
malignant neoplasm of other and unspecified sites of male breast
176.1
kaposi’s sarcoma soft tissue
176.3
kaposi’s sarcoma gastrointestinal sites
176.5
kaposi’s sarcoma lymph nodes
kaposi’s sarcoma other specified sites
179malignant neoplasm of uterus-part uns
180.0 - 181 malignant neoplasm of endocervix - malignant neoplasm of placenta
182.0 - 182.8 malignant neoplasm of corpus uteri except isthmus - malignant neoplasm of other specified sites of
body of uterus
183.0 - 183.9 malignant neoplasm of ovary - malignant neoplasm of uterine adnexa unspecified site
184.0 - 185 malignant neoplasm of vagina - malignant neoplasm of prostate
186.0
malignant neoplasm of undescended testis
186.9
malignant neoplasm of other and unspecified testis
187.1 - 187.9 malignant neoplasm of prepuce - malignant neoplasm of male genital organ site unspecified
188.0 - 188.9 malignant neoplasm of trigone of urinary bladder - malignant neoplasm of bladder part unspecified
189.0 - 189.9 malignant neoplasm of kidney except pelvis - malignant neoplasm of urinary organ site unspecified
193malignant neoplasm of thyroid gland
194.0
malignant neoplasm of adrenal gland
194.8
malignant neoplasm of other endocrine glands and related structures
194.9
malignant neoplasm of endocrine gland site unspecified
195.2
malignant neoplasm of abdomen
195.3
malignant neoplasm of pelvis
195.8
malignant neoplasm of other specified sites
196.0 - 196.9 secondary and unspecified malignant neoplasm of lymph nodes of head face and neck - secondary
and unspecified malignant neoplasm of lymph nodes site unspecified
197.0 - 197.8 secondary malignant neoplasm of lung - secondary malignant neoplasm of other digestive organs and
spleen
198.0 - 198.89 secondary malignant neoplasm of kidney - secondary malignant neoplasm of other specified sites
199.0
disseminated malignant neoplasm
199.1
other malignant neoplasm of unspecified site
199.2
malignant neoplasm associated with transplant organ
200.00 -208.92 reticulosarcoma unspecified site - unspecified leukemia, in relapse
209.00 -209.69 malignant carcinoid tumor of the small intestine, unspecified portion - benign carcinoid tumor of other
sites
211.0 - 211.9 benign neoplasm of esophagus - benign neoplasm of other and unspecified site in the digestive system
213.6
benign neoplasm of pelvic bones sacrum and coccyx
214.3 - 214.9 lipoma of intra-abdominal organs - lipoma unspecified site
215.3
other benign neoplasm of connective and other soft tissue of lower limb including hip
215.5 - 215.8 other benign neoplasm of connective and other soft tissue of abdomen - other benign neoplasm of
connective and other soft tissue of other specified sites
216.5 - 216.8 benign neoplasm of skin of trunk except scrotum - benign neoplasm of other specified sites of skin
218.0 - 218.9 submucous leiomyoma of uterus - leiomyoma of uterus unspecified
219.0 - 220 benign neoplasm of cervix uteri - benign neoplasm of ovary
221.0 - 221.9 benign neoplasm of fallopian tube and uterine ligaments - benign neoplasm of female genital organ
site unspecified
222.0 - 222.9 benign neoplasm of testis - benign neoplasm of male genital organ site unspecified
CMS Limitations
CT Abdomen and Pelvis (con’t)
223.0 - 223.9 227.0
227.6
227.8
228.04 - 228.1 229.0
229.8
230.1 - 230.9 232.5
232.7
232.8
233.1 - 233.9 235.2 - 235.5 benign neoplasm of kidney except pelvis - benign neoplasm of urinary organ site unspecified
benign neoplasm of adrenal gland
benign neoplasm of aortic body and other paraganglia
benign neoplasm of other endocrine glands and related structures
hemangioma of intra-abdominal structures - lymphangioma any site
benign neoplasm of lymph nodes
benign neoplasm of other specified sites
carcinoma in situ of esophagus - carcinoma in situ of other and unspecified digestive organs
carcinoma in situ of skin of trunk except scrotum
carcinoma in situ of skin of lower limb including hip
carcinoma in situ of other specified sites of skin
carcinoma in situ of cervix uteri - carcinoma in situ of other and unspecified urinary organs
neoplasm of uncertain behavior of stomach intestines and rectum - neoplasm of uncertain behavior of
other and unspecified digestive organs
236.0 - 236.99 neoplasm of uncertain behavior of uterus - neoplasm of uncertain behavior of other and unspecified
urinary organs
237.2 - 237.4 neoplasm of uncertain behavior of adrenal gland - neoplasm of uncertain behavior of other and unspecified endocrine glands
237.70 - 237.72 neurofibromatosis unspecified - neurofibromatosis type 2 acoustic neurofibromatosis
238.0
neoplasm of uncertain behavior of bone and articular cartilage
238.1
neoplasm of uncertain behavior of connective and other soft tissue
239.0 - 239.8 neoplasm of unspecified nature of digestive system - neoplasm of unspecified nature of other specified sites
251.4 - 251.9 abnormality of secretion of glucagon - unspecified disorder of pancreatic internal secretion
255.0 - 255.8 cushing’s syndrome - other specified disorders of adrenal glands
259.2
carcinoid syndrome
273.1
monoclonal paraproteinemia
277.00
cystic fibrosis without meconium ileus
277.01
cystic fibrosis with meconium ileus
277.03
cystic fibrosis with gastrointestinal manifestations
277.30
amyloidosis, unspecified
277.31
familial mediterranean fever
277.39
other amyloidosis
282.0 - 282.9 hereditary spherocytosis - hereditary hemolytic anemia unspecified
283.0 - 283.9 autoimmune hemolytic anemias - acquired hemolytic anemia unspecified
287.30 - 287.33 primary thrombocytopenia,unspecified - congenital and hereditary thrombocytopenic purpura
287.39
other primary thrombocytopenia
287.4
secondary thrombocytopenia
289.1 - 289.59 chronic lymphadenitis - other diseases of spleen
401.0 - 401.9 malignant essential hypertension - unspecified essential hypertension
440.0
atherosclerosis of aorta
440.1
atherosclerosis of renal artery
440.20 -440.29 atherosclerosis of native arteries of the extremities unspecified - other atherosclerosis of native arteries of the extremities
440.30
atherosclerosis of unspecified bypass graft of the extremities
440.8
atherosclerosis of other specified arteries
441.00 - 441.9 dissection of aorta aneurysm unspecified site - aortic aneurysm of unspecified site without rupture
442.1 - 442.9 aneurysm of renal artery - other aneurysm of unspecified site
443.81
peripheral angiopathy in diseases classified elsewhere
443.9
peripheral vascular disease unspecified
CMS Limitations
CT Abdomen and Pelvis (con’t)
444.0
embolism and thrombosis of abdominal aorta
444.22
arterial embolism and thrombosis of lower extremity
444.81
embolism and thrombosis of iliac artery
444.89
embolism and thrombosis of other artery
446.0 - 446.7 polyarteritis nodosa - takayasu’s disease
447.0
arteriovenous fistula acquired
449
septic arterial embolism
452
portal vein thrombosis
453.0 - 453.9 budd-chiari syndrome - embolism and thrombosis of unspecified site
457.1
other lymphedema
457.8
other noninfectious disorders of lymphatic channels
459.0
hemorrhage unspecified
530.0
achalasia and cardiospasm
530.20 - 530.89 ulcer of esophagus without bleeding - other diseases of esophagus
531.00 - 531.91 acute gastric ulcer with hemorrhage without obstruction - gastric ulcer unspecified as acute or chronic
without hemorrhage or perforation with obstruction
532.00 - 532.91 acute duodenal ulcer with hemorrhage without obstruction - duodenal ulcer unspecified as acute or
chronic without hemorrhage or perforation with obstruction
533.00 - 533.91 acute peptic ulcer of unspecified site with hemorrhage without obstruction - peptic ulcer of unspecified site unspecified as acute or chronic without hemorrhage or perforation with obstruction
534.00 - 534.91 acute gastrojejunal ulcer with hemorrhage without obstruction - gastrojejunal ulcer unspecified as
acute or chronic without hemorrhage or perforation with obstruction
535.00 - 535.61 acute gastritis (without hemorrhage) - duodenitis with hemorrhage
536.0 - 536.9 achlorhydria - unspecified functional disorder of stomach
537.0 - 537.9 acquired hypertrophic pyloric stenosis - unspecified disorder of stomach and duodenum
540.0 - 543.9 acute appendicitis with generalized peritonitis - other and unspecified diseases of appendix
550.00 - 550.93 unilateral or unspecified inguinal hernia with gangrene - recurrent bilateral inguinal hernia without obstruction or gangrene
551.00 - 551.9 unilateral or unspecified femoral hernia with gangrene - hernia of unspecified site with gangrene
552.00 - 552.9 unilateral or unspecified femoral hernia with obstruction - hernia of unspecified site with obstruction
553.01 - 553.9 recurrent unilateral or unspecified femoral hernia without obstruction or gangrene - hernia of unspecified site without obstruction or gangrene
555.0 - 555.9 regional enteritis of small intestine - regional enteritis of unspecified site
556.0 - 556.9 ulcerative (chronic) enterocolitis - ulcerative colitis unspecified
557.0 - 557.9 acute vascular insufficiency of intestine - unspecified vascular insufficiency of intestine
558.1 - 558.9 gastroenteritis and colitis due to radiation - other and unspecified noninfectious gastroenteritis and
colitis
560.0 - 560.9 intussusception - unspecified intestinal obstruction
562.00 - 562.13 diverticulosis of small intestine (without hemorrhage) - diverticulitis of colon with hemorrhage
564.00 - 564.9 unspecified constipation - unspecified functional disorder of intestine
565.0 - 566 anal fissure - abscess of anal and rectal regions
567.0 - 567.9 peritonitis in infectious diseases classified elsewhere - unspecified peritonitis
568.0 - 568.9 peritoneal adhesions (postoperative) (postinfection) - unspecified disorder of peritoneum
569.0 - 570 anal and rectal polyp - acute and subacute necrosis of liver
571.0 - 571.9 alcoholic fatty liver - unspecified chronic liver disease without alcohol
572.0 - 572.8 abscess of liver - other sequelae of chronic liver disease
573.0 - 573.9 chronic passive congestion of liver - unspecified disorder of liver
574.00 - 574.91 calculus of gallbladder with acute cholecystitis without obstruction - calculus of gallbladder and bile
duct without cholecystitis with obstruction
575.0 - 575.9 acute cholecystitis - unspecified disorder of gallbladder
CMS Limitations
CT Abdomen and Pelvis (con’t)
576.0 - 576.9 577.0 - 577.9 578.0 - 578.9 579.0 - 579.9 583.9
postcholecystectomy syndrome - unspecified disorder of biliary tract
acute pancreatitis - unspecified disease of pancreas
hematemesis - hemorrhage of gastrointestinal tract unspecified
celiac disease - unspecified intestinal malabsorption
nephritis and nephropathy not specified as acute or chronic with unspecified pathological lesion in
kidney
584.5 - 585.9 acute renal failure with lesion of tubular necrosis - chronic kidney disease, unspecified
590.00 - 591 chronic pyelonephritis without lesion of renal medullary necrosis - hydronephrosis
592.0 - 592.9 calculus of kidney - urinary calculus unspecified
593.0 - 593.9 nephroptosis - unspecified disorder of kidney and ureter
596.0 - 596.9 bladder neck obstruction - unspecified disorder of bladder
599.70 - 599.72 hematuria, unspecified - microscopic hematuria
600.00 - 600.91 hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract (luts) - hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (luts)
614.0 - 614.9 acute salpingitis and oophoritis - unspecified inflammatory disease of female pelvic organs and tissues
615.0 - 615.9 acute inflammatory diseases of uterus except cervix - unspecified inflammatory disease of uterus
616.0 - 616.11 cervicitis and endocervicitis - vaginitis and vulvovaginitis in diseases classified elsewhere
616.3
abscess of bartholin’s gland
616.4
other abscess of vulva
617.0 - 617.9 endometriosis of uterus - endometriosis site unspecified
618.6
vaginal enterocele congenital or acquired
618.7
old laceration of muscles of pelvic floor
619.0 - 619.9 urinary-genital tract fistula female - unspecified fistula involving female genital tract
620.0 - 620.9 follicular cyst of ovary - unspecified noninflammatory disorder of ovary fallopian tube and broad ligament
621.0
polyp of corpus uteri
621.2 - 621.7 hypertrophy of uterus - chronic inversion of uterus
625.5
pelvic congestion syndrome
626.0 - 626.9 absence of menstruation - unspecified disorders of menstruation and other abnormal bleeding from
female genital tract
627.0
premenopausal menorrhagia
627.1
postmenopausal bleeding
627.4
symptomatic states associated with artificial menopause
627.8
other specified menopausal and postmenopausal disorders
628.2
infertility female of tubal origin
628.3
infertility female of uterine origin
629.0 - 629.1 hematocele female not elsewhere classified - hydrocele canal of nuck
629.89
other specified disorders of female genital organs
682.2
cellulitis and abscess of trunk
707.10 - 707.19 unspecified ulcer of lower limb - ulcer of other part of lower limb
707.8
chronic ulcer of other specified sites
707.9
chronic ulcer of unspecified site
710.0 - 710.9 systemic lupus erythematosus - unspecified diffuse connective tissue disease
711.05
pyogenic arthritis involving pelvic region and thigh
711.25
arthropathy in behcet’s syndrome involving pelvic region and thigh
711.35
postdysenteric arthropathy involving pelvic region and thigh
711.45
arthropathy involving pelvic region and thigh associated with other bacterial diseases
711.55
arthropathy involving pelvic region and thigh associated with other viral diseases
711.65
arthropathy involving pelvic region and thigh associated with mycoses
711.75
arthropathy involving pelvic region and thigh associated with helminthiasis
CMS Limitations
CT Abdomen and Pelvis (con’t)
711.85
arthropathy involving pelvic region and thigh associated with other infectious and parasitic diseases
713.1
arthropathy associated with gastrointestinal conditions other than infections
713.2
arthropathy associated with hematological disorders
713.5
arthropathy associated with neurological disorders
714.0
rheumatoid arthritis
716.15
traumatic arthropathy involving pelvic region and thigh
718.05
articular cartilage disorder involving pelvic region and thigh
718.25
pathological dislocation of joint of pelvic region and thigh
718.35
recurrent dislocation of joint of pelvic region and thigh
718.45
contracture of joint of pelvic region and thigh
718.55
ankylosis of joint of pelvic region and thigh
718.65
unspecified intrapelvic protrusion of acetabulum pelvic region and thigh
718.75
developmental dislocation of joint pelvic region and thigh
719.05
effusion of joint of pelvic region and thigh
719.15
hemarthrosis involving pelvic region and thigh
719.25
villonodular synovitis involving pelvic region and thigh
719.45
pain in joint involving pelvic region and thigh
719.65
other symptoms referable to joint of pelvic region and thigh
719.85
other specified disorders of joint of pelvic region and thigh
724.9
other unspecified back disorders
729.5
pain in limb
730.05
acute osteomyelitis involving pelvic region and thigh
730.15
chronic osteomyelitis involving pelvic region and thigh
730.75
osteopathy resulting from poliomyelitis involving pelvic region and thigh
732.1
juvenile osteochondrosis of hip and pelvis
733.90
disorder of bone and cartilage unspecified
747.61
gastrointestinal vessel anomaly
747.62
renal vessel anomaly
750.6
congenital hiatus hernia
750.7
other specified congenital anomalies of stomach
751.0 - 751.9 meckel’s diverticulum - unspecified congenital anomaly of digestive system
752.0 - 752.9 congenital anomalies of ovaries - unspecified congenital anomaly of genital organs
753.0 - 753.9 renal agenesis and dysgenesis - unspecified congenital anomaly of urinary system
759.0 - 759.9 anomalies of spleen congenital - congenital anomaly unspecified
780.60 - 780.65 fever, unspecified - hypothermia not associated with low environmental temperature
782.3
edema
782.4
jaundice unspecified not of newborn
783.21
loss of weight
783.22
underweight
783.40 - 783.43 unspecified lack of normal physiological development - short stature
785.4
gangrene
785.59
other shock without trauma
785.6
enlargement of lymph nodes
786.59
other chest pain
787.01 - 787.03 nausea with vomiting - vomiting alone
787.4
visible peristalsis
787.91
diarrhea
787.99
other symptoms involving digestive system
788.0 - 788.30 renal colic - urinary incontinence unspecified
788.5
oliguria and anuria
CMS Limitations
CT Abdomen and Pelvis (con’t)
788.62
788.8
789.00 - 789.9 790.7
793.3 - 793.6 slowing of urinary stream
extravasation of urine
abdominal pain unspecified site - other symptoms involving abdomen and pelvis
bacteremia
nonspecific abnormal findings on radiological and other examination of biliary tract - nonspecific abnormal findings on radiological and other examination of abdominal area including retroperitoneum
794.8
nonspecific abnormal results of function study of liver
794.9
nonspecific abnormal results of other specified function study
808.0 - 808.9 closed fracture of acetabulum - unspecified open fracture of pelvis
809.0 - 809.1 fracture of bones of trunk closed - fracture of bones of trunk open
862.0
injury to diaphragm without open wound into cavity
862.1
injury to diaphragm with open wound into cavity
863.0 - 863.99 injury to stomach without open wound into cavity - injury to other and unspecified gastrointestinal
sites with open wound into cavity
864.00 - 864.19 unspecified injury to liver without open wound into cavity - other injury to liver with open wound into
cavity
865.00 - 865.19 unspecified injury to spleen without open wound into cavity - other injury to spleen with open wound
into cavity
866.00 - 866.13 unspecified injury to kidney without open wound into cavity - complete disruption of kidney parenchyma with open wound into cavity
867.0 - 867.9 injury to bladder and urethra without open wound into cavity - injury to unspecified pelvic organ with
open wound into cavity
868.00 - 868.19 injury to unspecified intra-abdominal organ without open wound into cavity - injury to other and multiple intra-abdominal organs with open wound into cavity
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
879.2 - 879.7 open wound of abdominal wall anterior without complication - open wound of other and unspecified
parts of trunk complicated
902.0 - 902.9 injury to abdominal aorta - injury to unspecified blood vessel of abdomen and pelvis
908.1
late effect of internal injury to intra-abdominal organs
908.4
late effect of injury to blood vessel of thorax abdomen and pelvis
908.5
late effect of foreign body in orifice
922.2
contusion of abdominal wall
922.4
contusion of genital organs
926.0
crushing injury of external genitalia
926.11
crushing injury of back
926.12
crushing injury of buttock
935.1 - 938 foreign body in esophagus - foreign body in digestive system unspecified
939.0 - 939.9 foreign body in bladder and urethra - foreign body in unspecified site in genitourinary tract
958.0 - 958.5 air embolism as an early complication of trauma - traumatic anuria
958.93
traumatic compartment syndrome of abdomen
959.12
other injury of abdomen
959.13
fracture of corpus cavernosum penis
959.14
other injury of external genitals
959.19
other and unspecified injury of other sites of trunk
995.90 - 995.94 systemic inflammatory response syndrome unspecified - systemic inflammatory response syndrome
due to noninfectious process with acute organ dysfunction
996.1
mechanical complication of other vascular device implant and graft
996.30 - 996.39 mechanical complication of unspecified genitourinary device implant and graft - other mechanical
complication of genitourinary device implant and graft
CMS Limitations
CT Abdomen and Pelvis (con’t)
996.60
infection and inflammatory reaction due to unspecified device implant and graft
996.62
infection and inflammatory reaction due to other vascular device implant and graft
996.64
infection and inflammatory reaction due to indwelling urinary catheter
996.65
infection and inflammatory reaction due to other genitourinary device implant and graft
996.70 - 996.72 other complications due to unspecified device implant and graft - other complications due to other
cardiac device implant and graft
996.74
other complications due to other vascular device implant and graft
996.76
other complications due to genitourinary device implant and graft
996.81
complications of transplanted kidney
996.82
complications of transplanted liver
996.86 - 996.89 complications of transplanted pancreas - complications of other specified transplanted organ
997.4
digestive system complications not elsewhere classified
997.5
urinary complications not elsewhere classified
997.71 - 997.79 vascular complications of mesenteric artery - vascular complications of other vessels
998.0 - 998.7 postoperative shock not elsewhere classified - acute reaction to foreign substance accidentally left
during a procedure not elsewhere classified
v10.00 - v10.09 personal history of malignant neoplasm of unspecified site in gastrointestinal tract - personal history of
malignant neoplasm of other sites in gastrointestinal tract
v10.40 - v10.49 personal history of malignant neoplasm of unspecified female genital organ - personal history of malignant neoplasm of other male genital organs
v10.50 - v10.59 personal history of malignant neoplasm of unspecified urinary organ - personal history of malignant
neoplasm of other urinary organs
v10.79
personal history of other lymphatic and hematopoietic neoplasms
v58.73
aftercare following surgery of the circulatory system not elsewhere classified
v67.00*
follow-up examination following unspecified surgery
v67.09*
follow-up examination following other surgery
v67.1*
follow-up examination following radiotherapy
v67.2*
follow-up examination following chemotherapy
v71.1*
observation for suspected malignant neoplasm
* These codes are non-specific and require an additional ICD-9 code for payment.
CMS Limitations
CT Cervical Spine
LCD # L28544, Effective Date: 03/25/2009
CPT/HCPCS Codes: CPT 72125, CPT 72126, CPT 72127, CPT 76376*, CPT 76377*
ICD-9 codes that SUPPORT medical necessity for computed tomography, cervical spine; without contrast material
(CPT 72125); computed tomography, cervical spine; with contrast material (CPT 72126); computed tomography, cervical
spine; without contrast material, followed by contrast material(s) and further sections (CPT 72127); 3D rendering with
interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic
modality; not requiring image postprocessing on an independent workstation (CPT 76376*); and 3D rendering with
interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic
modality; requiring image postprocessing on an independent workstation (CPT 76377*):
*Note: For the purposes of this LCD, CPT code 76376 or 76377 is allowed only when billed in conjunction with another
computed tomography procedure code.
170.2
172.4
185
191.0 - 191.9 malignant neoplasm of vertebral column excluding sacrum and coccyx
malignant melanoma of skin of scalp and neck
malignant neoplasm of prostate
malignant neoplasm of cerebrum except lobes and ventricles - malignant neoplasm of brain unspecified site
192.0 - 193 malignant neoplasm of cranial nerves - malignant neoplasm of thyroid gland
194.1
malignant neoplasm of parathyroid gland
194.3 - 194.6 malignant neoplasm of pituitary gland and craniopharyngeal duct - malignant neoplasm of aortic body
and other paraganglia
195.0
malignant neoplasm of head face and neck
196.0
secondary and unspecified malignant neoplasm of lymph nodes of head face and neck
198.3 - 198.5 secondary malignant neoplasm of brain and spinal cord - secondary malignant neoplasm of bone and
bone marrow
198.89
secondary malignant neoplasm of other specified sites
199.0
disseminated malignant neoplasm
199.1
other malignant neoplasm of unspecified site
199.2
malignant neoplasm associated with transplant organ
203.00
multiple myeloma, without mention of having achieved remission
203.02
multiple myeloma, in relapse
213.2
benign neoplasm of vertebral column excluding sacrum and coccyx
225.3
benign neoplasm of spinal cord
225.4
benign neoplasm of spinal meninges
228.1
lymphangioma any site
237.5
neoplasm of uncertain behavior of brain and spinal cord
239.2
neoplasm of unspecified nature of bone soft tissue and skin
322.0 - 322.9 nonpyogenic meningitis - meningitis unspecified
324.1
intraspinal abscess
336.0
syringomyelia and syringobulbia
336.1
vascular myelopathies
340
multiple sclerosis
344.00 - 344.2 quadriplegia unspecified - diplegia of upper limbs
344.40 - 344.5 monoplegia of upper limb affecting unspecified side - unspecified monoplegia
353.2
cervical root lesions not elsewhere classified
720.9
unspecified inflammatory spondylopathy
721.0
cervical spondylosis without myelopathy
CMS Limitations
CT Cervical Spine (con’t)
721.1
cervical spondylosis with myelopathy
721.90
spondylosis of unspecified site without myelopathy
721.91
spondylosis of unspecified site with myelopathy
722.0
displacement of cervical intervertebral disc without myelopathy
722.4
degeneration of cervical intervertebral disc
722.6
degeneration of intervertebral disc site unspecified
722.71
intervertebral disc disorder with myelopathy cervical region
722.81
postlaminectomy syndrome of cervical region
722.91
other and unspecified disc disorder of cervical region
723.0 - 723.2 spinal stenosis in cervical region - cervicocranial syndrome
723.4
brachial neuritis or radiculitis nos
724.5
backache unspecified
724.9
other unspecified back disorders
730.08
acute osteomyelitis involving other specified sites
730.18
chronic osteomyelitis involving other specified sites
730.19
chronic osteomyelitis involving multiple sites
730.28
unspecified osteomyelitis involving other specified sites
730.38
periostitis without osteomyelitis involving other specified sites
733.00 - 733.03 osteoporosis unspecified - disuse osteoporosis
733.13
pathological fracture of vertebrae
733.40
aseptic necrosis of bone site unspecified
737.40 - 737.43 unspecified curvature of spine associated with other conditions - scoliosis associated with other conditions
756.10
congenital anomaly of spine unspecified
756.12 - 756.16 spondylolisthesis congenital - klippel-feil syndrome
756.19
other congenital anomalies of spine
793.7
nonspecific abnormal findings on radiological and other examination of musculoskeletal system
793.99
other nonspecific abnormal findings on radiological and other examinations of body structure
805.00 - 805.18 closed fracture of cervical vertebra unspecified level - open fracture of multiple cervical vertebrae
806.00 - 806.19 closed fracture of c1-c4 level with unspecified spinal cord injury - open fracture of c5-c7 level with
other specified spinal cord injury
839.00 - 839.08 closed dislocation cervical vertebra unspecified - closed dislocation multiple cervical vertebrae
839.10 - 839.18 open dislocation cervical vertebra unspecified - open dislocation multiple cervical vertebrae
952.00 - 952.09 c1-c4 level spinal cord injury unspecified - c5-c7 level with other specified spinal cord injury
952.8
multiple sites of spinal cord injury without spinal bone injury
953.0
injury to cervical nerve root
959.09
other and unspecified injury to face and neck
959.19
other and unspecified injury of other sites of trunk
v10.01
personal history of malignant neoplasm of tongue
v10.02
personal history of malignant neoplasm of other and unspecified parts of oral cavity and pharynx
v10.21
personal history of malignant neoplasm of larynx
v10.22
personal history of malignant neoplasm of nasal cavities middle ear and accessory sinuses
v10.81
personal history of malignant neoplasm of bone
v10.86
personal history of malignant neoplasm of other parts of nervous system
v67.00*
follow-up examination following unspecified surgery
v67.09*
follow-up examination following other surgery
v67.1*
follow-up examination following radiotherapy
v67.2*
follow-up examination following chemotherapy
*Non-specific and require an additional ICD-9 code for payment
CMS Limitations
CT Chest and Thorax
LCD # L28544, Effective Date: 3/25/09
CPT/HCPCS Codes: CPT 71250, CPT 71260, CPT 71270, CPT 76376*, CPT 76377*
ICD-9 codes that support medical necessity for computed tomography, thorax; without contrast material (CPT 71250);
computed tomography, thorax; with contrast material(s) (CPT 71260); computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections (CPT 71270); 3D rendering with interpretation and
reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation (CPT 76376*); and 3D rendering with interpretation and
reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring
image postprocessing on an independent workstation (CPT 76377*):
*Note: For the purposes of this LCD, CPT code 76376 or 76377 is allowed only when billed in conjunction with another
computed tomography procedure code.
141.0 - 141.9 142.0
146.0
146.9
149.0
150.0 - 150.9 151.0 - 151.9 153.0 - 153.9 154.0
154.8
155.0
157.0 - 157.9 158.0
161.9
162.0 - 162.9 163.0 - 163.9 164.0 - 164.9 165.0 - 165.9 170.2
170.3
171.0
171.9
172.0
172.5
172.8
172.9
173.5
174.0 - 174.9 175.0
175.9
176.0
176.1
176.3 - 176.8 malignant neoplasm of base of tongue - malignant neoplasm of tongue unspecified
malignant neoplasm of parotid gland
malignant neoplasm of tonsil
malignant neoplasm of oropharynx unspecified site
malignant neoplasm of pharynx unspecified
malignant neoplasm of cervical esophagus - malignant neoplasm of esophagus unspecified site
malignant neoplasm of cardia - malignant neoplasm of stomach unspecified site
malignant neoplasm of hepatic flexure - malignant neoplasm of colon unspecified site
malignant neoplasm of rectosigmoid junction
malignant neoplasm of other sites of rectum rectosigmoid junction and anus
malignant neoplasm of liver primary
malignant neoplasm of head of pancreas - malignant neoplasm of pancreas part unspecified
malignant neoplasm of retroperitoneum
malignant neoplasm of larynx unspecified
malignant neoplasm of trachea - malignant neoplasm of bronchus and lung unspecified
malignant neoplasm of parietal pleura - malignant neoplasm of pleura unspecified
malignant neoplasm of thymus - malignant neoplasm of mediastinum part unspecified
malignant neoplasm of upper respiratory tract part unspecified - malignant neoplasm of ill-defined
sites within the respiratory system
malignant neoplasm of vertebral column excluding sacrum and coccyx
malignant neoplasm of ribs sternum and clavicle
malignant neoplasm of connective and other soft tissue of head face and neck
malignant neoplasm of connective and other soft tissue site unspecified
malignant melanoma of skin of lip
malignant melanoma of skin of trunk except scrotum
malignant melanoma of other specified sites of skin
melanoma of skin site unspecified
other malignant neoplasm of skin of trunk except scrotum
malignant neoplasm of nipple and areola of female breast - malignant neoplasm of breast (female)
unspecified site
malignant neoplasm of nipple and areola of male breast
malignant neoplasm of other and unspecified sites of male breast
kaposi’s sarcoma skin
kaposi’s sarcoma soft tissue
kaposi’s sarcoma gastrointestinal sites - kaposi’s sarcoma other specified sites
CMS Limitations
CT Chest and Thorax (con’t)
179
180.0 - 180.9 181
182.0 - 182.8 malignant neoplasm of uterus-part uns
malignant neoplasm of endocervix - malignant neoplasm of cervix uteri unspecified site
malignant neoplasm of placenta
malignant neoplasm of corpus uteri except isthmus - malignant neoplasm of other specified sites of
body of uterus
183.0 - 183.9 malignant neoplasm of ovary - malignant neoplasm of uterine adnexa unspecified site
184.0 - 184.9 malignant neoplasm of vagina - 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 - 187.9 malignant neoplasm of prepuce - malignant neoplasm of male genital organ site unspecified
188.0 - 188.9 malignant neoplasm of trigone of urinary bladder - malignant neoplasm of bladder part unspecified
189.0 - 189.9 malignant neoplasm of kidney except pelvis - malignant neoplasm of urinary organ site unspecified
193
malignant neoplasm of thyroid gland
194.1
malignant neoplasm of parathyroid gland
194.8
malignant neoplasm of other endocrine glands and related structures
195.0
malignant neoplasm of head face and neck
195.1
malignant neoplasm of thorax
196.0 - 196.9 secondary and unspecified malignant neoplasm of lymph nodes of head face and neck - secondary
and unspecified malignant neoplasm of lymph nodes site unspecified
197.0 - 197.8 secondary malignant neoplasm of lung - secondary malignant neoplasm of other digestive organs and
spleen
198.0 - 198.89 secondary malignant neoplasm of kidney - secondary malignant neoplasm of other specified sites
199.0
disseminated malignant neoplasm
199.1
other malignant neoplasm of unspecified site
199.2
malignant neoplasm associated with transplant organ
200.00-208.92 reticulosarcoma unspecified site - unspecified leukemia, in relapse
211.0
benign neoplasm of esophagus
211.1
benign neoplasm of stomach
212.2 - 212.9 benign neoplasm of trachea - benign neoplasm of respiratory and intrathoracic organs site unspecified
213.3
benign neoplasm of ribs sternum and clavicle
213.4
benign neoplasm of scapula and long bones of upper limb
213.9
benign neoplasm of bone and articular cartilage site unspecified
214.1
lipoma of other skin and subcutaneous tissue
214.2
lipoma of intrathoracic organs
215.0
other benign neoplasm of connective and other soft tissue of head face and neck
215.4
other benign neoplasm of connective and other soft tissue of thorax
215.7
other benign neoplasm of connective and other soft tissue of trunk unspecified
216.5
benign neoplasm of skin of trunk except scrotum
216.8
benign neoplasm of other specified sites of skin
217
benign neoplasm of breast
226
benign neoplasm of thyroid glands
227.1
benign neoplasm of parathyroid gland
227.6
benign neoplasm of aortic body and other paraganglia
227.8
benign neoplasm of other endocrine glands and related structures
228.00
hemangioma of unspecified site
228.01
hemangioma of skin and subcutaneous tissue
228.09
hemangioma of other sites
228.1
lymphangioma any site
229.0
benign neoplasm of lymph nodes
CMS Limitations
CT Chest and Thorax (con’t)
229.8
230.1
230.2
231.1 - 231.9 232.5
232.8
233.0
235.7 - 235.9 benign neoplasm of other specified sites
carcinoma in situ of esophagus
carcinoma in situ of stomach
carcinoma in situ of trachea - carcinoma in situ of respiratory system part unspecified
carcinoma in situ of skin of trunk except scrotum
carcinoma in situ of other specified sites of skin
carcinoma in situ of breast
neoplasm of uncertain behavior of trachea bronchus and lung - neoplasm of uncertain behavior of
other and unspecified respiratory organs
237.3
neoplasm of uncertain behavior of paraganglia
237.70
neurofibromatosis unspecified
237.71
neurofibromatosis type 1 von recklinghausen’s disease
238.0 - 238.3 neoplasm of uncertain behavior of bone and articular cartilage - neoplasm of uncertain behavior of
breast
238.5 - 238.8 neoplasm of uncertain behavior of histiocytic and mast cells - neoplasm of uncertain behavior of other
specified sites
239.0 - 239.3 neoplasm of unspecified nature of digestive system - neoplasm of unspecified nature of breast
240.0
goiter specified as simple
240.9
goiter unspecified
241.0 - 241.9 nontoxic uninodular goiter - unspecified nontoxic nodular goiter
242.00 - 243 toxic diffuse goiter without thyrotoxic crisis or storm - congenital hypothyroidism
244.0 - 244.9 postsurgical hypothyroidism - unspecified acquired hypothyroidism
245.0 - 245.9 acute thyroiditis - thyroiditis unspecified
246.0 - 246.9 disorders of thyrocalcitonin secretion - unspecified disorder of thyroid
254.0 - 254.9 persistent hyperplasia of thymus - unspecified disease of thymus gland
353.0
brachial plexus lesions
353.3
thoracic root lesions not elsewhere classified
353.8
other nerve root and plexus disorders
391.0 - 391.9 acute rheumatic pericarditis - acute rheumatic heart disease unspecified
398.0
rheumatic myocarditis
414.06
coronary atherosclerosis of native coronary artery of transplanted heart
414.07
coronary atherosclerosis of bypass graft (artery) (vein) of transplanted heart
414.10 - 414.19 aneurysm of heart (wall) - other aneurysm of heart
415.11
iatrogenic pulmonary embolism and infarction
415.12
septic pulmonary embolism
415.19
other pulmonary embolism and infarction
417.0 - 417.9 arteriovenous fistula of pulmonary vessels - unspecified disease of pulmonary circulation
420.0
acute pericarditis in diseases classified elsewhere
420.90-420.99 acute pericarditis unspecified - other acute pericarditis
422.0
acute myocarditis in diseases classified elsewhere
422.90 - 422.99 acute myocarditis unspecified - other acute myocarditis
423.0 - 423.9 hemopericardium - unspecified disease of pericardium
425.0 - 425.9 endomyocardial fibrosis - secondary cardiomyopathy unspecified
440.0
atherosclerosis of aorta
441.00 - 441.9 dissection of aorta aneurysm unspecified site - aortic aneurysm of unspecified site without rupture
442.82
aneurysm of subclavian artery
444.1
embolism and thrombosis of thoracic aorta
446.7
takayasu’s disease
447.0
arteriovenous fistula acquired
447.2
rupture of artery
CMS Limitations
CT Chest and Thorax (con’t)
453.2
456.0
456.1
456.20
456.21
459.0
459.2
492.0
492.8
494.0
494.1
508.0 - 508.9 embolism and thrombosis of vena cava
esophageal varices with bleeding
esophageal varices without bleeding
esophageal varices in diseases classified elsewhere with bleeding
esophageal varices in diseases classified elsewhere without bleeding
hemorrhage unspecified
compression of vein
emphysematous bleb
other emphysema
bronchiectasis without acute exacerbation
bronchiectasis with acute exacerbation
acute pulmonary manifestations due to radiation - respiratory conditions due to unspecified external
agent
510.0
empyema with fistula
510.9
empyema without fistula
511.0 - 511.9 pleurisy without effusion or current tuberculosis - unspecified pleural effusion
512.0 - 512.8 spontaneous tension pneumothorax - other spontaneous pneumothorax
513.0 - 515 abscess of lung - postinflammatory pulmonary fibrosis
518.0 - 518.89 pulmonary collapse - other diseases of lung not elsewhere classified
519.00 - 519.9 tracheostomy complication unspecified - unspecified disease of respiratory system
530.0 - 530.82 achalasia and cardiospasm - esophageal hemorrhage
530.84
tracheoesophageal fistula
530.85 - 530.87 barrett’s esophagus - mechanical complication of esophagostomy
610.0 - 610.9 solitary cyst of breast - benign mammary dysplasia unspecified
611.0 - 611.79 inflammatory disease of breast - other signs and symptoms in breast
611.82
hypoplasia of breast
611.83
capsular contracture of breast implant
611.89
other specified disorders of breast
683
acute lymphadenitis
745.0 - 745.9 common truncus - unspecified defect of septal closure
746.00 - 746.9 congenital pulmonary valve anomaly unspecified - unspecified congenital anomaly of heart
747.0 - 747.9 patent ductus arteriosus - unspecified congenital anomaly of circulatory system
748.0 - 748.9 choanal atresia - unspecified congenital anomaly of respiratory system
750.3
congenital tracheoesophageal fistula esophageal atresia and stenosis
750.4
other specified congenital anomalies of esophagus
750.6
congenital hiatus hernia
750.8
other specified congenital anomalies of upper alimentary tract
756.2
cervical rib
756.3
other congenital anomalies of ribs and sternum
756.6
congenital anomalies of diaphragm
780.2
syncope and collapse
780.60 - 780.65 fever, unspecified - hypothermia not associated with low environmental temperature
785.50 - 785.6 shock unspecified - enlargement of lymph nodes
786.00
respiratory abnormality unspecified
786.05
shortness of breath
786.09
respiratory abnormality other
786.1 - 786.3 stridor - hemoptysis
786.50 - 786.6 unspecified chest pain - swelling mass or lump in chest
793.1
nonspecific abnormal findings on radiological and other examination of lung field
793.2
nonspecific abnormal findings on radiological and other examination of other intrathoracic organs
CMS Limitations
CT Chest and Thorax (con’t)
793.80 - 793.89 unspecified abnormal mammogram - other abnormal findings on radiological examination of breast
794.2 - 794.39 nonspecific abnormal results of function study of pulmonary system - other nonspecific abnormal
function study of cardiovascular system
794.5
nonspecific abnormal results of function study of thyroid
860.0 - 860.5 traumatic pneumothorax without open wound into thorax - traumatic pneumohemothorax with open
wound into thorax
861.00 - 861.32 unspecified injury of heart without open wound into thorax - laceration of lung with open wound into
thorax
862.0 - 862.9 injury to diaphragm without open wound into cavity - injury to multiple and unspecified intrathoracic
organs with open wound into cavity
875.0
open wound of chest (wall) without complication
875.1
open wound of chest (wall) complicated
901.0 - 901.89 injury to thoracic aorta - injury to other specified blood vessels of thorax
906.0
late effect of open wound of head neck and trunk
908.0
late effect of internal injury to chest
908.4
late effect of injury to blood vessel of thorax abdomen and pelvis
922.0
contusion of breast
922.1
contusion of chest wall
926.8
crushing injury of multiple sites of trunk
934.0 - 934.9 foreign body in trachea - foreign body in respiratory tree unspecified
935.0 - 935.2 foreign body in mouth - foreign body in stomach
958.0 - 958.4 air embolism as an early complication of trauma - traumatic shock
959.11
other injury of chest wall
959.19
other and unspecified injury of other sites of trunk
995.90 - 995.94 systemic inflammatory response syndrome unspecified - systemic inflammatory response syndrome
due to noninfectious process with acute organ dysfunction
996.00 - 996.1 mechanical complications of unspecified cardiac device implant and graft - mechanical complication
of other vascular device implant and graft
996.54
mechanical complication of breast prosthesis
996.60 - 996.62 infection and inflammatory reaction due to unspecified device implant and graft - infection and inflammatory reaction due to other vascular device implant and graft
996.69
infection and inflammatory reaction due to other internal prosthetic device implant and graft
996.70 - 996.72 other complications due to unspecified device implant and graft - other complications due to other
cardiac device implant and graft
996.83
complications of transplanted heart
996.84
complications of transplanted lung
997.1
cardiac complications not elsewhere classified
997.31
ventilator associated pneumonia
997.39
other respiratory complications
998.0 - 998.6 postoperative shock not elsewhere classified - persistent postoperative fistula not elsewhere classified
v10.00 - v10.09 personal history of malignant neoplasm of unspecified site in gastrointestinal tract - personal history of
malignant neoplasm of other sites in gastrointestinal tract
v10.11
personal history of malignant neoplasm of bronchus and lung
v10.12
personal history of malignant neoplasm of trachea
v10.20 - v10.3 personal history of malignant neoplasm of unspecified respiratory organ - personal history of malignant neoplasm of breast
v10.40 - v10.49 personal history of malignant neoplasm of unspecified female genital organ - personal history of malignant neoplasm of other male genital organs
v10.50 - v10.59 personal history of malignant neoplasm of unspecified urinary organ - personal history of malignant
neoplasm of other urinary organs
CMS Limitations
CT Chest and Thorax (con’t)
v10.60 - v10.69 personal history of unspecified leukemia - personal history of other leukemia
v10.71 - v10.79 personal history of lymphosarcoma and reticulosarcoma - personal history of other lymphatic and
hematopoietic neoplasms
v10.81 - v10.89 personal history of malignant neoplasm of bone - personal history of malignant neoplasm of other
sites
v10.9
unspecified personal history of malignant neoplasm
v67.00*
follow-up examination following unspecified surgery
v67.09*
follow-up examination following other surgery
v67.1*
follow-up examination following radiotherapy
v67.2*
follow-up examination following chemotherapy
v71.1*
observation for suspected malignant neoplasm
*Non-specific and require an additional ICD-9 code for payment.
CMS Limitations
CT Head, Neck, Face, Orbit, Jaw
LCD # L28544, Effective Date: 03/25/2009
CPT/HCPCS Codes: CPT 70450, CPT 70460, CPT 70470, CPT 70480, CPT 70481, CPT 70482, CPT 70486, CPT 70487,
CPT 70488, CPT 70490, CPT 70491, CPT 70492, CPT 76376*, CPT 76377*
ICD-9 codes that SUPPORT medical necessity for computed tomography, head or brain; without contrast material (CPT
70450); computed tomography, head or brain; with contrast material(s) (CPT 70460); computed tomography, head or
brain; without contrast material, followed by contrast material(s) and further sections (CPT 70470); computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material (CPT 70480); computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) (CPT 70481); computed
tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast
material(s) and further sections (CPT 70482); computed tomography, maxillofacial area; without contrast material
(CPT 70486); computed tomography, maxillofacial area; with contrast material(s) (CPT 70487); computed tomography,
maxillofacial area; without contrast material, followed by contrast material(s) and further sections (CPT 70488); computed tomography, soft tissue neck; without contrast material (CPT 70490); computed tomography, soft tissue neck;
with contrast material(s) (CPT 70491); computed tomography, soft tissue neck; without contrast material followed by
contrast material(s) and further sections (CPT 70492); 3D rendering with interpretation and reporting of computed
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation (CPT 76376*); and 3D rendering with interpretation and reporting of computed
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing
on an independent workstation (CPT 76377*):
*Note: For the purposes of this LCD, CPT code 76376 or 76377 is allowed only when billed in conjunction with another
computed tomography procedure code.
013.00 - 013.46 tuberculous meningitis unspecified examination - tuberculoma of spinal cord tubercle bacilli not found
by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
013.60 - 013.96 tuberculous encephalitis or myelitis unspecified examination - unspecified tuberculosis of central nervous system tubercle bacilli not found by bacteriological or histological examination but tuberculosis
confirmed by other methods (inoculation of animals)
036.0
meningococcal meningitis
036.1
meningococcal encephalitis
036.3
waterhouse-friderichsen syndrome meningococcal
042
human immunodeficiency virus (hiv) disease
045.00-045.93 acute paralytic poliomyelitis specified as bulbar unspecified type of poliovirus - unspecified acute poliomyelitis poliovirus type iii
046.0 - 046.9 kuru - unspecified slow virus infection of central nervous system
047.0 - 048 meningitis due to coxsackie virus - other enterovirus diseases of central nervous system
049.0 - 049.9 non-arthopod borne lymphocytic choriomeningitis - unspecified non-arthropod-borne viral diseases of
central nervous system
052.0
postvaricella encephalitis
053.0
herpes zoster with meningitis
053.10 - 053.13 herpes zoster with unspecified nervous system complication - postherpetic polyneuropathy
054.3
herpetic meningoencephalitis
054.40 - 054.72 herpes simplex with unspecified ophthalmic complication - herpes simplex meningitis
055.0
postmeasles encephalitis
056.01
encephalomyelitis due to rubella
062.0 - 062.9 japanese encephalitis - mosquito-borne viral encephalitis unspecified
CMS Limitations
CT Head, Neck, Face, Orbit, Jaw (con’t)
063.0 - 064 066.2
072.1
072.2
090.0 - 090.9 091.0 - 091.9 092.0 - 092.9 093.0 - 093.9 094.0 - 094.9 095.0 - 096 097.0 - 097.9 100.81
112.83
114.2
115.01
115.11
123.1
130.0 - 130.2 135
136.1
139.0
140.0 - 140.9 141.0 - 141.9 142.0 - 142.9 143.0 - 143.9 144.0 - 144.9 145.0 - 145.9 146.0 - 146.9 147.0 - 147.9 148.0 - 148.9 149.0 - 149.9 150.0 - 150.9 151.1 - 151.9 157.0 - 157.9 159.0
160.0 - 160.9 161.0 - 161.9 162.0 - 162.9 164.0
164.2 - 164.9 165.0 - 165.9 170.0 - 170.3 russian spring-summer (taiga) encephalitis - viral encephalitis transmitted by other and unspecified
arthropods
venezuelan equine fever
mumps meningitis
mumps encephalitis
early congenital syphilis symptomatic - congenital syphilis unspecified
genital syphilis (primary) - unspecified secondary syphilis
early syphilis latent serological relapse after treatment - early syphilis latent unspecified
aneurysm of aorta specified as syphilitic - cardiovascular syphilis unspecified
tabes dorsalis - neurosyphilis unspecified
syphilitic episcleritis - late syphilis latent
late syphilis unspecified - syphilis unspecified
leptospiral meningitis (aseptic)
candidal meningitis
coccidioidal meningitis
histoplasma capsulatum meningitis
histoplasma duboisii meningitis
cysticercosis
meningoencephalitis due to toxoplasmosis - chorioretinitis due to toxoplasmosis
sarcoidosis
behcet’s syndrome
late effects of viral encephalitis
malignant neoplasm of upper lip vermilion border - malignant neoplasm of lip unspecified vermilion
border
malignant neoplasm of base of tongue - malignant neoplasm of tongue unspecified
malignant neoplasm of parotid gland - malignant neoplasm of salivary gland unspecified
malignant neoplasm of upper gum - malignant neoplasm of gum unspecified
malignant neoplasm of anterior portion of floor of mouth - malignant neoplasm of floor of mouth part
unspecified
malignant neoplasm of cheek mucosa - malignant neoplasm of mouth unspecified
malignant neoplasm of tonsil - malignant neoplasm of oropharynx unspecified site
malignant neoplasm of superior wall of nasopharynx - malignant neoplasm of nasopharynx unspecified site
malignant neoplasm of postcricoid region of hypopharynx - malignant neoplasm of hypopharynx unspecified site
malignant neoplasm of pharynx unspecified - malignant neoplasm of ill-defined sites within the lip and
oral cavity
malignant neoplasm of cervical esophagus - malignant neoplasm of esophagus unspecified site
malignant neoplasm of pylorus - malignant neoplasm of stomach unspecified site
malignant neoplasm of head of pancreas - malignant neoplasm of pancreas part unspecified
malignant neoplasm of intestinal tract part unspecified
malignant neoplasm of nasal cavities - malignant neoplasm of accessory sinus unspecified
malignant neoplasm of glottis - malignant neoplasm of larynx unspecified
malignant neoplasm of trachea - malignant neoplasm of bronchus and lung unspecified
malignant neoplasm of thymus
malignant neoplasm of anterior mediastinum - malignant neoplasm of mediastinum part unspecified
malignant neoplasm of upper respiratory tract part unspecified - malignant neoplasm of ill-defined
sites within the respiratory system
malignant neoplasm of bones of skull and face except mandible - malignant neoplasm of ribs sternum
and clavicle
CMS Limitations
CT Head, Neck, Face, Orbit, Jaw (con’t)
170.9
171.0 - 171.9 malignant neoplasm of bone and articular cartilage site unspecified
malignant neoplasm of connective and other soft tissue of head face and neck - malignant neoplasm
of connective and other soft tissue site unspecified
172.0 - 172.9 malignant melanoma of skin of lip - melanoma of skin site unspecified
173.0 - 173.4 other malignant neoplasm of skin of lip - other malignant neoplasm of scalp and skin of neck
173.6
other malignant neoplasm of skin of upper limb including shoulder
176.0 - 176.3 kaposi’s sarcoma skin - kaposi’s sarcoma gastrointestinal sites
176.5
kaposi’s sarcoma lymph nodes
176.8
kaposi’s sarcoma other specified sites
190.0 - 190.9 malignant neoplasm of eyeball except conjunctiva cornea retina and choroid - malignant neoplasm of
eye part unspecified
191.0 - 191.9 malignant neoplasm of cerebrum except lobes and ventricles - malignant neoplasm of brain unspecified site
192.0 - 193 malignant neoplasm of cranial nerves - malignant neoplasm of thyroid gland
194.1
malignant neoplasm of parathyroid gland
194.3 - 194.6 malignant neoplasm of pituitary gland and craniopharyngeal duct - malignant neoplasm of aortic body
and other paraganglia
195.0
malignant neoplasm of head face and neck
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
196.3
secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb
196.8
secondary and unspecified malignant neoplasm of lymph nodes of multiple sites
197.3
secondary malignant neoplasm of other respiratory organs
198.2 - 198.5 secondary malignant neoplasm of skin - secondary malignant neoplasm of bone and bone marrow
199.0
disseminated malignant neoplasm
199.1
other malignant neoplasm of unspecified site
199.2
malignant neoplasm associated with transplant organ
200.00-208.92 reticulosarcoma unspecified site - unspecified leukemia, in relapse
210.0 - 210.9 benign neoplasm of lip - benign neoplasm of pharynx unspecified
211.0
benign neoplasm of esophagus
211.9
benign neoplasm of other and unspecified site in the digestive system
212.0 - 212.2 benign neoplasm of nasal cavities middle ear and accessory sinuses - benign neoplasm of trachea
212.5
benign neoplasm of mediastinum
212.6
benign neoplasm of thymus
212.8
benign neoplasm of other specified sites of respiratory and intrathoracic organs
212.9
benign neoplasm of respiratory and intrathoracic organs site unspecified
213.0
benign neoplasm of bones of skull and face
213.1
benign neoplasm of lower jaw bone
213.3
benign neoplasm of ribs sternum and clavicle
213.9
benign neoplasm of bone and articular cartilage site unspecified
214.0
lipoma of skin and subcutaneous tissue of face
214.1
lipoma of other skin and subcutaneous tissue
215.0
other benign neoplasm of connective and other soft tissue of head face and neck
215.8
other benign neoplasm of connective and other soft tissue of other specified sites
216.0 - 216.4 benign neoplasm of skin of lip - benign neoplasm of scalp and skin of neck
224.0 - 224.9 benign neoplasm of eyeball except conjunctiva cornea retina and choroid - benign neoplasm of eye
part unspecified
225.0 - 226 benign neoplasm of brain - benign neoplasm of thyroid glands
227.1
benign neoplasm of parathyroid gland
CMS Limitations
CT Head, Neck, Face, Orbit, Jaw (con’t)
227.3 - 227.6 benign neoplasm of pituitary gland and craniopharyngeal duct - benign neoplasm of aortic body and
other paraganglia
227.8
benign neoplasm of other endocrine glands and related structures
228.00 - 228.03 hemangioma of unspecified site - hemangioma of retina
228.1
lymphangioma any site
229.0
benign neoplasm of lymph nodes
229.8
benign neoplasm of other specified sites
230.0
carcinoma in situ of lip oral cavity and pharynx
230.1
carcinoma in situ of esophagus
231.0
carcinoma in situ of larynx
231.1
carcinoma in situ of trachea
231.8
carcinoma in situ of other specified parts of respiratory system
232.0 - 232.4 carcinoma in situ of skin of lip - carcinoma in situ of scalp and skin of neck
232.8
carcinoma in situ of other specified sites of skin
234.0
carcinoma in situ of eye
234.8
carcinoma in situ of other specified sites
235.0
neoplasm of uncertain behavior of major salivary glands
235.1
neoplasm of uncertain behavior of lip oral cavity and pharynx
235.6 - 235.8 neoplasm of uncertain behavior of larynx - neoplasm of uncertain behavior of pleura thymus and mediastinum
237.0 - 237.9 neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct - neoplasm of uncertain
behavior of other and unspecified parts of nervous system
238.0 - 238.2 neoplasm of uncertain behavior of bone and articular cartilage - neoplasm of uncertain behavior of
skin
238.8
neoplasm of uncertain behavior of other specified sites
239.1 - 239.3 neoplasm of unspecified nature of respiratory system - neoplasm of unspecified nature of breast
239.6 - 239.8 neoplasm of unspecified nature of brain - neoplasm of unspecified nature of other specified sites
240.0 - 240.9 goiter specified as simple - goiter unspecified
241.0 - 241.9 nontoxic uninodular goiter - unspecified nontoxic nodular goiter
242.00 - 242.41 toxic diffuse goiter without thyrotoxic crisis or storm - thyrotoxicosis from ectopic thyroid nodule with
thyrotoxic crisis or storm
242.90
thyrotoxicosis without goiter or other cause and without thyrotoxic crisis or storm
242.91
thyrotoxicosis without goiter or other cause with thyrotoxic crisis or storm
245.0 - 245.9 acute thyroiditis - thyroiditis unspecified
246.0
disorders of thyrocalcitonin secretion
250.60 - 250.63 diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled - diabetes with neurological manifestations, type i [juvenile type], uncontrolled
252.00 - 252.9 hyperparathyroidism, unspecified - unspecified disorder of parathyroid gland
253.0 - 253.9 acromegaly and gigantism - unspecified disorder of the pituitary gland and its hypothalamic control
254.0 - 254.9 persistent hyperplasia of thymus - unspecified disease of thymus gland
256.0
hyperestrogenism
259.3
ectopic hormone secretion not elsewhere classified
289.3
lymphadenitis unspecified except mesenteric
683
acute lymphadenitis
290.0 - 290.9 senile dementia uncomplicated - unspecified senile psychotic condition
291.0 - 291.9 alcohol withdrawal delirium - unspecified alcohol-induced mental disorders
292.0 - 292.9 drug withdrawal - unspecified drug-induced mental disorder
293.0 - 293.9 delirium due to conditions classified elsewhere - unspecified transient mental disorder in conditions
classified elsewhere
CMS Limitations
CT Head, Neck, Face, Orbit, Jaw (con’t)
294.0 - 294.9 amnestic disorder in conditions classified elsewhere - unspecified persistent mental disorders due to
conditions classified elsewhere
298.8
other and unspecified reactive psychosis
298.9
unspecified psychosis
310.0 - 310.9 frontal lobe syndrome - unspecified nonpsychotic mental disorder following organic brain damage
319
unspecified mental retardation
320.0 - 320.9 hemophilus meningitis - meningitis due to unspecified bacterium
321.0 - 321.8 cryptococcal meningitis - meningitis due to other nonbacterial organisms classified elsewhere
322.0 - 322.9 nonpyogenic meningitis - meningitis unspecified
323.01 - 323.9 encephalitis and encephalomyelitis in viral diseases classified elsewhere - unspecified causes of encephalitis, myelitis, and encephalomyelitis
324.0 - 326 intracranial abscess - late effects of intracranial abscess or pyogenic infection
330.0 - 330.9 leukodystrophy - unspecified cerebral degeneration in childhood
331.0 - 331.9 alzheimer’s disease - cerebral degeneration unspecified
332.0
paralysis agitans
332.1
secondary parkinsonism
333.0 - 333.99 other degenerative diseases of the basal ganglia - other extrapyramidal diseases and abnormal movement disorders
334.0 - 334.9 friedreich’s ataxia - spinocerebellar disease unspecified
335.20 - 335.29 amyotrophic lateral sclerosis - other motor neuron diseases
337.00
idiopathic peripheral autonomic neuropathy, unspecified
337.01
carotid sinus syndrome
337.09
other idiopathic peripheral autonomic neuropathy
339.00 - 339.89 cluster headache syndrome, unspecified - other headache syndromes
340
multiple sclerosis
341.0 - 341.9 neuromyelitis optica - demyelinating disease of central nervous system unspecified
342.00 - 342.92 flaccid hemiplegia and hemiparesis affecting unspecified side - unspecified hemiplegia and hemiparesis affecting nondominant side
343.0 - 343.9 congenital diplegia - infantile cerebral palsy unspecified
345.00 - 345.91 generalized nonconvulsive epilepsy without intractable epilepsy - epilepsy unspecified with intractable
epilepsy
346.00 - 346.91 migraine with aura, without mention of intractable migraine without mention of status migrainosus
- migraine, unspecified, with intractable migraine, so stated, without mention of status migrainosus
347.00 - 348.9 narcolepsy, without cataplexy - unspecified condition of brain
349.0 - 349.2 reaction to spinal or lumbar puncture - disorders of meninges not elsewhere classified
349.81 - 349.9 cerebrospinal fluid rhinorrhea - unspecified disorders of nervous system
350.1 - 350.9 trigeminal neuralgia - trigeminal nerve disorder unspecified
351.0 - 351.9 bell’s palsy - facial nerve disorder unspecified
352.0 - 352.9 disorders of olfactory (1st) nerve - unspecified disorder of cranial nerves
353.0
brachial plexus lesions
353.5
neuralgic amyotrophy
357.0
acute infective polyneuritis
358.00
myasthenia gravis without (acute) exacerbation
358.01
myasthenia gravis with (acute) exacerbation
359.0 - 359.3 congenital hereditary muscular dystrophy - periodic paralysis
360.00 - 360.89 purulent endophthalmitis unspecified - other disorders of globe
361.00 - 361.9 retinal detach with retinal defect unspecified - unspecified retinal detach
362.14
retinal microaneurysms nos
362.17 - 362.34 other intraretinal microvascular abnormalities - transient retinal arterial occlusion
368.00 - 368.9 amblyopia unspecified - unspecified visual disturbance
CMS Limitations
CT Head, Neck, Face, Orbit, Jaw (con’t)
369.00
blindness of both eyes impairment level not further specified
374.85
vascular anomalies of eyelid
375.12
other lacrimal cysts and cystic degeneration
375.16
dislocation of lacrimal gland
375.31 - 375.9 acute canaliculitis lacrimal - unspecified disorder of lacrimal system
376.00 - 376.9 acute inflammation of orbit unspecified - unspecified disorder of orbit
377.00 - 377.9 papilledema unspecified - unspecified disorder of optic nerve and visual pathways
378.00 - 378.9 esotropia unspecified - unspecified disorder of eye movements
379.00 - 379.99 scleritis unspecified - other ill-defined disorders of eye
380.00 - 380.10 perichondritis of pinna unspecified - infective otitis externa unspecified
381.00 - 381.9 acute nonsuppurative otitis media unspecified - unspecified eustachian tube disorder
382.00 - 382.9 acute suppurative otitis media without spontaneous rupture of eardrum - unspecified otitis media
383.00 - 383.9 acute mastoiditis without complications - unspecified mastoiditis
385.00 - 385.9 tympanosclerosis unspecified as to involvement - unspecified disorder of middle ear and mastoid
386.00 - 386.9 ménière’s disease, unspecified - unspecified vertiginous syndromes and labyrinthine disorders
388.2 - 388.9 sudden hearing loss unspecified - unspecified disorder of ear
389.00 - 389.22 conductive hearing loss unspecified - mixed hearing loss, bilateral
430 - 432.9 subarachnoid hemorrhage - unspecified intracranial hemorrhage
433.00 - 433.91 occlusion and stenosis of basilar artery without cerebral infarction - occlusion and stenosis of unspecified precerebral artery with cerebral infarction
434.00 - 434.91 cerebral thrombosis without cerebral infarction - cerebral artery occlusion unspecified with cerebral
infarction
435.0 - 436 basilar artery syndrome - acute but ill-defined cerebrovascular disease
437.0 - 437.9 cerebral atherosclerosis - unspecified cerebrovascular disease
438.0
cognitive deficits
438.11
aphasia
438.12
dysphasia
438.20 - 438.53 hemiplegia affecting unspecified side - other paralytic syndrome bilateral
438.81
apraxia cerebrovascular disease
438.9
unspecified late effects of cerebrovascular disease
461.0 - 462 acute maxillary sinusitis - acute pharyngitis
473.0 - 473.9 chronic maxillary sinusitis - unspecified sinusitis (chronic)
475
peritonsillar abscess
476.0
chronic laryngitis
476.1
chronic laryngotracheitis
478.11
nasal mucositis (ulcerative)
478.19
other disease of nasal cavity and sinuses
478.22
parapharyngeal abscess
478.24
retropharyngeal abscess
478.26
cyst of pharynx or nasopharynx
478.30 - 478.4 unspecified paralysis of vocal cords - polyp of vocal cord or larynx
519.00 - 519.09 tracheostomy complication unspecified - other tracheostomy complications
519.8
other diseases of respiratory system not elsewhere classified
524.00 - 524.59 major anomalies of jaw size unspecified anomaly - other dentofacial functional abnormalities
524.60 - 524.62 temporomandibular joint disorders unspecified - temporomandibular joint disorders arthralgia of temporomandibular joint
526.0 - 526.5 developmental odontogenic cysts - alveolitis of jaw
526.81 - 526.9 exostosis of jaw - unspecified disease of the jaws
527.0 - 527.9 atrophy of salivary gland - unspecified disease of the salivary glands
528.3
cellulitis and abscess of oral soft tissues
CMS Limitations
CT Head, Neck, Face, Orbit, Jaw (con’t)
718.98
719.08
729.2
733.3
740.0 - 740.2 741.00 - 741.93 742.0 - 742.9 743.00 - 743.9 744.00 - 744.9 unspecified derangement of joint of other specified sites
effusion of joint of other specified sites
neuralgia neuritis and radiculitis unspecified
hyperostosis of skull
anencephalus - iniencephaly
spina bifida unspecified region with hydrocephalus - spina bifida lumbar region without hydrocephalus
encephalocele - unspecified congenital anomaly of brain spinal cord and nervous system
clinical anophthalmos unspecified - unspecified anomaly of eye congenital
unspecified congenital anomaly of ear with impairment of hearing - unspecified congenital anomalies
of face and neck
747.81
congenital anomalies of cerebrovascular system
748.0 - 748.3 choanal atresia - other congenital anomalies of larynx trachea and bronchus
748.9
unspecified congenital anomaly of respiratory system
754.0
congenital musculoskeletal deformities of skull face and jaw
754.1
congenital musculoskeletal deformities of sternocleidomastoid muscle
759.2
anomalies of other endocrine glands congenital
767.0 - 767.9 subdural and cerebral hemorrhage due to birth trauma - unspecified birth trauma
772.10 - 772.2 intraventricular hemorrhage unspecified grade - subarachnoid hemorrhage of newborn
779.0 - 779.2 convulsions in newborn - cerebral depression coma and other abnormal cerebral signs in fetus or newborn
779.4
drug reactions and intoxications specific to newborn
779.5
drug withdrawal syndrome in newborn
779.7
preventricular leukomalacia
780.01-780.4 coma-dizziness and giddiness
780.53
hypersomnia with sleep apnea, unspecified
780.60-780.65 fever, unspecified-hypothermia not associated with low environmental temperature
780.93
memory loss
780.97
altered mental status
780.99
other general symptoms
781.0-781.4 abnormal involuntary movements-transient paralysis of limb
781.6-781.8 meningismus-neurological neglect syndrome
781.92-781.99 abnormal posture-other symptoms involving nervous and musculoskeletal systems
782.0
disturbance of skin sensation
784.0-784.99 headache-other symptoms involving head and neck
785.6
enlargement of lymph nodes
786.1
stridor
787.20-787.24 dysphagia, unspecified-dysphagia, pharyngoesophageal phase
787.29
other dysphagia
793.0
nonspecific abnormal findings on radiological and other examination of skull and head
794.00-794.9 unspecified abnormal function study of brain and central nervous system-nonspecific abnormal results
of other specified function study
797senility without psychosis
800.00-800.99 closed fracture of vault of skull without intracranial injury with state of consciousness unspecified-open
fracture of vault of skull with intracranial injury of other and unspecified nature with concussion unspecified
801.00-801.99 closed fracture of base of skull without intra cranial injury with state of consciousness unspecifiedopen fracture of base of skull with intracranial injury of other and unspecified nature with concussion
unspecified
802.0
closed fracture of nasal bones
802.4-802.8 closed fracture of malar and maxillary bones-closed fracture of other facial bones
CMS Limitations
CT Head, Neck, Face, Orbit, Jaw (con’t)
803.00-803.99 other closed skull fracture without intracranial injury with state of consciousness unspecified-other
open skull fracture with intracranial injury of other and unspecified nature with concussion unspecified
804.00-804.99 closed fractures involving skull or face with other bones without intracranial injury with state of consciousness unspecified-open fractures involving skull or face with other bones with intracranial injury
of other and unspecified nature with concussion unspecified
830.0
closed dislocation of jaw
830.1
open dislocation of jaw
847.0
neck sprain
850.0-850.9 concussion with no loss of consciousness-concussion unspecified
851.00-851.99 cortex (cerebral) contusion without open intracranial wound state of consciousness unspecified-other
and unspecified cerebral laceration and contusion with open intracranial wound with concussion unspecified
852.00-852.59 subarachnoid hemorrhage following injury without open intracranial wound with state of consciousness unspecified-extradural hemorrhage following injury with open intracranial wound with concussion
unspecified
853.00-853.19 other and unspecified intracranial hemorrhage following injury without open intracranial wound with
state of consciousness unspecified-other and unspecified intracranial hemorrhage following injury with
open intracranial wound with concussion unspecified
854.00-854.19 intracranial injury of other and unspecified nature without open intracranial wound with state of consciousness unspecified-intracranial injury of other and unspecified nature with open intracranial wound
with concussion unspecified
873.0
open wound of scalp without complication
907.0
late effect of intracranial injury without skull fracture
907.1
late effect of injury to cranial nerve
920
contusion of face scalp and neck except eye(s)
921.1 - 921.9 contusion of eyelids and periocular area - unspecified contusion of eye
925.1
crushing injury of face and scalp
925.2
crushing injury of neck
933.0
foreign body in pharynx
933.1
foreign body in larynx
950.0 - 950.9 optic nerve injury - injury to unspecified optic nerve and pathways
951.0 - 951.9 injury to oculomotor nerve - injury to unspecified cranial nerve
958.0 - 958.2 air embolism as an early complication of trauma - secondary and recurrent hemorrhage as an early
complication of trauma
959.01
other and unspecified injury to head
959.09
other and unspecified injury to face and neck
986
toxic effect of carbon monoxide
990
effects of radiation unspecified
995.90 - 995.94 systemic inflammatory response syndrome unspecified - systemic inflammatory response syndrome
due to noninfectious process with acute organ dysfunction
997.00 - 997.09 nervous system complication unspecified - other nervous system complications
997.71
vascular complications of mesenteric artery
997.79
vascular complications of other vessels
998.11 - 998.59 hemorrhage complicating a procedure - other postoperative infection
999.31
infection duet central venous catheter
999.39
infection following other infusion, injection, transfusion, or vaccination
v10.01
personal history of malignant neoplasm of tongue
v10.02
personal history of malignant neoplasm of other and unspecified parts of oral cavity and pharynx
v10.12
personal history of malignant neoplasm of trachea
v10.21
personal history of malignant neoplasm of larynx
CMS Limitations
CT Head, Neck, Face, Orbit, Jaw (con’t)
v10.22
v10.81 - v10.87 v67.00*
v67.09*
v67.1*
v67.2*
v71.1*
personal history of malignant neoplasm of nasal cavities middle ear and accessory sinuses
personal history of malignant neoplasm of bone - personal history of malignant neoplasm of thyroid
follow-up examination following unspecified surgery
follow-up examination following other surgery
follow-up examination following radiotherapy
follow-up examination following chemotherapy
observation for suspected malignant neoplasm
Note: ICD-9-CM code V58.61 (Long-term [current] use of anticoagulants) must be billed with code 959.01 (Head injury,
unspecified) in order to be processed as a payable claim.
*Non-specific and require an additional ICD-9 code for payment.
CMS Limitations
CT Lumbar Spine
LCD # L28544, Effective Date: 03/25/2009
CPT/HCPCS Codes: CPT 72131, CPT 72132, CPT 72133, CPT 76376*, CPT 76377*
ICD-9 codes that SUPPORT medical necessity for computed tomography, lumbar spine; without contrast material
(CPT 72131); computed tomography, lumbar spine; with contrast material (CPT 72132); computed tomography, lumbar
spine; without contrast material, followed by contrast material(s) and further sections (CPT 72133); 3D rendering with
interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic
modality; not requiring image postprocessing on an independent workstation (CPT 76376*); and 3D rendering with
interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic
modality; requiring image postprocessing on an independent workstation (CPT 76377*):
*Note: For the purposes of this LCD, CPT code 76376 or 76377 is allowed only when billed in conjunction with another
computed tomography procedure code.
170.2
170.6
185
192.1 - 192.3 192.8
192.9
196.2
196.5
196.6
198.3 - 198.5 malignant neoplasm of vertebral column excluding sacrum and coccyx
malignant neoplasm of pelvic bones sacrum and coccyx
malignant neoplasm of prostate
malignant neoplasm of cerebral meninges - malignant neoplasm of spinal meninges
malignant neoplasm of other specified sites of nervous system
malignant neoplasm of nervous system part unspecified
secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and lower limb
secondary and unspecified malignant neoplasm of intrapelvic lymph nodes
secondary malignant neoplasm of brain and spinal cord - secondary malignant neoplasm of bone and
bone marrow
198.89
secondary malignant neoplasm of other specified sites
199.0
disseminated malignant neoplasm
199.1
other malignant neoplasm of unspecified site
199.2
malignant neoplasm associated with transplant organ
203.00 - 203.02 multiple myeloma, without mention of having achieved remission - multiple myeloma, in relapse
213.2
benign neoplasm of vertebral column excluding sacrum and coccyx
225.3
benign neoplasm of spinal cord
225.4
benign neoplasm of spinal meninges
237.5
neoplasm of uncertain behavior of brain and spinal cord
239.2
neoplasm of unspecified nature of bone soft tissue and skin
322.0 - 322.9 nonpyogenic meningitis - meningitis unspecified
324.1
intraspinal abscess
336.1
vascular myelopathies
340
multiple sclerosis
341.8
other demyelinating diseases of central nervous system
341.9
demyelinating disease of central nervous system unspecified
342.00 - 342.92 flaccid hemiplegia and hemiparesis affecting unspecified side - unspecified hemiplegia and hemiparesis affecting nondominant side
344.1
paraplegia
344.30 - 344.32 monoplegia of lower limb affecting unspecified side - monoplegia of lower limb affecting nondominant
side
344.60
cauda equina syndrome without neurogenic bladder
344.61
cauda equina syndrome with neurogenic bladder
353.1
lumbosacral plexus lesions
CMS Limitations
CT Lumbar Spine (con’t)
353.4
353.8
357.1 - 357.3 357.5
715.00
715.09
715.10
715.18
715.30
715.38
715.80
lumbosacral root lesions not elsewhere classified
other nerve root and plexus disorders
polyneuropathy in collagen vascular disease - polyneuropathy in malignant disease
alcoholic polyneuropathy
osteoarthrosis generalized involving unspecified site
osteoarthrosis generalized involving multiple sites
osteoarthrosis localized primary involving unspecified site
osteoarthrosis localized primary involving other specified sites
osteoarthrosis localized not specified whether primary or secondary involving unspecified site
osteoarthrosis localized not specified whether primary or secondary involving other specified sites
osteoarthrosis involving or with more than one site but not specified as generalized and involving unspecified site
715.89
osteoarthrosis involving or with multiple sites but not specified as generalized
720.0 - 720.81 ankylosing spondylitis - inflammatory spondylopathies in diseases classified elsewhere
721.3
lumbosacral spondylosis without myelopathy
721.42
spondylosis with myelopathy lumbar region
721.6 - 721.8 ankylosing vertebral hyperostosis - other allied disorders of spine
721.91
spondylosis of unspecified site with myelopathy
722.10
displacement of lumbar intervertebral disc without myelopathy
722.2
displacement of intervertebral disc site unspecified without myelopathy
722.32
schmorl’s nodes of lumbar region
722.52
degeneration of lumbar or lumbosacral intervertebral disc
722.6
degeneration of intervertebral disc site unspecified
722.73
intervertebral disc disorder with myelopathy lumbar region
722.83
postlaminectomy syndrome of lumbar region
722.93
other and unspecified disc disorder of lumbar region
724.00
spinal stenosis of unspecified region
724.02
spinal stenosis of lumbar region
724.2 - 724.6 lumbago - disorders of sacrum
724.71
hypermobility of coccyx
724.79
other disorders of coccyx
724.9
other unspecified back disorders
730.00
acute osteomyelitis site unspecified
730.05
acute osteomyelitis involving pelvic region and thigh
730.08
acute osteomyelitis involving other specified sites
730.09
acute osteomyelitis involving multiple sites
730.15
chronic osteomyelitis involving pelvic region and thigh
730.18
chronic osteomyelitis involving other specified sites
730.19
chronic osteomyelitis involving multiple sites
730.25
unspecified osteomyelitis involving pelvic region and thigh
730.28
unspecified osteomyelitis involving other specified sites
730.35
periostitis without osteomyelitis involving pelvic region and thigh
730.38
periostitis without osteomyelitis involving other specified sites
733.00 - 733.03 osteoporosis unspecified - disuse osteoporosis
733.10
pathological fracture unspecified site
733.13
pathological fracture of vertebrae
733.20 - 733.29 cyst of bone (localized) unspecified - other bone cyst
733.40
aseptic necrosis of bone site unspecified
737.20 - 737.33 lordosis (acquired) (postural) - scoliosis due to radiation
737.43
scoliosis associated with other conditions
CMS Limitations
CT Lumbar Spine (con’t)
738.4 - 738.6 741.03
741.93
742.53
754.2
756.10 - 756.15 756.17
756.19
793.7
793.91
793.99
805.4 - 805.9 acquired spondylolisthesis - acquired deformity of pelvis
spina bifida lumbar region with hydrocephalus
spina bifida lumbar region without hydrocephalus
hydromyelia
congenital musculoskeletal deformities of spine
congenital anomaly of spine unspecified - fusion of spine (vertebra) congenital
spina bifida occulta
other congenital anomalies of spine
nonspecific abnormal findings on radiological and other examination of musculoskeletal system
image test inconclusive due to excess body fat
other nonspecific abnormal findings on radiological and other examinations of body structure
closed fracture of lumbar vertebra without spinal cord injury - open fracture of unspecified part of vertebral column without spinal cord injury
806.4 - 806.9 closed fracture of lumbar spine with spinal cord injury - open fracture of unspecified vertebra with
spinal cord injury
839.20
closed dislocation lumbar vertebra
839.30
open dislocation lumbar vertebra
839.41
closed dislocation coccyx
839.42
closed dislocation sacrum
839.51
open dislocation coccyx
839.52
open dislocation sacrum
952.2 - 952.8 lumbar spinal cord injury without spinal bone injury - multiple sites of spinal cord injury without spinal
bone injury
953.2
injury to lumbar nerve root
953.3
injury to sacral nerve root
953.5
injury to lumbosacral plexus
953.8
injury to multiple sites of nerve roots and spinal plexus
959.19
other and unspecified injury of other sites of trunk
v10.81
personal history of malignant neoplasm of bone
v10.86
personal history of malignant neoplasm of other parts of nervous system
v67.00*
follow-up examination following unspecified surgery
v67.09*
follow-up examination following other surgery
v67.1*
follow-up examination following radiotherapy
v67.2*
follow-up examination following chemotherapy
* non-specific and require an additional ICD-9 code for payment.
CMS Limitations
CT Thoracic Spine
LCD # L28544, Effective Date: 03/25/2009
CPT/HCPCS Codes: CPT 72128, CPT 72129, CPT 72130, CPT 76376*, CPT 76377*
ICD-9 codes that SUPPORT medical necessity for computed tomography, thoracic spine; without contrast material
(CPT 72128); computed tomography, thoracic spine; with contrast material (CPT 72129); computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections (CPT 72130); 3D rendering with
interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic
modality; not requiring image postprocessing on an independent workstation (CPT 76376*); and 3D rendering with
interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic
modality; requiring image postprocessing on an independent workstation (CPT 76377*):
*Note: For the purposes of this LCD, CPT code 76376 or 76377 is allowed only when billed in conjunction with another
computed tomography procedure code. See item 3(c) in the “Limitations” section above.
170.2
185
192.2 - 193 195.1
196.1
197.0 - 197.3 198.3 - 198.5 malignant neoplasm of vertebral column excluding sacrum and coccyx
malignant neoplasm of prostate
malignant neoplasm of spinal cord - malignant neoplasm of thyroid gland
malignant neoplasm of thorax
secondary and unspecified malignant neoplasm of intrathoracic lymph nodes
secondary malignant neoplasm of lung - secondary malignant neoplasm of other respiratory organs
secondary malignant neoplasm of brain and spinal cord - secondary malignant neoplasm of bone and
bone marrow
198.89
secondary malignant neoplasm of other specified sites
199.0
disseminated malignant neoplasm
199.1
other malignant neoplasm of unspecified site
199.2
malignant neoplasm associated with transplant organ
203.00
multiple myeloma, without mention of having achieved remission
203.02
multiple myeloma, in relapse
213.2
benign neoplasm of vertebral column excluding sacrum and coccyx
225.3
benign neoplasm of spinal cord
225.4
benign neoplasm of spinal meninges
228.1
lymphangioma any site
237.5
neoplasm of uncertain behavior of brain and spinal cord
239.2
neoplasm of unspecified nature of bone soft tissue and skin
322.0 - 322.9 nonpyogenic meningitis - meningitis unspecified
324.1
intraspinal abscess
334.8
other spinocerebellar diseases
334.9
spinocerebellar disease unspecified
336.0
syringomyelia and syringobulbia
336.1
vascular myelopathies
340
multiple sclerosis
341.8
other demyelinating diseases of central nervous system
341.9
demyelinating disease of central nervous system unspecified
342.00 - 342.92 flaccid hemiplegia and hemiparesis affecting unspecified side - unspecified hemiplegia and hemiparesis affecting nondominant side
344.00
quadriplegia unspecified
344.1
paraplegia
344.30 - 344.5 monoplegia of lower limb affecting unspecified side - unspecified monoplegia
353.3
thoracic root lesions not elsewhere classified
CMS Limitations
CT Thoracic Spine (con’t)
353.8
other nerve root and plexus disorders
357.1 - 357.3 polyneuropathy in collagen vascular disease - polyneuropathy in malignant disease
357.5
alcoholic polyneuropathy
720.0
ankylosing spondylitis
720.1
spinal enthesopathy
720.81
inflammatory spondylopathies in diseases classified elsewhere
721.2
thoracic spondylosis without myelopathy
721.41
spondylosis with myelopathy thoracic region
721.91
spondylosis of unspecified site with myelopathy
722.11
displacement of thoracic intervertebral disc without myelopathy
722.2
displacement of intervertebral disc site unspecified without myelopathy
722.31
schmorl’s nodes of thoracic region
722.51
degeneration of thoracic or thoracolumbar intervertebral disc
722.6
degeneration of intervertebral disc site unspecified
722.70
intervertebral disc disorder with myelopathy unspecified region
722.72
intervertebral disc disorder with myelopathy thoracic region
722.82
postlaminectomy syndrome of thoracic region
722.92
other and unspecified disc disorder of thoracic region
724.01
spinal stenosis of thoracic region
724.1
pain in thoracic spine
724.4
thoracic or lumbosacral neuritis or radiculitis unspecified
724.9
other unspecified back disorders
730.08
acute osteomyelitis involving other specified sites
730.18
chronic osteomyelitis involving other specified sites
730.28
unspecified osteomyelitis involving other specified sites
730.38
periostitis without osteomyelitis involving other specified sites
733.00 - 733.09 osteoporosis unspecified - other osteoporosis
733.10
pathological fracture unspecified site
733.13
pathological fracture of vertebrae
733.19
pathological fracture of other specified site
733.20 - 733.29 cyst of bone (localized) unspecified - other bone cyst
733.40
aseptic necrosis of bone site unspecified
737.10
kyphosis (acquired) (postural)
737.30
scoliosis (and kyphoscoliosis) idiopathic
738.4
acquired spondylolisthesis
738.5
other acquired deformity of back or spine
741.02
spina bifida dorsal (thoracic) region with hydrocephalus
741.92
spina bifida dorsal (thoracic) region without hydrocephalus
742.51 - 742.59 diastematomyelia - other specified congenital anomalies of spinal cord
754.2
congenital musculoskeletal deformities of spine
756.10
congenital anomaly of spine unspecified
756.12 - 756.15 spondylolisthesis congenital - fusion of spine (vertebra) congenital
756.19
other congenital anomalies of spine
793.7
nonspecific abnormal findings on radiological and other examination of musculoskeletal system
793.99
other nonspecific abnormal findings on radiological and other examinations of body structure
805.2 - 805.3 closed fracture of dorsal (thoracic) vertebra without spinal cord injury - open fracture of dorsal (thoracic) vertebra without spinal cord injury
806.20 - 806.39 closed fracture of t1-t6 level with unspecified spinal cord injury - open fracture of t7-t12 level with
other specified spinal cord injury
839.21
closed dislocation thoracic vertebra
CMS Limitations
CT Thoracic Spine (con’t)
839.31
952.10 - 952.19 952.8
953.1
959.19
v10.81
v10.86
v67.00*
v67.09*
v67.1*
v67.2*
open dislocation thoracic vertebra
t1-t6 level spinal cord injury unspecified - t7-t12 level with other specified spinal cord injury
multiple sites of spinal cord injury without spinal bone injury
injury to dorsal nerve root
other and unspecified injury of other sites of trunk
personal history of malignant neoplasm of bone
personal history of malignant neoplasm of other parts of nervous system
follow-up examination following unspecified surgery
follow-up examination following other surgery
follow-up examination following radiotherapy
follow-up examination following chemotherapy
* non-specific and require an additional ICD-9 code for payment.
CMS Limitations
CT Upper and Lower Extremity
LCD # L28544, Effective Date: 03/25/2009
CPT/HCPCS Codes: CPT 73200-73206, CPT 73700-76706
ICD-9 codes that SUPPORT medical necessity for computed tomography, upper extremity; without contrast material - computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if
performed, and image postprocessing (CPT 73200 - 73206); computed tomography, lower extremity; without contrast
material - computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing (CPT 73700 - 73706):
Upper Extremity (73200-73206)
170.4
malignant neoplasm of scapula and long bones of upper limb
170.5
malignant neoplasm of short bones of upper limb
170.9
malignant neoplasm of bone and articular cartilage site unspecified
171.2
malignant neoplasm of connective and other soft tissue of upper limb including shoulder
172.6
malignant melanoma of skin of upper limb including shoulder
173.6
other malignant neoplasm of skin of upper limb including shoulder
195.4
malignant neoplasm of upper limb
198.5
secondary malignant neoplasm of bone and bone marrow
198.89
secondary malignant neoplasm of other specified sites
213.4
benign neoplasm of scapula and long bones of upper limb
213.5
benign neoplasm of short bones of upper limb
215.2
other benign neoplasm of connective and other soft tissue of upper limb including shoulder
216.6
benign neoplasm of skin of upper limb including shoulder
228.1
lymphangioma any site
232.6
carcinoma in situ of skin of upper limb including shoulder
238.0
neoplasm of uncertain behavior of bone and articular cartilage
239.2
neoplasm of unspecified nature of bone soft tissue and skin
333.84
organic writers’ cramp
354.0 - 354.5 carpal tunnel syndrome - mononeuritis multiplex
359.21 - 359.24 myotonic muscular dystrophy - drug induced myotonia
359.29
other specified myotonic disorder
359.3
periodic paralysis
440.0
atherosclerosis of aorta
440.20-440.29 atherosclerosis of native arteries of the extremities unspecified - other atherosclerosis of native arteries of the extremities
442.0
aneurysm of artery of upper extremity
443.9
peripheral vascular disease unspecified
444.21
arterial embolism and thrombosis of upper extremity
447.1
stricture of artery
457.0
postmastectomy lymphedema syndrome
457.1
other lymphedema
682.3
cellulitis and abscess of upper arm and forearm
682.4
cellulitis and abscess of hand except fingers and thumb
711.01 - 711.04 pyogenic arthritis involving shoulder region - pyogenic arthritis involving hand
715.00
osteoarthrosis generalized involving unspecified site
715.04
osteoarthrosis generalized involving hand
715.09
osteoarthrosis generalized involving multiple sites
715.10 - 715.14 osteoarthrosis localized primary involving unspecified site - osteoarthrosis localized primary involving
hand
CMS Limitations
CT Upper and Lower Extremity (Upper Extremity con’t)
715.20 - 715.24 osteoarthrosis localized secondary involving unspecified site - osteoarthrosis localized secondary involving hand
715.30 - 715.34 osteoarthrosis localized not specified whether primary or secondary involving unspecified site - osteoarthrosis localized not specified whether primary or secondary involving hand
715.80
osteoarthrosis involving or with more than one site but not specified as generalized and involving unspecified site
715.89
osteoarthrosis involving or with multiple sites but not specified as generalized
715.90 - 715.94 osteoarthrosis unspecified whether generalized or localized involving unspecified site - osteoarthrosis
unspecified whether generalized or localized involving hand
716.11 - 716.14 traumatic arthropathy involving shoulder region - traumatic arthropathy involving hand
718.00 - 718.04 articular cartilage disorder site unspecified - articular cartilage disorder involving hand
718.10 - 718.14 loose body in joint site unspecified - loose body in hand joint
718.20 - 718.24 pathological dislocation of joint site unspecified - pathological dislocation of hand joint
718.30 - 718.34 recurrent dislocation of joint site unspecified - recurrent dislocation of hand joint
718.40 - 718.44 contracture of joint site unspecified - contracture of hand joint
718.50 - 718.54 ankylosis of joint site unspecified - ankylosis of hand joint
718.70 - 718.74 developmental dislocation of joint site unspecified - developmental dislocation of joint hand
718.80 - 718.84 other joint derangement not elsewhere classified involving unspecified site - other joint derangement
not elsewhere classified involving hand
718.90 - 718.94 unspecified derangement of joint site unspecified - unspecified derangement of hand joint
719.01 - 719.04 effusion of joint of shoulder region - effusion of hand joint
719.11 - 719.14 herarthrosis involving shoulder region - hemarthrosis involving hand
719.21 - 719.24 villonodular synovitis involving shoulder region - villonodular synovitis involving hand
719.41 - 719.44 pain in joint involving shoulder region - pain in joint involving hand
726.0
adhesive capsulitis of shoulder
726.10 - 726.12 disorders of bursae and tendons in shoulder region unspecified - bicipital tenosynovitis
726.19
other specified disorders of bursae and tendons in shoulder region
726.2
other affections of shoulder region not elsewhere classified
726.30 - 726.33 enthesopathy of elbow unspecified - olecranon bursitis
727.02 - 727.05 giant cell tumor of tendon sheath - other tenosynovitis of hand and wrist
727.40 - 727.42 synovial cyst unspecified - ganglion of tendon sheath
727.61 - 727.64 complete rupture of rotator cuff - nontraumatic rupture of flexor tendons of hand and wrist
729.5
pain in limb
729.81
swelling of limb
730.01 - 730.04 acute osteomyelitis involving shoulder region - acute osteomyelitis involving hand
730.11 - 730.14 chronic osteomyelitis involving shoulder region - chronic osteomyelitis involving hand
730.20 - 730.24 unspecified osteomyelitis site unspecified - unspecified osteomyelitis involving hand
733.00 - 733.09 osteoporosis unspecified - other osteoporosis
733.11
pathological fracture of humerus
733.12
pathological fracture of distal radius and ulna
733.20 - 733.22 cyst of bone (localized) unspecified - aneurysmal bone cyst
733.40
aseptic necrosis of bone site unspecified
733.41
aseptic necrosis of head of humerus
733.81
malunion of fracture
733.82
nonunion of fracture
733.90
disorder of bone and cartilage unspecified
747.63
upper limb vessel anomaly
793.7
nonspecific abnormal findings on radiological and other examination of musculoskeletal system
810.00 - 819.1 closed fracture of clavicle unspecified part - multiple open fractures involving both upper limbs and
upper limb with rib(s) and sternum
CMS Limitations
CT Upper and Lower Extremity (Upper Extremity con’t)
840.0 - 840.9 acromioclavicular (joint) (ligament) sprain - sprain of unspecified site of shoulder and upper arm
841.0 - 841.9 radial collateral ligament sprain - sprain of unspecified site of elbow and forearm
842.00 - 842.19 sprain of unspecified site of wrist - other hand sprain
927.00 - 927.8 crushing injury of shoulder region - crushing injury of multiple sites of upper limb
959.2 - 959.4 other and unspecified injury to shoulder and upper arm - other and unspecified injury to hand except
finger
996.1
mechanical complication of other vascular device implant and graft
996.40 - 996.49 unspecified mechanical complication of internal orthopedic device, implant, and graft - other
mechanical complication of other internal orthopedic device, implant, and graft
996.62
infection and inflammatory reaction due to other vascular device implant and graft
996.68
infection and inflammatory reaction due to peritoneal dialysis catheter
v10.81
personal history of malignant neoplasm of bone
v67.00*
follow-up examination following unspecified surgery
v67.09*
follow-up examination following other surgery
v67.1*
follow-up examination following radiotherapy
v67.2*
follow-up examination following chemotherapy
*non-specific and require an additional ICD-9 code for payment.
Lower Extremity (73700-73706)
170.7 - 170.9 malignant neoplasm of long bones of lower limb - malignant neoplasm of bone and articular cartilage
site unspecified
171.3
malignant neoplasm of connective and other soft tissue of lower limb including hip
172.7
malignant melanoma of skin of lower limb including hip
173.7
other malignant neoplasm of skin of lower limb including hip
195.5
malignant neoplasm of lower limb
198.5
secondary malignant neoplasm of bone and bone marrow
198.89
secondary malignant neoplasm of other specified sites
213.7
benign neoplasm of long bones of lower limb
213.8
benign neoplasm of short bones of lower limb
215.3
other benign neoplasm of connective and other soft tissue of lower limb including hip
216.7
benign neoplasm of skin of lower limb including hip
228.1
lymphangioma any site
232.7
carcinoma in situ of skin of lower limb including hip
238.0
neoplasm of uncertain behavior of bone and articular cartilage
239.2
neoplasm of unspecified nature of bone soft tissue and skin
250.70 - 250.73 diabetes with peripheral circulatory disorders, type ii or unspecified type, not stated as uncontrolled
- diabetes with peripheral circulatory disorders, type i [juvenile type], uncontrolled
353.6
phantom limb (syndrome)
354.5
mononeuritis multiplex
355.0 - 355.79 lesion of sciatic nerve - other mononeuritis of lower limb
359.21 - 359.24 myotonic muscular dystrophy - drug induced myotonia
359.29
other specified myotonic disorder
359.3
periodic paralysis
440.0
atherosclerosis of aorta
440.20 - 440.29 atherosclerosis of native arteries of the extremities unspecified - other atherosclerosis of native
arteries of the extremities
442.2
aneurysm of iliac artery
442.3
aneurysm of artery of lower extremity
442.89
aneurysm of other specified site
CMS Limitations
CT Upper and Lower Extremity (Lower Extremity con’t)
442.9
443.9
444.22
447.0
447.1
457.1
682.6
682.7
711.05 - 711.07 715.00
715.09
715.10
715.15 - 715.17 715.20
715.25 - 715.27 715.30
715.35 - 715.37 715.80
715.90
715.95 - 715.97 716.15 - 716.17 717.0 - 717.3 717.40 - 717.49 717.5 - 717.7 717.81 - 717.9 718.00
718.05
718.07
718.09
718.10
718.15
718.17
718.19
718.20
718.25 - 718.27 718.29
718.30
718.35 - 718.37 718.39
718.40
718.45 - 718.47 718.49
718.50
other aneurysm of unspecified site
peripheral vascular disease unspecified
arterial embolism and thrombosis of lower extremity
arteriovenous fistula acquired
stricture of artery
other lymphedema
cellulitis and abscess of leg except foot
cellulitis and abscess of foot except toes
pyogenic arthritis involving pelvic region and thigh - pyogenic arthritis involving ankle and foot
osteoarthrosis generalized involving unspecified site
osteoarthrosis generalized involving multiple sites
osteoarthrosis localized primary involving unspecified site
osteoarthrosis localized primary involving pelvic region and thigh - osteoarthrosis localized primary
involving ankle and foot
osteoarthrosis localized secondary involving unspecified site
osteoarthrosis localized secondary involving pelvic region and thigh - osteoarthrosis localized secondary involving ankle and foot
osteoarthrosis localized not specified whether primary or secondary involving unspecified site
osteoarthrosis localized not specified whether primary or secondary involving pelvic region and thigh
- osteoarthrosis localized not specified whether primary or secondary involving ankle and foot
osteoarthrosis involving or with more than one site but not specified as generalized and involving unspecified site
osteoarthrosis unspecified whether generalized or localized involving unspecified site
osteoarthrosis unspecified whether generalized or localized involving pelvic region and thigh - osteoarthrosis unspecified whether generalized or localized involving ankle and foot
traumatic arthropathy involving pelvic region and thigh - traumatic arthropathy involving ankle and
foot
old bucket handle tear of medial meniscus - other and unspecified derangement of medial meniscus
derangement of lateral meniscus unspecified - other derangement of lateral meniscus
derangement of meniscus not elsewhere classified - chondromalacia of patella
old disruption of lateral collateral ligament - unspecified internal derangement of knee
articular cartilage disorder site unspecified
articular cartilage disorder involving pelvic region and thigh
articular cartilage disorder involving ankle and foot
articular cartilage disorder involving multiple sites
loose body in joint site unspecified
loose body in joint of pelvic region and thigh
loose body in ankle and foot joint
loose body in joint of multiple sites
pathological dislocation of joint site unspecified
pathological dislocation of joint of pelvic region and thigh - pathological dislocation of ankle and foot
joint
pathological dislocation of joint of multiple sites
recurrent dislocation of joint site unspecified
recurrent dislocation of joint of pelvic region and thigh - recurrent dislocation of ankle and foot joint
recurrent dislocation of joint of multiple sites
contracture of joint site unspecified
contracture of joint of pelvic region and thigh - contracture of ankle and foot joint
contracture of joint of multiple sites
ankylosis of joint site unspecified
CMS Limitations
CT Upper and Lower Extremity (Lower Extremity con’t)
718.55 - 718.57 718.59
718.60
718.65
718.70
718.75 - 718.77 ankylosis of joint of pelvic region and thigh - ankylosis of ankle and foot joint
ankylosis of joint of multiple sites
unspecified intrapelvic protrusion of acetabulum site unspecified
unspecified intrapelvic protrusion of acetabulum pelvic region and thigh
developmental dislocation of joint site unspecified
developmental dislocation of joint pelvic region and thigh - developmental dislocation of joint ankle
and foot
718.79
developmental dislocation of joint multiple sites
718.80
other joint derangement not elsewhere classified involving unspecified site
718.85 - 718.87 other joint derangement not elsewhere classified involving pelvic region and thigh - other joint derangement not elsewhere classified involving ankle and foot
718.89
other joint derangement not elsewhere classified involving multiple sites
718.90
unspecified derangement of joint site unspecified
718.95
unspecified derangement of joint of pelvic region and thigh
718.97 - 718.99 unspecified derangement of ankle and foot joint - unspecified derangement of joint of multiple sites
719.05 - 719.07 effusion of joint of pelvic region and thigh - effusion of ankle and foot joint
719.15 - 719.17 hemarthrosis involving pelvic region and thigh - hemarthrosis involving ankle and foot
719.25 - 719.27 villonodular synovitis involving pelvic region and thigh - villonodular synovitis involving ankle and foot
719.40
pain in joint site unspecified
719.45 - 719.47 pain in joint involving pelvic region and thigh - pain in joint involving ankle and foot
726.5 - 726.65 enthesopathy of hip region - prepatellar bursitis
726.71
achilles bursitis or tendinitis
727.02
giant cell tumor of tendon sheath
727.06
tenosynovitis of foot and ankle
727.40 - 727.42 synovial cyst unspecified - ganglion of tendon sheath
727.50
rupture of synovium unspecified
727.51
synovial cyst of popliteal space
727.65 - 727.68 nontraumatic rupture of quadriceps tendon - nontraumatic rupture of other tendons of foot and ankle
727.83
plica syndrome
728.3
other specific muscle disorders
729.5
pain in limb
729.81
swelling of limb
730.05 - 730.07 acute osteomyelitis involving pelvic region and thigh - acute osteomyelitis involving ankle and foot
730.09
acute osteomyelitis involving multiple sites
730.15 - 730.17 chronic osteomyelitis involving pelvic region and thigh - chronic osteomyelitis involving ankle and foot
730.19
chronic osteomyelitis involving multiple sites
730.25 - 730.27 unspecified osteomyelitis involving pelvic region and thigh - unspecified osteomyelitis involving ankle
and foot
733.00 - 733.09 osteoporosis unspecified - other osteoporosis
733.14 - 733.16 pathological fracture of neck of femur - pathological fracture of tibia or fibula
733.20 - 733.22 cyst of bone (localized) unspecified - aneurysmal bone cyst
733.40
aseptic necrosis of bone site unspecified
733.42 - 733.44 aseptic necrosis of head and neck of femur - aseptic necrosis of talus
733.81
malunion of fracture
733.82
nonunion of fracture
733.90
disorder of bone and cartilage unspecified
747.60
anomaly of the peripheral vascular system unspecified site
747.64
lower limb vessel anomaly
793.7
nonspecific abnormal findings on radiological and other examination of musculoskeletal system
CMS Limitations
CT Upper and Lower Extremity (Lower Extremity con’t)
820.00 - 829.1 fracture of unspecified intracapsular section of neck of femur closed - fracture of unspecified bone
open
836.0 - 836.2 tear of medial cartilage or meniscus of knee current - other tear of cartilage or meniscus of knee current
843.0 - 843.9 iliofemoral (ligament) sprain - sprain of unspecified site of hip and thigh
844.0 - 844.9 sprain of lateral collateral ligament of knee - sprain of unspecified site of knee and leg
845.00 - 845.19 unspecified site of ankle sprain - other foot sprain
928.00 - 928.9 crushing injury of thigh - crushing injury of unspecified site of lower limb
959.6
other and unspecified injury to hip and thigh
959.7
other and unspecified injury to knee leg ankle and foot
996.1
mechanical complication of other vascular device implant and graft
996.40-996.49 unspecified mechanical complication of internal orthopedic device, implant, and graft - other mechanical complication of other internal orthopedic device, implant, and graft
996.62
infection and inflammatory reaction due to other vascular device implant and graft
v10.81
personal history of malignant neoplasm of bone
v67.00*
follow-up examination following unspecified surgery
v67.09*
follow-up examination following other surgery
v67.1*
follow-up examination following radiotherapy
v67.2
follow-up examination following chemotherapy
* non specific and require an additional ICD-9 code for payment.
CMS Limitations
MRI Abdomen and Pelvis
LCD # L28723, Effective Date: 03/25/2009
CPT/HCPCS Codes: CPT 72195, CPT 72196, CPT 72197, CPT 74181, CPT 74182, CPT 74183, CPT 76376*, CPT 76377*
ICD-9 code that SUPPORT medical necessity for magnetic resonance (eg, proton) imaging, pelvis; without contrast
material(s) (CPT 72195); magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) (CPT 72196); magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further
sequences (CPT 72197); magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) (CPT 74181);
magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s) (CPT 74182); magnetic resonance (eg,
proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences
(CPT 74183); 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging,
ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation (CPT
76376*); and 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation (CPT
76377*):
*Note: For the purposes of this LCD, CPT code 76376 or 76377 is allowed only when billed in conjunction with another
MRI procedure code.
150.2
150.4
150.5
150.8
151.0
151.1
151.2
151.3
151.4
151.5
151.6
151.8
151.9
152.0
152.1
152.2
152.3
152.8
152.9
153.0
153.1
153.2
153.3
153.4
153.5
153.6
153.7
153.8
153.9
154.0
154.1
malignant neoplasm of abdominal esophagus
malignant neoplasm of middle third of esophagus
malignant neoplasm of lower third of esophagus
malignant neoplasm of other specified part of esophagus
malignant neoplasm of cardia
malignant neoplasm of pylorus
malignant neoplasm of pyloric antrum
malignant neoplasm of fundus of stomach
malignant neoplasm of body of stomach
malignant neoplasm of lesser curvature of stomach unspecified
malignant neoplasm of greater curvature of stomach unspecified
malignant neoplasm of other specified sites of stomach
malignant neoplasm of stomach unspecified site
malignant neoplasm of duodenum
malignant neoplasm of jejunum
malignant neoplasm of ileum
malignant neoplasm of meckel’s diverticulum
malignant neoplasm of other specified sites of small intestine
malignant neoplasm of small intestine unspecified site
malignant neoplasm of hepatic flexure
malignant neoplasm of transverse colon
malignant neoplasm of descending colon
malignant neoplasm of sigmoid colon
malignant neoplasm of cecum
malignant neoplasm of appendix vermiformis
malignant neoplasm of ascending colon
malignant neoplasm of splenic flexure
malignant neoplasm of other specified sites of large intestine
malignant neoplasm of colon unspecified site
malignant neoplasm of rectosigmoid junction
malignant neoplasm of rectum
CMS Limitations
MRI Abdomen and Pelvis (con’t)
154.2
154.3
154.8
155.0
155.1
155.2
156.0
156.1
156.2
156.8
156.9
157.0
157.1
157.2
157.3
157.4
157.8
157.9
158.0
158.8
158.9
159.0
159.1
159.8
159.9
176.1
176.3
176.5
176.8
179
180.0
180.1
180.8
180.9
181
182.0
182.1
182.8
183.0
183.2
183.3
183.4
183.5
183.8
183.9
184.0
184.1
184.2
184.3
184.4
malignant neoplasm of anal canal
malignant neoplasm of anus unspecified site
malignant neoplasm of other sites of rectum rectosigmoid junction and anus
malignant neoplasm of liver primary
malignant neoplasm of intrahepatic bile ducts
malignant neoplasm of liver not specified as primary or secondary
malignant neoplasm of gallbladder
malignant neoplasm of extrahepatic bile ducts
malignant neoplasm of ampulla of vater
malignant neoplasm of other specified sites of gallbladder and extrahepatic bile ducts
malignant neoplasm of biliary tract part unspecified site
malignant neoplasm of head of pancreas
malignant neoplasm of body of pancreas
malignant neoplasm of tail of pancreas
malignant neoplasm of pancreatic duct
malignant neoplasm of islets of langerhans
malignant neoplasm of other specified sites of pancreas
malignant neoplasm of pancreas part unspecified
malignant neoplasm of retroperitoneum
malignant neoplasm of specified parts of peritoneum
malignant neoplasm of peritoneum unspecified
malignant neoplasm of intestinal tract part unspecified
malignant neoplasm of spleen not elsewhere classified
malignant neoplasm of other sites of digestive system and intra-abdominal organs
malignant neoplasm of ill-defined sites within the digestive organs and peritoneum
kaposi’s sarcoma soft tissue
kaposi’s sarcoma gastrointestinal sites
kaposi’s sarcoma lymph nodes
kaposi’s sarcoma other specified sites
malignant neoplasm of uterus-part uns
malignant neoplasm of endocervix
malignant neoplasm of exocervix
malignant neoplasm of other specified sites of cervix
malignant neoplasm of cervix uteri unspecified site
malignant neoplasm of placenta
malignant neoplasm of corpus uteri except isthmus
malignant neoplasm of isthmus
malignant neoplasm of other specified sites of body of uterus
malignant neoplasm of ovary
malignant neoplasm of fallopian tube
malignant neoplasm of broad ligament of uterus
malignant neoplasm of parametrium
malignant neoplasm of round ligament of uterus
malignant neoplasm of other specified sites of uterine adnexa
malignant neoplasm of uterine adnexa unspecified site
malignant neoplasm of vagina
malignant neoplasm of labia majora
malignant neoplasm of labia minora
malignant neoplasm of clitoris
malignant neoplasm of vulva unspecified site
CMS Limitations
MRI Abdomen and Pelvis (con’t)
184.8
184.9
185
186.0
186.9
187.3
187.5
187.6
187.7
188.0
188.1
188.2
188.3
188.4
188.5
188.6
188.7
188.8
188.9
189.0
189.1
189.2
189.3
189.4
189.8
189.9
194.0
194.8
194.9
195.2
195.3
196.2
196.5
196.6
196.8
197.4
197.5
197.6
197.7
197.8
198.0
198.1
198.6
198.7
198.82
198.89
199.0
199.1
199.2
200.00
malignant neoplasm of other specified sites of female genital organs
malignant neoplasm of female genital organ site unspecified
malignant neoplasm of prostate
malignant neoplasm of undescended testis
malignant neoplasm of other and unspecified testis
malignant neoplasm of body of penis
malignant neoplasm of epididymis
malignant neoplasm of spermatic cord
malignant neoplasm of scrotum
malignant neoplasm of trigone of urinary bladder
malignant neoplasm of dome of urinary bladder
malignant neoplasm of lateral wall of urinary bladder
malignant neoplasm of anterior wall of urinary bladder
malignant neoplasm of posterior wall of urinary bladder
malignant neoplasm of bladder neck
malignant neoplasm of ureteric orifice
malignant neoplasm of urachus
malignant neoplasm of other specified sites of bladder
malignant neoplasm of bladder part unspecified
malignant neoplasm of kidney except pelvis
malignant neoplasm of renal pelvis
malignant neoplasm of ureter
malignant neoplasm of urethra
malignant neoplasm of paraurethral glands
malignant neoplasm of other specified sites of urinary organs
malignant neoplasm of urinary organ site unspecified
malignant neoplasm of adrenal gland
malignant neoplasm of other endocrine glands and related structures
malignant neoplasm of endocrine gland site unspecified
malignant neoplasm of abdomen
malignant neoplasm of pelvis
secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and lower limb
secondary and unspecified malignant neoplasm of intrapelvic lymph nodes
secondary and unspecified malignant neoplasm of lymph nodes of multiple sites
secondary malignant neoplasm of small intestine including duodenum
secondary malignant neoplasm of large intestine and rectum
secondary malignant neoplasm of retroperitoneum and peritoneum
malignant neoplasm of liver secondary
secondary malignant neoplasm of other digestive organs and spleen
secondary malignant neoplasm of kidney
secondary malignant neoplasm of other urinary organs
secondary malignant neoplasm of ovary
secondary malignant neoplasm of adrenal gland
secondary malignant neoplasm of genital organs
secondary malignant neoplasm of other specified sites
disseminated malignant neoplasm
other malignant neoplasm of unspecified site
malignant neoplasm associated with transplant organ
reticulosarcoma unspecified site
CMS Limitations
MRI Abdomen and Pelvis (con’t)
200.03
200.05
200.06
200.07
200.08
200.10
200.13
200.15
200.16
200.17
200.18
200.20
200.23
200.25
200.26
200.27
200.28
200.30
200.31
200.32
200.33
200.34
200.35
200.36
200.37
200.38
200.40
200.41
200.42
200.43
200.44
200.45
200.46
200.47
200.48
200.50
200.51
200.52
200.53
200.54
200.55
200.56
200.57
200.58
200.60
200.61
200.62
200.63
200.64
200.65
reticulosarcoma involving intra-abdominal lymph nodes
reticulosarcoma involving lymph nodes of inguinal region and lower limb
reticulosarcoma involving intrapelvic lymph nodes
reticulosarcoma involving spleen
reticulosarcoma involving lymph nodes of multiple sites
lymphosarcoma unspecified site
lymphosarcoma involving intra-abdominal lymph nodes
lymphosarcoma involving lymph nodes of inguinal region and lower limb
lymphosarcoma involving intrapelvic lymph nodes
lymphosarcoma involving spleen
lymphosarcoma involving lymph nodes of multiple sites
burkitt’s tumor or lymphoma unspecified site
burkitt’s tumor or lymphoma involving intra-abdominal lymph nodes
burkitt’s tumor or lymphoma involving lymph nodes of inguinal region and lower limb
burkitt’s tumor or lymphoma involving intrapelvic lymph nodes
burkitt’s tumor or lymphoma involving spleen
burkitt’s tumor or lymphoma involving lymph nodes of multiple sites
marginal zone lymphoma, unspecified site, extranodal and solid organ sites
marginal zone lymphoma,lymph nodes of head, face, and neck
marginal zone lymphoma,intrathoracic lymph nodes
marginal zone lymphoma, intraabdominal lymph nodes
marginal zone lymphoma, lymph nodes of axilla and upper limb
marginal zone lymphoma, lymph nodes of inguinal region and lower limb
marginal zone lymphoma, intrapelvic lymph nodes
marginal zone lymphoma, spleen
marginal zone lymphoma, lymph nodes of multiple sites
mantle cell lymphoma, unspecified site, extranodal and solid organ sites
mantle cell lymphoma, lymph nodes of head, face, and neck
mantle cell lymphoma, intrathoracic lymph nodes
mantle cell lymphoma, intra-abdominal lymph nodes
mantle cell lymphoma, lymph nodes of axilla and upper limb
mantle cell lymphoma, lymph nodes of inguinal region and lower limb
mantle cell lymphoma, intrapelvic lymph nodes
mantle cell lymphoma, spleen
mantle cell lymphoma, lymph nodes of multiple sites
primary central nervous system lymphoma, unspecified site, extranodal and solid organ sites
primary central nervous system lymphoma, lymph nodes of head, face, and neck
primary central nervous system lymphoma, intrathoracic lymph nodes
primary central nervous system lymphoma, intra-abdominal lymph nodes
primary central nervous system lymphoma, lymph nodes of axilla and upper limb
primary central nervous system lymphoma, lymph nodes of inguinal region and lower limb
primary central nervous system lymphoma, intrapelvic lymph nodes
primary central nervous system lymphoma, spleen
primary central nervous system lymphoma, lymph nodes of multiple sites
anaplastic large cell lymphoma, unspecified site, extranodal and solid organ sites
anaplastic large cell lymphoma, lymph nodes of head, face, and neck
anaplastic large cell lymphoma, intrathoracic lymph nodes
anaplastic large cell lymphoma, intra-abdominal lymph nodes
anaplastic large cell lymphoma, lymph nodes of axilla and upper limb
anaplastic large cell lymphoma, lymph nodes of inguinal region and lower limb
CMS Limitations
MRI Abdomen and Pelvis (con’t)
200.66
200.67
200.68
200.70
200.71
200.72
200.73
200.74
200.75
200.76
200.77
200.78
200.80
200.83
200.85
200.86
200.87
200.88
201.00
201.03
201.05
201.06
201.07
201.08
201.10
201.13
201.15
201.16
201.17
201.18
201.20
201.23
201.25
201.26
201.27
201.28
201.40
201.43
201.45
201.46
201.47
201.48
201.50
201.53
201.55
201.56
201.57
201.58
anaplastic large cell lymphoma, intrapelvic lymph nodes
anaplastic large cell lymphoma, spleen
anaplastic large cell lymphoma, lymph nodes of multiple sites
large cell lymphoma, unspecified site, extranodal and solid organ sites
large cell lymphoma, lymph nodes of head, face, and neck
large cell lymphoma, intrathoracic lymph nodes
large cell lymphoma, intra-abdominal lymph nodes
large cell lymphoma, lymph nodes of axilla and upper limb
large cell lymphoma, lymph nodes of inguinal region and lower limb
large cell lymphoma, intrapelvic lymph nodes
large cell lymphoma, spleen
large cell lymphoma, lymph nodes of multiple sites
other named variants of lymphosarcoma and reticulosarcoma unspecified site
other named variants of lymphosarcoma and reticulosarcoma involving intra-abdominal lymph nodes
other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of inguinal region
and lower limb
other named variants of lymphosarcoma and reticulosarcoma involving intrapelvic lymph nodes
other named variants of lymphosarcoma and reticulosarcoma involving spleen
other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of multiple sites
hodgkin’s paragranuloma unspecified site
hodgkin’s paragranuloma involving intra-abdominal lymph nodes
hodgkin’s paragranuloma involving lymph nodes of inguinal region and lower limb
hodgkin’s paragranuloma involving intrapelvic lymph nodes
hodgkin’s paragranuloma involving spleen
hodgkin’s paragranuloma involving lymph nodes of multiple sites
hodgkin’s granuloma unspecified site
hodgkin’s granuloma involving intra-abdominal lymph nodes
hodgkin’s granuloma involving lymph nodes of inguinal region and lower limb
hodgkin’s granuloma involving intrapelvic lymph nodes
hodgkin’s granuloma involving spleen
hodgkin’s granuloma involving lymph nodes of multiple sites
hodgkin’s sarcoma unspecified site
hodgkin’s sarcoma involving intra-abdominal lymph nodes
hodgkin’s sarcoma involving lymph nodes of inguinal region and lower limb
hodgkin’s sarcoma involving intrapelvic lymph nodes
hodgkin’s sarcoma involving spleen
hodgkin’s sarcoma involving lymph nodes of multiple sites
hodgkin’s disease lymphocytic-histiocytic predominance unspecified site
hodgkin’s disease lymphocytic-histiocytic predominance involving intra-abdominal lymph nodes
hodgkin’s disease lymphocytic-histiocytic predominance involving lymph nodes of inguinal region and
lower limb
hodgkin’s disease lymphocytic-histiocytic predominance involving intrapelvic lymph nodes
hodgkin’s disease lymphocytic-histiocytic predominance involving spleen
hodgkin’s disease lymphocytic-histiocytic predominance involving lymph nodes of multiple sites
hodgkin’s disease nodular sclerosis unspecified site
hodgkin’s disease nodular sclerosis involving intra-abdominal lymph nodes
hodgkin’s disease nodular sclerosis involving lymph nodes of inguinal region and lower limb
hodgkin’s disease nodular sclerosis involving intrapelvic lymph nodes
hodgkin’s disease nodular sclerosis involving spleen
hodgkin’s disease nodular sclerosis involving lymph nodes of multiple sites
CMS Limitations
MRI Abdomen and Pelvis (con’t)
201.60
201.63
201.65
201.66
201.67
201.68
201.70
201.73
201.75
201.76
201.77
201.78
201.90
201.93
201.95
201.96
201.97
201.98
202.00
202.03
202.05
202.06
202.07
202.08
202.10
202.13
202.15
202.16
202.17
202.18
202.20
202.23
202.25
202.26
202.27
202.28
202.30
202.33
202.35
202.36
202.37
202.38
202.40
202.43
202.45
202.46
202.47
202.48
202.50
202.53
hodgkin’s disease mixed cellularity unspecified site
hodgkin’s disease mixed cellularity involving intra-abdominal lymph nodes
hodgkin’s disease mixed cellularity involving lymph nodes of inguinal region and lower limb
hodgkin’s disease mixed cellularity involving intrapelvic lymph nodes
hodgkin’s disease mixed cellularity involving spleen
hodgkin’s disease mixed cellularity involving lymph nodes of multiple sites
hodgkin’s disease lymphocytic depletion unspecified site
hodgkin’s disease lymphocytic depletion involving intra-abdominal lymph nodes
hodgkin’s disease lymphocytic depletion involving lymph nodes of inguinal region and lower limb
hodgkin’s disease lymphocytic depletion involving intrapelvic lymph nodes
hodgkin’s disease lymphocytic depletion involving spleen
hodgkin’s disease lymphocytic depletion involving lymph nodes of multiple sites
hodgkin’s disease unspecified type unspecified site
hodgkin’s disease unspecified type involving intra-abdominal lymph nodes
hodgkin’s disease unspecified type involving lymph nodes of inguinal region and lower limb
hodgkin’s disease unspecified type involving intrapelvic lymph nodes
hodgkin’s disease unspecified type involving spleen
hodgkin’s disease unspecified type involving lymph nodes of multiple sites
nodular lymphoma unspecified site
nodular lymphoma involving intra-abdominal lymph nodes
nodular lymphoma involving lymph nodes of inguinal region and lower limb
nodular lymphoma involving intrapelvic lymph nodes
nodular lymphoma involving spleen
nodular lymphoma involving lymph nodes of multiple sites
mycosis fungoides unspecified site
mycosis fungoides involving intra-abdominal lymph nodes
mycosis fungoides involving lymph nodes of inguinal region and lower limb
mycosis fungoides involving intrapelvic lymph nodes
mycosis fungoides involving spleen
mycosis fungoides involving lymph nodes of multiple sites
sezary’s disease unspecified site
sezary’s disease involving intra-abdominal lymph nodes
sezary’s disease involving lymph nodes of inguinal region and lower limb
sezary’s disease involving intrapelvic lymph nodes
sezary’s disease involving spleen
sezary’s disease involving lymph nodes of multiple sites
malignant histiocytosis unspecified site
malignant histiocytosis involving intra-abdominal lymph nodes
malignant histiocytosis involving lymph nodes of inguinal region and lower limb
malignant histiocytosis involving intrapelvic lymph nodes
malignant histiocytosis involving spleen
malignant histiocytosis involving lymph nodes of multiple sites
leukemic reticuloendotheliosis unspecified site
leukemic reticuloendotheliosis involving intra-abdominal lymph nodes
leukemic reticuloendotheliosis involving lymph nodes of inguinal region and lower limb
leukemic reticuloendotheliosis involving intrapelvic lymph nodes
leukemic reticuloendotheliosis involving spleen
leukemic reticuloendotheliosis involving lymph nodes of multiple sites
letterer-siwe disease unspecified site
letterer-siwe disease involving intra-abdominal lymph nodes
CMS Limitations
MRI Abdomen and Pelvis (con’t)
202.55
202.56
202.57
202.58
202.60
202.63
202.65
202.66
202.67
202.68
202.70
202.71
202.72
202.73
202.74
202.75
202.76
202.77
202.78
202.80
202.83
202.85
202.86
202.87
202.88
202.90
202.93
202.95
202.96
202.97
202.98
203.00
203.01
203.02
209.00
209.01
209.02
209.03
209.10
209.11
209.12
209.13
209.14
209.15
209.16
209.17
letterer-siwe disease involving lymph nodes of inguinal region and lower limb
letterer-siwe disease involving intrapelvic lymph nodes
letterer-siwe disease involving spleen
letterer-siwe disease involving lymph nodes of multiple sites
malignant mast cell tumors unspecified site
malignant mast cell tumors involving intra-abdominal lymph nodes
malignant mast cell tumors involving lymph nodes of inguinal region and lower limb
malignant mast cell tumors involving intrapelvic lymph nodes
malignant mast cell tumors involving spleen
malignant mast cell tumors involving lymph nodes of multiple sites
peripheral t cell lymphoma, unspecified site, extranodal and solid organ sites
peripheral t cell lymphoma, lymph nodes of head, face, and neck
peripheral t cell lymphoma, intrathoracic lymph nodes
peripheral t cell lymphoma, intra-abdominal lymph nodes
peripheral t cell lymphoma, lymph nodes of axilla and upper limb
peripheral t cell lymphoma, lymph nodes of inguinal region and lower limb
peripheral t cell lymphoma, intrapelvic lymph nodes
peripheral t cell lymphoma, spleen
peripheral t cell lymphoma, lymph nodes of multiple sites
other malignant lymphomas unspecified site
other malignant lymphomas involving intra-abdominal lymph nodes
other malignant lymphomas involving lymph nodes of inguinal region and lower limb
other malignant lymphomas involving intrapelvic lymph nodes
other malignant lymphomas involving spleen
other malignant lymphomas involving lymph nodes of multiple sites
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue unspecified site
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving intra-abdominal lymph nodes
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes
of inguinal region and lower limb
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving intrapelvic
lymph nodes
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving spleen
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes
of multiple sites
multiple myeloma, without mention of having achieved remission
multiple myeloma in remission
multiple myeloma, in relapse
malignant carcinoid tumor of the small intestine, unspecified portion
malignant carcinoid tumor of the duodenum
malignant carcinoid tumor of the jejunum
malignant carcinoid tumor of the ileum
malignant carcinoid tumor of the large intestine, unspecified portion
malignant carcinoid tumor of the appendix
malignant carcinoid tumor of the cecum
malignant carcinoid tumor of the ascending colon
malignant carcinoid tumor of the transverse colon
malignant carcinoid tumor of the descending colon
malignant carcinoid tumor of the sigmoid colon
malignant carcinoid tumor of the rectum
CMS Limitations
MRI Abdomen and Pelvis (con’t)
209.20
209.23
209.24
209.30
209.40
209.41
209.42
209.43
209.50
209.51
209.52
209.53
209.54
209.55
209.56
209.57
209.60
209.63
209.64
211.0
211.1
211.2
211.3
211.4
211.5
211.6
211.7
211.8
214.3
214.4
214.8
214.9
215.5
215.6
215.7
215.8
216.6
216.7
216.8
218.0
218.1
218.2
218.9
219.0
219.1
219.8
219.9
220
221.0
221.1
malignant carcinoid tumor of unknown primary site
malignant carcinoid tumor of the stomach
malignant carcinoid tumor of the kidney
malignant poorly differentiated neuroendocrine carcinoma, any site
benign carcinoid tumor of the small intestine, unspecified portion
benign carcinoid tumor of the duodenum
benign carcinoid tumor of the jejunum
benign carcinoid tumor of the ileum
benign carcinoid tumor of the large intestine, unspecified portion
benign carcinoid tumor of the appendix
benign carcinoid tumor of the cecum
benign carcinoid tumor of the ascending colon
benign carcinoid tumor of the transverse colon
benign carcinoid tumor of the descending colon
benign carcinoid tumor of the sigmoid colon
benign carcinoid tumor of the rectum
benign carcinoid tumor of unknown primary site
benign carcinoid tumor of the stomach
benign carcinoid tumor of the kidney
benign neoplasm of esophagus
benign neoplasm of stomach
benign neoplasm of duodenum jejunum and ileum
benign neoplasm of colon
benign neoplasm of rectum and anal canal
benign neoplasm of liver and biliary passages
benign neoplasm of pancreas except islets of langerhans
benign neoplasm of islets of langerhans
benign neoplasm of retroperitoneum and peritoneum
lipoma of intra-abdominal organs
lipoma of spermatic cord
lipoma of other specified sites
lipoma unspecified site
other benign neoplasm of connective and other soft tissue of abdomen
other benign neoplasm of connective and other soft tissue of pelvis
other benign neoplasm of connective and other soft tissue of trunk unspecified
other benign neoplasm of connective and other soft tissue of other specified sites
benign neoplasm of skin of upper limb including shoulder
benign neoplasm of skin of lower limb including hip
benign neoplasm of other specified sites of skin
submucous leiomyoma of uterus
intramural leiomyoma of uterus
subserous leiomyoma of uterus
leiomyoma of uterus unspecified
benign neoplasm of cervix uteri
benign neoplasm of corpus uteri
benign neoplasm of other specified parts of uterus
benign neoplasm of uterus part unspecified
benign neoplasm of ovary
benign neoplasm of fallopian tube and uterine ligaments
benign neoplasm of vagina
CMS Limitations
MRI Abdomen and Pelvis (con’t)
221.8
221.9
222.0
222.2
222.3
222.4
222.8
223.0
223.1
223.2
223.3
223.81
223.89
223.9
227.0
227.8
228.04
228.09
228.1
229.0
229.8
230.1
230.2
230.3
230.4
230.5
230.6
230.7
230.8
230.9
232.5
232.7
232.8
233.1
233.2
233.30
233.31
233.32
233.39
233.4
233.6
233.7
233.9
235.2
235.3
235.4
235.5
236.0
236.1
236.2
benign neoplasm of other specified sites of female genital organs
benign neoplasm of female genital organ site unspecified
benign neoplasm of testis
benign neoplasm of prostate
benign neoplasm of epididymis
benign neoplasm of scrotum
benign neoplasm of other specified sites of male genital organs
benign neoplasm of kidney except pelvis
benign neoplasm of renal pelvis
benign neoplasm of ureter
benign neoplasm of bladder
benign neoplasm of urethra
benign neoplasm of other specified sites of urinary organs
benign neoplasm of urinary organ site unspecified
benign neoplasm of adrenal gland
benign neoplasm of other endocrine glands and related structures
hemangioma of intra-abdominal structures
hemangioma of other sites
lymphangioma any site
benign neoplasm of lymph nodes
benign neoplasm of other specified sites
carcinoma in situ of esophagus
carcinoma in situ of stomach
carcinoma in situ of colon
carcinoma in situ of rectum
carcinoma in situ of anal canal
carcinoma in situ of anus unspecified
carcinoma in situ of other and unspecified parts of intestine
carcinoma in situ of liver and biliary system
carcinoma in situ of other and unspecified digestive organs
carcinoma in situ of skin of trunk except scrotum
carcinoma in situ of skin of lower limb including hip
carcinoma in situ of other specified sites of skin
carcinoma in situ of cervix uteri
carcinoma in situ of other and unspecified parts of uterus
carcinoma in situ, unspecified female genital organ
carcinoma in situ, vagina
carcinoma in situ, vulva
carcinoma in situ, other female genital organ
carcinoma in situ of prostate
carcinoma in situ of other and unspecified male genital organs
carcinoma in situ of bladder
carcinoma in situ of other and unspecified urinary organs
neoplasm of uncertain behavior of stomach intestines and rectum
neoplasm of uncertain behavior of liver and biliary passages
neoplasm of uncertain behavior of retroperitoneum and peritoneum
neoplasm of uncertain behavior of other and unspecified digestive organs
neoplasm of uncertain behavior of uterus
neoplasm of uncertain behavior of placenta
neoplasm of uncertain behavior of ovary
CMS Limitations
MRI Abdomen and Pelvis (con’t)
236.3
236.4
236.5
236.6
236.7
236.90
236.91
236.99
237.2
237.3
237.4
237.70
237.71
237.72
238.0
238.1
239.0
239.2
239.4
239.5
239.8
255.0
255.10
255.11
255.12
255.13
255.14
255.2
255.3
255.41
255.42
255.5
255.6
255.8
258.01
258.02
258.03
273.4
277.30
277.31
277.39
289.1
289.2
289.3
289.4
289.50
289.51
289.52
289.59
441.00
neoplasm of uncertain behavior of other and unspecified female genital organs
neoplasm of uncertain behavior of testis
neoplasm of uncertain behavior of prostate
neoplasm of uncertain behavior of other and unspecified male genital organs
neoplasm of uncertain behavior of bladder
neoplasm of uncertain behavior of urinary organ unspecified
neoplasm of uncertain behavior of kidney and ureter
neoplasm of uncertain behavior of other and unspecified urinary organs
neoplasm of uncertain behavior of adrenal gland
neoplasm of uncertain behavior of paraganglia
neoplasm of uncertain behavior of other and unspecified endocrine glands
neurofibromatosis unspecified
neurofibromatosis type 1 von recklinghausen’s disease
neurofibromatosis type 2 acoustic neurofibromatosis
neoplasm of uncertain behavior of bone and articular cartilage
neoplasm of uncertain behavior of connective and other soft tissue
neoplasm of unspecified nature of digestive system
neoplasm of unspecified nature of bone soft tissue and skin
neoplasm of unspecified nature of bladder
neoplasm of unspecified nature of other genitourinary organs
neoplasm of unspecified nature of other specified sites
cushing’s syndrome
hyperaldosteronism, unspecified
glucocorticoid-remediable aldosteronism
conn’s syndrome
bartter’s syndrome
other secondary aldosteronism
adrenogenital disorders
other corticoadrenal overactivity
glucocorticoid deficiency
mineralocorticoid deficiency
other adrenal hypofunction
medulloadrenal hyperfunction
other specified disorders of adrenal glands
multiple endocrine neoplasia [men] type i
multiple endocrine neoplasia [men] type iia
multiple endocrine neoplasia [men] type iib
alpha-1-antitrypsin deficiency
amyloidosis, unspecified
familial mediterranean fever
other amyloidosis
chronic lymphadenitis
nonspecific mesenteric lymphadenitis
lymphadenitis unspecified except mesenteric
hypersplenism
disease of spleen unspecified
chronic congestive splenomegaly
splenic sequestration
other diseases of spleen
dissection of aorta aneurysm unspecified site
CMS Limitations
MRI Abdomen and Pelvis (con’t)
441.01
441.02
441.03
441.1
441.2
441.3
441.4
441.5
441.6
441.7
441.9
442.1
442.83
442.84
443.22
443.23
444.22
444.81
453.0
453.1
453.2
453.3
453.8
453.9
530.0
530.20
530.21
530.3
530.4
530.6
530.7
530.82
530.83
530.84
530.85
530.86
530.87
530.89
536.2
536.3
537.0
537.1
537.2
537.3
537.4
537.6
537.81
537.82
537.83
537.84
dissection of aorta thoracic
dissection of aorta abdominal
dissection of aorta thoracoabdominal
thoracic aneurysm ruptured
thoracic aneurysm without rupture
abdominal aneurysm ruptured
abdominal aneurysm without rupture
aortic aneurysm of unspecified site ruptured
thoracoabdominal aneurysm ruptured
thoracoabdominal aneurysm without rupture
aortic aneurysm of unspecified site without rupture
aneurysm of renal artery
aneurysm of splenic artery
aneurysm of other visceral artery
dissection of iliac artery
dissection of renal artery
arterial embolism and thrombosis of lower extremity
embolism and thrombosis of iliac artery
budd-chiari syndrome
thrombophlebitis migrans
embolism and thrombosis of vena cava
embolism and thrombosis of renal vein
embolism and thrombosis of other specified veins
embolism and thrombosis of unspecified site
achalasia and cardiospasm
ulcer of esophagus without bleeding
ulcer of esophagus with bleeding
stricture and stenosis of esophagus
perforation of esophagus
diverticulum of esophagus acquired
gastroesophageal laceration-hemorrhage syndrome
esophageal hemorrhage
esophageal leukoplakia
tracheoesophageal fistula
barrett’s esophagus
infection of esophagostomy
mechanical complication of esophagostomy
other diseases of esophagus
persistent vomiting
gastroparesis
acquired hypertrophic pyloric stenosis
gastric diverticulum
chronic duodenal ileus
other obstruction of duodenum
fistula of stomach or duodenum
hourglass stricture or stenosis of stomach
pylorospasm
angiodysplasia of stomach and duodenum (without hemorrhage)
angiodysplasia of stomach and duodenum with hemorrhage
dieulafoy lesion (hemorrhagic) of stomach and duodenum
CMS Limitations
MRI Abdomen and Pelvis (con’t)
537.89
550.00
550.01
550.02
550.03
550.10
550.11
550.12
550.13
551.00
551.01
551.02
551.03
551.1
551.20
551.21
551.29
551.3
551.8
551.9
552.00
552.01
552.02
552.03
552.1
552.20
552.21
552.29
552.3
552.8
552.9
553.01
553.02
553.03
553.1
553.20
553.21
553.29
553.3
553.8
553.9
555.0
555.1
555.2
555.9
556.0
556.1
556.2
556.3
556.4
other specified disorders of stomach and duodenum
unilateral or unspecified inguinal hernia with gangrene
recurrent unilateral or unspecified inguinal hernia with gangrene
bilateral inguinal hernia with gangrene
recurrent bilateral inguinal hernia with gangrene
unilateral or unspecified inguinal hernia with obstruction without gangrene
recurrent unilateral or unspecified inguinal hernia with obstruction without gangrene
bilateral inguinal hernia with obstruction without gangrene
recurrent bilateral inguinal hernia with obstruction without gangrene
unilateral or unspecified femoral hernia with gangrene
recurrent unilateral or unspecified femoral hernia with gangrene
bilateral femoral hernia with gangrene
recurrent bilateral femoral hernia with gangrene
umbilical hernia with gangrene
unspecified ventral hernia with gangrene
incisional ventral hernia with gangrene
other ventral hernia with gangrene
diaphragmatic hernia with gangrene
hernia of other specified sites with gangrene
hernia of unspecified site with gangrene
unilateral or unspecified femoral hernia with obstruction
recurrent unilateral or unspecified femoral hernia with obstruction
bilateral femoral hernia with obstruction
recurrent bilateral femoral hernia with obstruction
umbilical hernia with obstruction
unspecified ventral hernia with obstruction
incisional hernia with obstruction
other ventral hernia with obstruction
diaphragmatic hernia with obstruction
hernia of other specified sites with obstruction
hernia of unspecified site with obstruction
recurrent unilateral or unspecified femoral hernia without obstruction or gangrene
bilateral femoral hernia without obstruction or gangrene
recurrent bilateral femoral hernia without obstruction or gangrene
umbilical hernia without obstruction or gangrene
unspecified ventral hernia without obstruction or gangrene
incisional hernia without obstruction or gangrene
other ventral hernia without obstruction or gangrene
diaphragmatic hernia without obstruction or gangrene
hernia of other specified sites without obstruction or gangrene
hernia of unspecified site without obstruction or gangrene
regional enteritis of small intestine
regional enteritis of large intestine
regional enteritis of small intestine with large intestine
regional enteritis of unspecified site
ulcerative (chronic) enterocolitis
ulcerative (chronic) ileocolitis
ulcerative (chronic) proctitis
ulcerative (chronic) proctosigmoiditis
pseudopolyposis of colon
CMS Limitations
MRI Abdomen and Pelvis (con’t)
556.5
556.6
556.8
556.9
557.0
557.1
557.9
558.1
558.2
558.3
558.41
558.42
558.9
560.0
560.1
560.2
560.30
560.31
560.39
560.81
560.89
560.9
562.00
562.01
562.02
562.03
562.10
562.11
562.12
562.13
564.00
564.01
564.09
564.1
564.2
564.3
564.7
564.81
564.89
565.1
566
567.0
567.1
567.21
567.22
567.23
567.29
567.31
567.38
567.39
left-sided ulcerative (chronic) colitis
universal ulcerative (chronic) colitis
other ulcerative colitis
ulcerative colitis unspecified
acute vascular insufficiency of intestine
chronic vascular insufficiency of intestine
unspecified vascular insufficiency of intestine
gastroenteritis and colitis due to radiation
toxic gastroenteritis and colitis
allergic gastroenteritis and colitis
eosinophilic gastroenteritis
eosinophilic colitis
other and unspecified noninfectious gastroenteritis and colitis
intussusception
paralytic ileus
volvulus
impaction of intestine unspecified
gallstone ileus
other impaction of intestine
intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)
other specified intestinal obstruction
unspecified intestinal obstruction
diverticulosis of small intestine (without hemorrhage)
diverticulitis of small intestine (without hemorrhage)
diverticulosis of small intestine with hemorrhage
diverticulitis of small intestine with hemorrhage
diverticulosis of colon (without hemorrhage)
diverticulitis of colon (without hemorrhage)
diverticulosis of colon with hemorrhage
diverticulitis of colon with hemorrhage
unspecified constipation
slow transit constipation
other constipation
irritable bowel syndrome
postgastric surgery syndromes
vomiting following gastrointestinal surgery
megacolon other than hirschsprung’s
neurogenic bowel
other functional disorders of intestine
anal fistula
abscess of anal and rectal regions
peritonitis in infectious diseases classified elsewhere
pneumococcal peritonitis
peritonitis (acute) generalized
peritoneal abscess
spontaneous bacterial peritonitis
other suppurative peritonitis
psoas muscle abscess
other retroperitoneal abscess
other retroperitoneal infections
CMS Limitations
MRI Abdomen and Pelvis (con’t)
567.81
567.82
567.89
567.9
568.0
568.81
568.82
568.89
568.9
569.3
569.42
569.5
569.60
569.61
569.69
569.81
569.82
569.83
569.84
569.85
569.86
569.89
570
571.0
571.1
571.2
571.3
571.40
571.41
571.42
571.49
571.5
571.6
571.8
571.9
572.0
572.1
572.2
572.3
572.4
572.8
573.1
573.2
573.3
573.4
573.8
574.00
574.01
574.10
574.11
choleperitonitis
sclerosing mesenteritis
other specified peritonitis
unspecified peritonitis
peritoneal adhesions (postoperative) (postinfection)
hemoperitoneum (nontraumatic)
peritoneal effusion (chronic)
other specified disorders of peritoneum
unspecified disorder of peritoneum
hemorrhage of rectum and anus
anal or rectal pain
abscess of intestine
colostomy and enterostomy complication unspecified
infection of colostomy or enterostomy
other colostomy and enterostomy complication
fistula of intestine excluding rectum and anus
ulceration of intestine
perforation of intestine
angiodysplasia of intestine (without hemorrhage)
angiodysplasia of intestine with hemorrhage
dieulafoy lesion (hemorrhagic) of intestine
other specified disorders of intestines
acute and subacute necrosis of liver
alcoholic fatty liver
acute alcoholic hepatitis
alcoholic cirrhosis of liver
alcoholic liver damage unspecified
chronic hepatitis unspecified
chronic persistent hepatitis
autoimmune hepatitis
other chronic hepatitis
cirrhosis of liver without alcohol
biliary cirrhosis
other chronic nonalcoholic liver disease
unspecified chronic liver disease without alcohol
abscess of liver
portal pyemia
hepatic coma
portal hypertension
hepatorenal syndrome
other sequelae of chronic liver disease
hepatitis in viral diseases classified elsewhere
hepatitis in other infectious diseases classified elsewhere
hepatitis unspecified
hepatic infarction
other specified disorders of liver
calculus of gallbladder with acute cholecystitis without obstruction
calculus of gallbladder with acute cholecystitis with obstruction
calculus of gallbladder with other cholecystitis without obstruction
calculus of gallbladder with other cholecystitis with obstruction
CMS Limitations
MRI Abdomen and Pelvis (con’t)
574.20
574.21
574.30
574.31
574.40
574.41
574.50
574.51
574.60
574.61
574.70
574.71
574.80
574.81
574.90
574.91
575.0
575.10
575.11
575.12
575.2
575.3
575.4
575.5
575.6
575.8
575.9
576.0
576.1
576.2
576.3
576.4
576.5
576.8
576.9
577.0
577.1
577.2
577.8
577.9
578.0
578.1
578.9
579.0
579.1
579.2
579.3
579.8
583.9
calculus of gallbladder without cholecystitis without obstruction
calculus of gallbladder without cholecystitis with obstruction
calculus of bile duct with acute cholecystitis without obstruction
calculus of bile duct with acute cholecystitis with obstruction
calculus of bile duct with other cholecystitis without obstruction
calculus of bile duct with other cholecystitis with obstruction
calculus of bile duct without cholecystitis without obstruction
calculus of bile duct without cholecystitis with obstruction
calculus of gallbladder and bile duct with acute cholecystitis without obstruction
calculus of gallbladder and bile duct with acute cholecystitis with obstruction
calculus of gallbladder and bile duct with other cholecystitis without obstruction
calculus of gallbladder and bile duct with other cholecystitis with obstruction
calculus of gallbladder and bile duct with acute and chronic cholecystitis without obstruction
calculus of gallbladder and bile duct with acute and chronic cholecystitis with obstruction
calculus of gallbladder and bile duct without cholecystitis without obstruction
calculus of gallbladder and bile duct without cholecystitis with obstruction
acute cholecystitis
cholecystitis unspecified
chronic cholecystitis
acute and chronic cholecystitis
obstruction of gallbladder
hydrops of gallbladder
perforation of gallbladder
fistula of gallbladder
cholesterolosis of gallbladder
other specified disorders of gallbladder
unspecified disorder of gallbladder
postcholecystectomy syndrome
cholangitis
obstruction of bile duct
perforation of bile duct
fistula of bile duct
spasm of sphincter of oddi
other specified disorders of biliary tract
unspecified disorder of biliary tract
acute pancreatitis
chronic pancreatitis
cyst and pseudocyst of pancreas
other specified diseases of pancreas
unspecified disease of pancreas
hematemesis
blood in stool
hemorrhage of gastrointestinal tract unspecified
celiac disease
tropical sprue
blind loop syndrome
other and unspecified postsurgical nonabsorption
other specified intestinal malabsorption
nephritis and nephropathy not specified as acute or chronic with unspecified pathological lesion in
kidney
CMS Limitations
MRI Abdomen and Pelvis (con’t)
590.00
590.01
590.10
590.11
590.2
590.3
590.80
590.81
590.9
591
592.0
592.1
592.9
593.0
593.1
593.2
593.3
593.4
593.5
593.81
593.82
593.89
593.9
596.0
596.1
596.2
596.3
596.4
596.51
596.53
596.54
596.6
596.7
596.8
599.70
599.71
599.72
600.00
600.01
600.10
600.11
600.20
600.21
600.3
600.90
600.91
chronic pyelonephritis without lesion of renal medullary necrosis
chronic pyelonephritis with lesion of renal medullary necrosis
acute pyelonephritis without lesion of renal medullary necrosis
acute pyelonephritis with lesion of renal medullary necrosis
renal and perinephric abscess
pyeloureteritis cystica
pyelonephritis unspecified
pyelitis or pyelonephritis in diseases classified elsewhere
infection of kidney unspecified
hydronephrosis
calculus of kidney
calculus of ureter
urinary calculus unspecified
nephroptosis
hypertrophy of kidney
cyst of kidney acquired
stricture or kinking of ureter
other ureteric obstruction
hydroureter
vascular disorders of kidney
ureteral fistula
other specified disorders of kidney and ureter
unspecified disorder of kidney and ureter
bladder neck obstruction
intestinovesical fistula
vesical fistula not elsewhere classified
diverticulum of bladder
atony of bladder
hypertonicity of bladder
paralysis of bladder
neurogenic bladder nos
rupture of bladder nontraumatic
hemorrhage into bladder wall
other specified disorders of bladder
hematuria, unspecified
gross hematuria
microscopic hematuria
hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract (luts)
hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms
(luts)
nodular prostate without urinary obstruction
nodular prostate with urinary obstruction
benign localized hyperplasia of prostate without urinary obstruction and other lower urinary tract
symptoms (luts)
benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms (luts)
cyst of prostate
hyperplasia of prostate, unspecified, without urinary obstruction and other lower urinary symptoms
(luts)
hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (luts)
CMS Limitations
MRI Abdomen and Pelvis (con’t)
614.0
614.1
614.2
614.3
614.4
614.5
614.6
614.7
614.8
614.9
615.0
615.1
615.9
616.0
616.10
616.11
616.3
616.4
617.0
617.1
617.2
617.3
617.4
617.5
617.6
617.8
618.6
618.7
619.0
619.1
619.2
619.8
619.9
620.4
620.5
620.6
620.7
621.0
621.2
621.30
621.31
621.32
621.33
621.4
621.5
621.6
621.7
625.5
625.9
626.0
acute salpingitis and oophoritis
chronic salpingitis and oophoritis
salpingitis and oophoritis not specified as acute subacute or chronic
acute parametritis and pelvic cellulitis
chronic or unspecified parametritis and pelvic cellulitis
acute or unspecified pelvic peritonitis female
pelvic peritoneal adhesions female (postoperative) (postinfection)
other chronic pelvic peritonitis female
other specified inflammatory disease of female pelvic organs and tissues
unspecified inflammatory disease of female pelvic organs and tissues
acute inflammatory diseases of uterus except cervix
chronic inflammatory diseases of uterus except cervix
unspecified inflammatory disease of uterus
cervicitis and endocervicitis
vaginitis and vulvovaginitis unspecified
vaginitis and vulvovaginitis in diseases classified elsewhere
abscess of bartholin’s gland
other abscess of vulva
endometriosis of uterus
endometriosis of ovary
endometriosis of fallopian tube
endometriosis of pelvic peritoneum
endometriosis of rectovaginal septum and vagina
endometriosis of intestine
endometriosis in scar of skin
endometriosis of other specified sites
vaginal enterocele congenital or acquired
old laceration of muscles of pelvic floor
urinary-genital tract fistula female
digestive-genital tract fistula female
genital tract-skin fistula female
other specified fistulas involving female genital tract
unspecified fistula involving female genital tract
prolapse or hernia of ovary and fallopian tube
torsion of ovary ovarian pedicle or fallopian tube
broad ligament laceration syndrome
hematoma of broad ligament
polyp of corpus uteri
hypertrophy of uterus
endometrial hyperplasia, unspecified
simple endometrial hyperplasia without atypia
complex endometrial hyperplasia without atypia
endometrial hyperplasia with atypia
hematometra
intrauterine synechiae
malposition of uterus
chronic inversion of uterus
pelvic congestion syndrome
unspecified symptom associated with female genital organs
absence of menstruation
CMS Limitations
MRI Abdomen and Pelvis (con’t)
626.1
626.2
626.3
626.4
626.5
626.6
626.8
626.9
627.0
627.1
627.4
627.8
628.2
628.3
629.0
629.1
682.2
711.05
711.25
711.35
711.45
711.55
711.65
711.75
711.85
713.1
713.2
713.5
714.0
716.15
718.05
718.25
718.35
718.45
718.55
718.65
718.75
718.78
718.79
719.05
719.15
719.25
719.45
719.65
719.7
719.85
720.0
724.6
730.05
730.15
scanty or infrequent menstruation
excessive or frequent menstruation
puberty bleeding
irregular menstrual cycle
ovulation bleeding
metrorrhagia
other disorders of menstruation and other abnormal bleeding from female genital tract
unspecified disorders of menstruation and other abnormal bleeding from female genital tract
premenopausal menorrhagia
postmenopausal bleeding
symptomatic states associated with artificial menopause
other specified menopausal and postmenopausal disorders
infertility female of tubal origin
infertility female of uterine origin
hematocele female not elsewhere classified
hydrocele canal of nuck
cellulitis and abscess of trunk
pyogenic arthritis involving pelvic region and thigh
arthropathy in behcet’s syndrome involving pelvic region and thigh
postdysenteric arthropathy involving pelvic region and thigh
arthropathy involving pelvic region and thigh associated with other bacterial diseases
arthropathy involving pelvic region and thigh associated with other viral diseases
arthropathy involving pelvic region and thigh associated with mycoses
arthropathy involving pelvic region and thigh associated with helminthiasis
arthropathy involving pelvic region and thigh associated with other infectious and parasitic diseases
arthropathy associated with gastrointestinal conditions other than infections
arthropathy associated with hematological disorders
arthropathy associated with neurological disorders
rheumatoid arthritis
traumatic arthropathy involving pelvic region and thigh
articular cartilage disorder involving pelvic region and thigh
pathological dislocation of joint of pelvic region and thigh
recurrent dislocation of joint of pelvic region and thigh
contracture of joint of pelvic region and thigh
ankylosis of joint of pelvic region and thigh
unspecified intrapelvic protrusion of acetabulum pelvic region and thigh
developmental dislocation of joint pelvic region and thigh
developmental dislocation of joint other specified site
developmental dislocation of joint multiple sites
effusion of joint of pelvic region and thigh
hemarthrosis involving pelvic region and thigh
villonodular synovitis involving pelvic region and thigh
pain in joint involving pelvic region and thigh
other symptoms referable to joint of pelvic region and thigh
difficulty in walking
other specified disorders of joint of pelvic region and thigh
ankylosing spondylitis
disorders of sacrum
acute osteomyelitis involving pelvic region and thigh
chronic osteomyelitis involving pelvic region and thigh
CMS Limitations
MRI Abdomen and Pelvis (con’t)
730.75
732.1
733.96
733.98
747.61
747.62
751.0
751.1
751.2
751.3
751.4
751.5
751.60
751.61
751.62
751.69
751.7
751.8
751.9
752.0
752.10
752.11
752.19
752.2
752.3
752.40
752.41
752.49
752.51
752.52
752.7
752.89
752.9
753.0
753.10
753.11
753.12
753.13
753.14
753.15
753.16
753.17
753.19
753.20
753.21
753.22
753.23
753.29
753.3
753.4
osteopathy resulting from poliomyelitis involving pelvic region and thigh
juvenile osteochondrosis of hip and pelvis
stress fracture of femoral neck
stress fracture of pelvis
gastrointestinal vessel anomaly
renal vessel anomaly
meckel’s diverticulum
congenital atresia and stenosis of small intestine
congenital atresia and stenosis of large intestine rectum and anal canal
hirschsprung’s disease and other congenital functional disorders of colon
congenital anomalies of intestinal fixation
other congenital anomalies of intestine
unspecified congenital anomaly of gallbladder bile ducts and liver
biliary atresia congenital
congenital cystic disease of liver
other congenital anomalies of gallbladder bile ducts and liver
congenital anomalies of pancreas
other specified congenital anomalies of digestive system
unspecified congenital anomaly of digestive system
congenital anomalies of ovaries
unspecified congenital anomaly of fallopian tubes and broad ligaments
embryonic cyst of fallopian tubes and broad ligaments
other congenital anomalies of fallopian tubes and broad ligaments
doubling of uterus
other congenital anomalies of uterus
unspecified congenital anomaly of cervix vagina and external female genitalia
embryonic cyst of cervix vagina and external female genitalia
other congenital anomalies of cervix vagina and external female genitalia
undescended testis
retractile testis
indeterminate sex and pseudohermaphroditism
other specified anomalies of genital organs
unspecified congenital anomaly of genital organs
renal agenesis and dysgenesis
cystic kidney disease unspecified
congenital single renal cyst
polycystic kidney unspecified type
polycystic kidney autosomal dominant
polycystic kidney autosomal recessive
renal dysplasia
medullary cystic kidney
medullary sponge kidney
other specified cystic kidney disease
unspecified obstructive defect of renal pelvis and ureter
congenital obstruction of ureteropelvic junction
congenital obstruction of ureterovesical junction
congenital ureterocele
other obstructive defect of renal pelvis and ureter
other specified anomalies of kidney
other specified anomalies of ureter
CMS Limitations
MRI Abdomen and Pelvis (con’t)
753.5
753.6
753.7
753.8
753.9
759.0
759.1
759.3
780.61
780.62
780.64
782.4
783.21
783.40
783.41
783.43
785.52
785.59
785.6
787.01
787.03
787.4
787.91
787.99
788.0
788.1
788.20
788.21
788.29
788.30
788.5
788.62
788.8
789.00
789.01
789.02
789.03
789.04
789.05
789.06
789.07
789.09
789.1
789.2
789.30
789.31
789.32
789.33
789.34
789.35
exstrophy of urinary bladder
congenital atresia and stenosis of urethra and bladder neck
congenital anomalies of urachus
other specified congenital anomalies of bladder and urethra
unspecified congenital anomaly of urinary system
anomalies of spleen congenital
anomalies of adrenal gland congenital
situs inversus
fever presenting with conditions classified elsewhere
postprocedural fever
chills (without fever)
jaundice unspecified not of newborn
loss of weight
unspecified lack of normal physiological development
failure to thrive
short stature
septic shock
other shock without trauma
enlargement of lymph nodes
nausea with vomiting
vomiting alone
visible peristalsis
diarrhea
other symptoms involving digestive system
renal colic
dysuria
retention of urine unspecified
incomplete bladder emptying
other specified retention of urine
urinary incontinence unspecified
oliguria and anuria
slowing of urinary stream
extravasation of urine
abdominal pain unspecified site
abdominal pain right upper quadrant
abdominal pain left upper quadrant
abdominal pain right lower quadrant
abdominal pain left lower quadrant
abdominal pain periumbilic
abdominal pain epigastric
abdominal pain generalized
abdominal pain other specified site
hepatomegaly
splenomegaly
abdominal or pelvic swelling mass or lump unspecified site
abdominal or pelvic swelling mass or lump right upper quardant
abdominal or pelvic swelling mass or lump left upper quadrant
abdominal or pelvic swelling mass or lump right lower quadrant
abdominal or pelvic swelling mass or lump left lower quadrant
abdominal or pelvic swelling mass or lump periumbilic
CMS Limitations
MRI Abdomen and Pelvis (con’t)
789.36
789.37
789.39
789.40
789.41
789.42
789.43
789.44
789.45
789.46
789.47
789.49
789.51
789.59
789.60
789.61
789.62
789.63
789.64
789.65
789.66
789.67
789.69
808.0
808.1
808.2
808.3
808.41
808.42
808.43
808.49
808.51
808.52
808.53
808.59
808.8
808.9
862.0
862.1
863.0
863.1
863.20
863.21
863.29
863.30
863.31
863.39
863.40
863.41
863.42
abdominal or pelvic swelling mass or lump epigastric
abdominal or pelvic swelling mass or lump generalized
abdominal or pelvic swelling mass or lump other specified site
abdominal rigidity unspecified site
abdominal rigidity right upper quadrant
abdominal rigidity left upper quadrant
abdominal rigidity right lower quadrant
abdominal rigidity left lower quadrant
abdominal rigidity periumbilic
abdominal rigidity epigastric
abdominal rigidity generalized
abdominal rigidity other specified site
malignant ascites
other ascites
abdominal tenderness unspecified site
abdominal tenderness right upper quadrant
abdominal tenderness left upper quadrant
abdominal tenderness right lower quadrant
abdominal tenderness left lower quadrant
abdominal tenderness periumbilic
abdominal tenderness epigastric
abdominal tenderness generalized
abdominal tenderness other specified site
closed fracture of acetabulum
open fracture of acetabulum
closed fracture of pubis
open fracture of pubis
closed fracture of ilium
closed fracture of ischium
multiple closed pelvic fractures with disruption of pelvic circle
closed fracture of other specified part of pelvis
open fracture of ilium
open fracture of ischium
multiple open pelvic fractures with disruption of pelvic circle
open fracture of other specified part of pelvis
unspecified closed fracture of pelvis
unspecified open fracture of pelvis
injury to diaphragm without open wound into cavity
injury to diaphragm with open wound into cavity
injury to stomach without open wound into cavity
injury to stomach with open wound into cavity
injury to small intestine unspecified site without open wound into cavity
injury to duodenum without open wound into cavity
other injury to small intestine without open wound into cavity
injury to small intestine unspecified site with open wound into cavity
injury to duodenum with open wound into cavity
other injury to small intestine with open wound into cavity
injury to colon unspecified site without open wound into cavity
injury to ascending (right) colon without open wound into cavity
injury to transverse colon without open wound into cavity
CMS Limitations
MRI Abdomen and Pelvis (con’t)
863.43
863.44
863.45
863.46
863.49
863.50
863.51
863.52
863.53
863.54
863.55
863.56
863.59
863.80
863.81
863.82
863.83
863.84
863.85
863.89
863.90
863.91
863.92
863.93
863.94
863.95
863.99
864.00
864.01
864.02
864.03
864.04
864.05
864.09
864.10
864.11
864.12
864.13
864.14
864.15
864.19
865.00
865.01
865.02
865.03
865.04
865.09
865.10
865.11
865.12
injury to descending (left) colon without open wound into cavity
injury to sigmoid colon without open wound into cavity
injury to rectum without open wound into cavity
injury to multiple sites in colon and rectum without open wound into cavity
other injury to colon and rectum without open wound into cavity
injury to colon unspecified site with open wound into cavity
injury to ascending (right) colon with open wound into cavity
injury to transverse colon with open wound into cavity
injury to descending (left) colon with open wound into cavity
injury to sigmoid colon with open wound into cavity
injury to rectum with open wound into cavity
injury to multiple sites in colon and rectum with open wound into cavity
other injury to colon and rectum with open wound into cavity
injury to gastrointestinal tract unspecified site without open wound into cavity
injury to pancreas head without open wound into cavity
injury to pancreas body without open wound into cavity
injury to pancreas tail without open wound into cavity
injury to pancreas multiple and unspecified sites without open wound into cavity
injury to appendix without open wound into cavity
injury to other and unspecified gastrointestinal sites without open wound into cavity
injury to gastrointestinal tract unspecified site with open wound into cavity
injury to pancreas head with open wound into cavity
injury to pancreas body with open wound into cavity
injury to pancreas tail with open wound into cavity
injury to pancreas multiple and unspecified sites with open wound into cavity
injury to appendix with open wound into cavity
injury to other and unspecified gastrointestinal sites with open wound into cavity
unspecified injury to liver without open wound into cavity
hematoma and contusion of liver without open wound into cavity
laceration of liver minor without open wound into cavity
laceration of liver moderate without open wound into cavity
laceration of liver major without open wound into cavity
laceration of liver unspecified without open wound into cavity
other injury to liver without open wound into cavity
unspecified injury to liver with open wound into cavity
hematoma and contusion of liver with open wound into cavity
laceration of liver minor with open wound into cavity
laceration of liver moderate with open wound into cavity
laceration of liver major with open wound into cavity
laceration of liver unspecified with open wound into cavity
other injury to liver with open wound into cavity
unspecified injury to spleen without open wound into cavity
hematoma of spleen without rupture of capsule without open wound into cavity
capsular tears to spleen without major disruption of parenchyma without open wound into cavity
laceration of spleen extending into parenchyma without open wound into cavity
massive parenchymal disruption of spleen without open wound into cavity
other injury into spleen without open wound into cavity
unspecified injury to spleen with open wound into cavity
hematoma of spleen without rupture of capsule with open wound into cavity
capsular tears to spleen without major disruption of parenchyma with open wound into cavity
CMS Limitations
MRI Abdomen and Pelvis (con’t)
865.13
865.14
865.19
866.00
866.01
866.02
866.03
866.10
866.11
866.12
866.13
867.0
867.1
867.2
867.3
867.4
867.5
867.6
867.7
867.8
867.9
868.00
868.01
868.02
868.03
868.04
868.09
868.10
868.11
868.12
868.13
868.14
868.19
869.0
869.1
902.0
902.10
902.11
902.19
902.20
902.21
902.22
902.23
902.24
902.25
902.26
902.27
902.29
902.31
902.32
laceration of spleen extending into parenchyma with open wound into cavity
massive parenchyma disruption of spleen with open wound into cavity
other injury to spleen with open wound into cavity
unspecified injury to kidney without open wound into cavity
hematoma of kidney without rupture of capsule without open wound into cavity
laceration of kidney without open wound into cavity
complete disruption of kidney parenchyma without open wound into cavity
unspecified injury to kidney with open wound into cavity
hematoma of kidney without rupture of capsule with open wound into cavity
laceration of kidney with open wound into cavity
complete disruption of kidney parenchyma with open wound into cavity
injury to bladder and urethra without open wound into cavity
injury to bladder and urethra with open wound into cavity
injury to ureter without open wound into cavity
injury to ureter with open wound into cavity
injury to uterus without open wound into cavity
injury to uterus with open wound into cavity
injury to other specified pelvic organs without open wound into cavity
injury to other specified pelvic organs with open wound into cavity
injury to unspecified pelvic organ without open wound into cavity
injury to unspecified pelvic organ with open wound into cavity
injury to unspecified intra-abdominal organ without open wound into cavity
injury to adrenal gland without open wound into cavity
injury to bile duct and gallbladder without open wound into cavity
injury to peritoneum without open wound into cavity
injury to retroperitoneum without open wound into cavity
injury to other and multiple intra-abdominal organs without open wound into cavity
injury to unspecified intra-abdominal organ with open wound into cavity
injury to adrenal gland with open wound into cavity
injury to bile duct and gallbladder with open wound into cavity
injury to peritoneum with open wound into cavity
injury to retroperitoneum with open wound into cavity
injury to other and multiple intra-abdominal organs with open wound into cavity
internal injury to unspecified or ill-defined organs without open wound into cavity
internal injury to unspecified or ill-defined organs with open wound into cavity
injury to abdominal aorta
injury to inferior vena cava unspecified
injury to hepatic veins
injury to other specified branches of inferior vena cava
injury to celiac and mesenteric arteries unspecified
injury to gastric artery
injury to hepatic artery
injury to splenic artery
injury to other specified branches of celiac axis
injury to superior mesenteric artery (trunk)
injury to primary branches of superior mesenteric artery
injury to inferior mesenteric artery
injury to other celiac and mesenteric arteries
injury to superior mesenteric vein and primary subdivisions
injury to inferior mesenteric vein
CMS Limitations
MRI Abdomen and Pelvis (con’t)
902.33
902.34
902.39
902.40
902.41
902.42
902.49
902.50
902.51
902.52
902.53
902.54
902.55
902.56
902.59
902.82
902.87
902.89
902.9
908.1
908.4
908.5
922.2
922.4
926.0
926.11
926.12
935.1
935.2
936
939.0
939.1
939.2
958.0
958.1
958.2
958.3
958.4
958.5
959.12
959.19
996.1
996.30
996.43
996.44
996.45
996.47
996.49
996.60
996.62
injury to portal vein
injury to splenic vein
injury to other portal and splenic veins
injury to renal vessel(s) unspecified
injury to renal artery
injury to renal vein
injury to other renal blood vessels
injury to iliac vessel(s) unspecified
injury to hypogastric artery
injury to hypogastric vein
injury to iliac artery
injury to iliac vein
injury to uterine artery
injury to uterine vein
injury to other iliac blood vessels
injury to ovarian vein
injury to multiple blood vessels of abdomen and pelvis
injury to other specified blood vessels of abdomen and pelvis
injury to unspecified blood vessel of abdomen and pelvis
late effect of internal injury to intra-abdominal organs
late effect of injury to blood vessel of thorax abdomen and pelvis
late effect of foreign body in orifice
contusion of abdominal wall
contusion of genital organs
crushing injury of external genitalia
crushing injury of back
crushing injury of buttock
foreign body in esophagus
foreign body in stomach
foreign body in intestine and colon
foreign body in bladder and urethra
foreign body in uterus any part
foreign body in vulva and vagina
air embolism as an early complication of trauma
fat embolism as an early complication of trauma
secondary and recurrent hemorrhage as an early complication of trauma
posttraumatic wound infection not elsewhere classified
traumatic shock
traumatic anuria
other injury of abdomen
other and unspecified injury of other sites of trunk
mechanical complication of other vascular device implant and graft
mechanical complication of unspecified genitourinary device implant and graft
prosthetic joint implant failure
peri-prosthetic fracture around prosthetic joint
peri-prosthetic osteolysis
other mechanical complication of prosthetic joint implant
other mechanical complication of other internal orthopedic device, implant, and graft
infection and inflammatory reaction due to unspecified device implant and graft
infection and inflammatory reaction due to other vascular device implant and graft
CMS Limitations
MRI Abdomen and Pelvis (con’t)
996.71
996.74
996.81
996.82
996.86
996.87
997.4
997.5
997.71
997.72
997.79
998.0
998.11
998.12
998.13
998.2
998.31
998.33
998.4
998.51
998.59
998.6
998.7
v10.00
v10.03
v10.04
v10.05
v10.06
v10.07
v10.09
v10.40
v10.41
v10.42
v10.43
v10.44
v10.45
v10.46
v10.47
v10.49
v10.50
v10.51
v10.52
v10.53
v10.59
v67.00
v67.09
v67.1
v67.2
v71.1
other complications due to heart valve prosthesis
other complications due to other vascular device implant and graft
complications of transplanted kidney
complications of transplanted liver
complications of transplanted pancreas
complications of transplanted organ intestine
digestive system complications not elsewhere classified
urinary complications not elsewhere classified
vascular complications of mesenteric artery
vascular complications of renal artery
vascular complications of other vessels
postoperative shock not elsewhere classified
hemorrhage complicating a procedure
hematoma complicating a procedure
seroma complicating a procedure
accidental puncture or laceration during a procedure not elsewhere classified
disruption of internal operation (surgical) wound
disruption of traumatic injury wound repair
foreign body accidentally left during a procedure not elsewhere classified
infected postoperative seroma
other postoperative infection
persistent postoperative fistula not elsewhere classified
acute reaction to foreign substance accidentally left during a procedure not elsewhere classified
personal history of malignant neoplasm of unspecified site in gastrointestinal tract
personal history of malignant neoplasm of esophagus
personal history of malignant neoplasm of stomach
personal history of malignant neoplasm of large intestine
personal history of malignant neoplasm of rectum rectosigmoid junction and anus
personal history of malignant neoplasm of liver
personal history of malignant neoplasm of other sites in gastrointestinal tract
personal history of malignant neoplasm of unspecified female genital organ
personal history of malignant neoplasm of cervix uteri
personal history of malignant neoplasm of other parts of uterus
personal history of malignant neoplasm of ovary
personal history of malignant neoplasm of other female genital organs
personal history of malignant neoplasm of unspecified male genital organ
personal history of malignant neoplasm of prostate
personal history of malignant neoplasm of testis
personal history of malignant neoplasm of other male genital organs
personal history of malignant neoplasm of unspecified urinary organ
personal history of malignant neoplasm of bladder
personal history of malignant neoplasm of kidney
personal history of malignant neoplasm of renal pelvis
personal history of malignant neoplasm of other urinary organs
follow-up examination following unspecified surgery
follow-up examination following other surgery
follow-up examination following radiotherapy
follow-up examination following chemotherapy
observation for suspected malignant neoplasm
CMS Limitations
MRI Breast
LCD # L28723, Effective Date: 03/25/2009
CPT/HCPCS Codes: CPT 77058, CPT 77059, HCPCS C8903, HCPCS C8904, HCPCS C8905, HCPCS C8906, HCPCS
C8907, HCPCS C8908, CPT 76376*, CPT 76377*
ICD-9 codes that SUPPORT medical necessity for magnetic resonance imaging, breast, without and/or with contrast
material(s); unilateral (CPT 77058); magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral (CPT 77059); magnetic resonance imaging with contrast, breast; unilateral (HCPCS C8903); magnetic resonance
imaging without contrast, breast; unilateral (HCPCS C8904); magnetic resonance imaging without contrast followed by
with contrast, breast; unilateral (HCPCS C8905); magnetic resonance imaging with contrast, breast; bilateral (HCPCS
C8906); magnetic resonance imaging without contrast, breast; bilateral (HCPCS C8907); magnetic resonance imaging without contrast followed by with contrast, breast; bilateral (HCPCS C8908); 3D rendering with interpretation and
reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation (CPT 76376*); and 3D rendering with interpretation and
reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring
image postprocessing on an independent workstation (CPT 76377*):
*Note: For the purposes of this LCD, CPT code 76376 or 76377 is allowed only when billed in conjunction with another
MRI procedure code.
174.0
174.1
174.2
174.3
174.4
174.5
174.6
174.8
174.9
175.0
175.9
196.3
198.81
217
233.0
238.3
239.3
610.0
610.1
610.2
610.3
610.4
610.8
610.9
611.0
611.1
611.2
611.3
611.4
611.5
malignant neoplasm of nipple and areola of female breast
malignant neoplasm of central portion of female breast
malignant neoplasm of upper-inner quadrant of female breast
malignant neoplasm of lower-inner quadrant of female breast
malignant neoplasm of upper-outer quadrant of female breast
malignant neoplasm of lower-outer quadrant of female breast
malignant neoplasm of axillary tail of female breast
malignant neoplasm of other specified sites of female breast
malignant neoplasm of breast (female) unspecified site
malignant neoplasm of nipple and areola of male breast
malignant neoplasm of other and unspecified sites of male breast
secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb
secondary malignant neoplasm of breast
benign neoplasm of breast
carcinoma in situ of breast
neoplasm of uncertain behavior of breast
neoplasm of unspecified nature of breast
solitary cyst of breast
diffuse cystic mastopathy
fibroadenosis of breast
fibrosclerosis of breast
mammary duct ectasia
other specified benign mammary dysplasias
benign mammary dysplasia unspecified
inflammatory disease of breast
hypertrophy of breast
fissure of nipple
fat necrosis of breast
atrophy of breast
galactocele
CMS Limitations
MRI Breast (con’t)
611.6
611.71
611.72
611.79
611.83
611.89
612.0
793.80
793.81
793.89
996.54
996.69
v10.3
v67.00
v67.09
v67.1
v67.2
v71.1
galactorrhea not associated with childbirth
mastodynia
lump or mass in breast
other signs and symptoms in breast
capsular contracture of breast implant
other specified disorders of breast
deformity of reconstructed breast
unspecified abnormal mammogram
mammographic microcalcification
other abnormal findings on radiological examination of breast
mechanical complication of breast prosthesis
infection and inflammatory reaction due to other internal prosthetic device implant and graft
personal history of malignant neoplasm of breast
follow-up examination following unspecified surgery
follow-up examination following other surgery
follow-up examination following radiotherapy
follow-up examination following chemotherapy
observation for suspected malignant neoplasm
CMS Limitations
MRI Cervical Spine
LCD # L28723, Effective Date: 3/25/09
CPT codes: CPT 72141, CPT 72142, CPT 72156, CPT 76376, CPT 76377
ICD-9 codes that SUPPORT medical necessity for magnetic resonance (eg, proton) imaging, spinal canal and contents,
cervical; without contrast material (CPT 72141); magnetic resonance (eg, proton) imaging, spinal canal and contents,
cervical; with contrast material(s) (CPT 72142); magnetic resonance (eg, proton) imaging, spinal canal and contents,
without contrast material, followed by contrast material(s) and further sequences; thoracic (CPT 72157); 3D rendering
with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation (CPT 76376); and 3D rendering
with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation (CPT 76377):
170.2
172.4
185
191.0
191.1
191.2
191.3
191.4
191.5
191.6
191.7
191.8
191.9
192.0
192.1
192.2
192.3
192.8
192.9
193
194.1
194.3
194.4
194.5
194.6
195.0
196.0
198.3
198.4
198.5
199.0
199.2
203.00
203.01
203.02
209.30
213.2
malignant neoplasm of vertebral column excluding sacrum and coccyx
malignant melanoma of skin of scalp and neck
malignant neoplasm of prostate
malignant neoplasm of cerebrum except lobes and ventricles
malignant neoplasm of frontal lobe
malignant neoplasm of temporal lobe
malignant neoplasm of parietal lobe
malignant neoplasm of occipital lobe
malignant neoplasm of ventricles
malignant neoplasm of cerebellum nos
malignant neoplasm of brain stem
malignant neoplasm of other parts of brain
malignant neoplasm of brain unspecified site
malignant neoplasm of cranial nerves
malignant neoplasm of cerebral meninges
malignant neoplasm of spinal cord
malignant neoplasm of spinal meninges
malignant neoplasm of other specified sites of nervous system
malignant neoplasm of nervous system part unspecified
malignant neoplasm of thyroid gland
malignant neoplasm of parathyroid gland
malignant neoplasm of pituitary gland and craniopharyngeal duct
malignant neoplasm of pineal gland
malignant neoplasm of carotid body
malignant neoplasm of aortic body and other paraganglia
malignant neoplasm of head face and neck
secondary and unspecified malignant neoplasm of lymph nodes of head face and neck
secondary malignant neoplasm of brain and spinal cord
secondary malignant neoplasm of other parts of nervous system
secondary malignant neoplasm of bone and bone marrow
disseminated malignant neoplasm
malignant neoplasm associated with transplant organ
multiple myeloma, without mention of having achieved remission
multiple myeloma in remission
multiple myeloma, in relapse
malignant poorly differentiated neuroendocrine carcinoma, any site
benign neoplasm of vertebral column excluding sacrum and coccyx
CMS Limitations
MRI Cervical Spine (con’t)
225.3
225.4
228.1
237.5
322.0
322.1
322.2
322.9
324.1
336.0
336.1
340
344.00
344.01
344.02
344.03
344.04
344.09
344.2
344.40
344.41
344.42
344.5
349.31
349.39
353.2
718.78
718.79
720.9
721.0
721.1
721.90
721.91
722.0
722.4
722.6
722.71
722.81
722.91
723.0
723.1
723.2
723.4
730.08
730.18
730.19
730.28
730.38
733.00
733.01
benign neoplasm of spinal cord
benign neoplasm of spinal meninges
lymphangioma any site
neoplasm of uncertain behavior of brain and spinal cord
nonpyogenic meningitis
eosinophilic meningitis
chronic meningitis
meningitis unspecified
intraspinal abscess
syringomyelia and syringobulbia
vascular myelopathies
multiple sclerosis
quadriplegia unspecified
quadriplegia c1-c4 complete
quadriplegia c1-c4 incomplete
quadriplegia c5-c7 complete
quadriplegia c5-c7 incomplete
other quadriplegia
diplegia of upper limbs
monoplegia of upper limb affecting unspecified side
monoplegia of upper limb affecting dominant side
monoplegia of upper limb affecting nondominant sde
unspecified monoplegia
accidental puncture or laceration of dura during a procedure
other dural tear
cervical root lesions not elsewhere classified
developmental dislocation of joint other specified site
developmental dislocation of joint multiple sites
unspecified inflammatory spondylopathy
cervical spondylosis without myelopathy
cervical spondylosis with myelopathy
spondylosis of unspecified site without myelopathy
spondylosis of unspecified site with myelopathy
displacement of cervical intervertebral disc without myelopathy
degeneration of cervical intervertebral disc
degeneration of intervertebral disc site unspecified
intervertebral disc disorder with myelopathy cervical region
postlaminectomy syndrome of cervical region
other and unspecified disc disorder of cervical region
spinal stenosis in cervical region
cervicalgia
cervicocranial syndrome
brachial neuritis or radiculitis nos
acute osteomyelitis involving other specified sites
chronic osteomyelitis involving other specified sites
chronic osteomyelitis involving multiple sites
unspecified osteomyelitis involving other specified sites
periostitis without osteomyelitis involving other specified sites
osteoporosis unspecified
senile osteoporosis
CMS Limitations
MRI Cervical Spine (con’t)
733.02
733.03
733.13
733.40
733.45
737.40
737.41
737.42
737.43
756.10
756.12
756.13
756.14
756.15
756.16
793.7
805.00
805.01
805.02
805.03
805.04
805.05
805.06
805.07
805.08
805.10
805.11
805.12
805.13
805.14
805.15
805.16
805.17
805.18
806.00
806.01
806.02
806.03
806.04
806.05
806.06
806.07
806.08
806.09
806.10
806.11
806.12
806.13
806.14
806.15
idiopathic osteoporosis
disuse osteoporosis
pathological fracture of vertebrae
aseptic necrosis of bone site unspecified
aseptic necrosis of bone, jaw
unspecified curvature of spine associated with other conditions
kyphosis associated with other conditions
lordosis associated with other conditions
scoliosis associated with other conditions
congenital anomaly of spine unspecified
spondylolisthesis congenital
absence of vertebra congenital
hemivertebra
fusion of spine (vertebra) congenital
klippel-feil syndrome
nonspecific abnormal findings on radiological and other examination of musculoskeletal system
closed fracture of cervical vertebra unspecified level
closed fracture of first cervical vertebra
closed fracture of second cervical vertebra
closed fracture of third cervical vertebra
closed fracture of fourth cervical vertebra
closed fracture of fifth cervical vertebra
closed fracture of sixth cervical vertebra
closed fracture of seventh cervical vertebra
closed fracture of multiple cervical vertebrae
open fracture of cervical vertebra unspecified level
open fracture of first cervical vertebra
open fracture of second cervical vertebra
open fracture of third cervical vertebra
open fracture of fourth cervical vertebra
open fracture of fifth cervical vertebra
open fracture of sixth cervical vertebra
open fracture of seventh cervical vertebra
open fracture of multiple cervical vertebrae
closed fracture of c1-c4 level with unspecified spinal cord injury
closed fracture of c1-c4 level with complete lesion of cord
closed fracture of c1-c4 level with anterior cord syndrome
closed fracture of c1-c4 level with central cord syndrome
closed fracture of c1-c4 level with other specified spinal cord injury
closed fracture of c5-c7 level with unspecified spinal cord injury
closed fracture of c5-c7 level with complete lesion of cord
closed fracture of c5-c7 level with anterior cord syndrome
closed fracture of c5-c7 level with central cord syndrome
closed fracture of c5-c7 level with other specified spinal cord injury
open fracture of c1-c4 level with unspecified spinal cord injury
open fracture of c1-c4 level with complete lesion of cord
open fracture of c1-c4 level with anterior cord syndrome
open fracture of c1-c4 level with central cord syndrome
open fracture of c1-c4 level with other specified spinal cord injury
open fracture of c5-c7 level with unspecified spinal cord injury
CMS Limitations
MRI Cervical Spine (con’t)
806.16
806.17
806.18
806.19
839.00
839.01
839.02
839.03
839.04
839.05
839.06
839.07
839.08
839.10
839.11
839.12
839.13
839.14
839.15
839.16
839.17
839.18
952.00
952.01
952.02
952.03
952.04
952.05
952.06
952.07
952.08
952.09
952.8
953.0
v10.01
v10.02
v10.21
v10.22
v10.81
v10.86
v67.00
v67.09
v67.1
v67.2
v71.1
open fracture of c5-c7 level with complete lesion of cord
open fracture of c5-c7 level with anterior cord syndrome
open fracture of c5-c7 level with central cord syndrome
open fracture of c5-c7 level with other specified spinal cord injury
closed dislocation cervical vertebra unspecified
closed dislocation first cervical vertebra
closed dislocation second cervical vertebra
closed dislocation third cervical vertebra
closed dislocation fourth cervical vertebra
closed dislocation fifth cervical vertebra
closed dislocation sixth cervical vertebra
closed dislocation seventh cervical vertebra
closed dislocation multiple cervical vertebrae
open dislocation cervical vertebra unspecified
open dislocation first cervical vertebra
open dislocation second cervical vertebra
open dislocation third cervical vertebra
open dislocation fourth cervical vertebra
open dislocation fifth cervical vertebra
open dislocation sixth cervical vertebra
open dislocation seventh cervical vertebra
open dislocation multiple cervical vertebrae
c1-c4 level spinal cord injury unspecified
c1-c4 level with complete lesion of spinal cord
c1-c4 level with anterior cord syndrome
c1-c4 level with central cord syndrome
c1-c4 level with other specified spinal cord injury
c5-c7 level spinal cord injury unspecified
c5-c7 level with complete lesion of spinal cord
c5-c7 level with anterior cord syndrome
c5-c7 level with central cord syndrome
c5-c7 level with other specified spinal cord injury
multiple sites of spinal cord injury without spinal bone injury
injury to cervical nerve root
personal history of malignant neoplasm of tongue
personal history of malignant neoplasm of other and unspecified parts of oral cavity and pharynx
personal history of malignant neoplasm of larynx
personal history of malignant neoplasm of nasal cavities middle ear and accessory sinuses
personal history of malignant neoplasm of bone
personal history of malignant neoplasm of other parts of nervous system
follow-up examination following unspecified surgery
follow-up examination following other surgery
follow-up examination following radiotherapy
follow-up examination following chemotherapy
observation for suspected malignant neoplasm
CMS Limitations
MRI Chest
LCD # L28723, Effective Date: 03/25/2009
CPT codes: CPT 71550, CPT 71551, CPT 71552, CPT 76376, CPT 76377
ICD-9 codes that SUPPORT medical necessity for magnetic resonance (eg, proton) imaging, chest (eg, for evaluation
of hilar and mediastinal lymphadenopathy); without contrast material(s) (CPT 71550); magnetic resonance (eg, proton)
imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s) (CPT 71551);
magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without
contrast material(s), followed by contrast material(s) and further sequences (CPT 71552); 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality;
not requiring image postprocessing on an independent workstation (CPT 76376); and 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality;
requiring image postprocessing on an independent workstation (CPT 76377):
150.0 - 150.9 151.0 - 151.9 158.0
162.0 - 162.9 163.0 - 163.9 164.0 - 164.9 165.0 - 165.9 malignant neoplasm of cervical esophagus - malignant neoplasm of esophagus unspecified site
malignant neoplasm of cardia - malignant neoplasm of stomach unspecified site
malignant neoplasm of retroperitoneum
malignant neoplasm of trachea - malignant neoplasm of bronchus and lung unspecified
malignant neoplasm of parietal pleura - malignant neoplasm of pleura unspecified
malignant neoplasm of thymus - malignant neoplasm of mediastinum part unspecified
malignant neoplasm of upper respiratory tract part unspecified - malignant neoplasm of ill-defined
sites within the respiratory system
170.2
malignant neoplasm of vertebral column excluding sacrum and coccyx
170.3
malignant neoplasm of ribs sternum and clavicle
171.4
malignant neoplasm of connective and other soft tissue of thorax
171.8
malignant neoplasm of other specified sites of connective and other soft tissue
172.0
malignant melanoma of skin of lip
172.5
malignant melanoma of skin of trunk except scrotum
172.8
malignant melanoma of other specified sites of skin
172.9
melanoma of skin site unspecified
173.5
other malignant neoplasm of skin of trunk except scrotum
174.0 - 174.9 malignant neoplasm of nipple and areola of female breast - malignant neoplasm of breast (female)
unspecified site
175.0
malignant neoplasm of nipple and areola of male breast
175.9
malignant neoplasm of other and unspecified sites of male breast
176.0
kaposi’s sarcoma skin
176.1
kaposi’s sarcoma soft tissue
176.3 - 176.8 kaposi’s sarcoma gastrointestinal sites - kaposi’s sarcoma other specified sites
193
malignant neoplasm of thyroid gland
194.1
malignant neoplasm of parathyroid gland
194.8
malignant neoplasm of other endocrine glands and related structures
195.0
malignant neoplasm of head face and neck
195.1
malignant neoplasm of thorax
196.0 - 196.9* secondary and unspecified malignant neoplasm of lymph nodes of head face and neck - secondary
and unspecified malignant neoplasm of lymph nodes site unspecified
197.0 - 197.8 secondary malignant neoplasm of lung - secondary malignant neoplasm of other digestive organs and
spleen
198.0 - 198.89* secondary malignant neoplasm of kidney - secondary malignant neoplasm of other specified sites
199.0
disseminated malignant neoplasm
199.1
other malignant neoplasm of unspecified site
CMS Limitations
MRI Chest (con’t)
199.2
malignant neoplasm associated with transplant organ
200.00-208.92 reticulosarcoma unspecified site - unspecified leukemia, in relapse
211.0
benign neoplasm of esophagus
211.1
benign neoplasm of stomach
212.2 - 212.9 benign neoplasm of trachea - benign neoplasm of respiratory and intrathoracic organs site unspecified
213.3
benign neoplasm of ribs sternum and clavicle
213.4
benign neoplasm of scapula and long bones of upper limb
213.9
benign neoplasm of bone and articular cartilage site unspecified
214.1
lipoma of other skin and subcutaneous tissue
214.2
lipoma of intrathoracic organs
215.0
other benign neoplasm of connective and other soft tissue of head face and neck
215.4
other benign neoplasm of connective and other soft tissue of thorax
215.7
other benign neoplasm of connective and other soft tissue of trunk unspecified
216.5
benign neoplasm of skin of trunk except scrotum
216.8
benign neoplasm of other specified sites of skin
217
benign neoplasm of breast
226
benign neoplasm of thyroid glands
227.1
benign neoplasm of parathyroid gland
227.6
benign neoplasm of aortic body and other paraganglia
227.8
benign neoplasm of other endocrine glands and related structures
228.00
hemangioma of unspecified site
228.01
hemangioma of skin and subcutaneous tissue
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
230.1
carcinoma in situ of esophagus
230.2
carcinoma in situ of stomach
231.1 - 231.9 carcinoma in situ of trachea - carcinoma in situ of respiratory system part unspecified
232.5
carcinoma in situ of skin of trunk except scrotum
232.8
carcinoma in situ of other specified sites of skin
233.0
carcinoma in situ of breast
235.7 - 235.9 neoplasm of uncertain behavior of trachea bronchus and lung - neoplasm of uncertain behavior of
other and unspecified respiratory organs
237.3
neoplasm of uncertain behavior of paraganglia
237.70
neurofibromatosis unspecified
237.71
neurofibromatosis type 1 von recklinghausen’s disease
238.0 - 238.3 neoplasm of uncertain behavior of bone and articular cartilage - neoplasm of uncertain behavior of
breast
238.5 - 238.8 neoplasm of uncertain behavior of histiocytic and mast cells - neoplasm of uncertain behavior of other
specified sites
239.0 - 239.3 neoplasm of unspecified nature of digestive system - neoplasm of unspecified nature of breast
240.0
goiter specified as simple
240.9
goiter unspecified
241.0 - 241.9 nontoxic uninodular goiter - unspecified nontoxic nodular goiter
242.00 - 243 toxic diffuse goiter without thyrotoxic crisis or storm - congenital hypothyroidism
244.0 - 244.9 postsurgical hypothyroidism - unspecified acquired hypothyroidism
245.0 - 245.9 acute thyroiditis - thyroiditis unspecified
246.0 - 246.9 disorders of thyrocalcitonin secretion - unspecified disorder of thyroid
254.0 - 254.9 persistent hyperplasia of thymus - unspecified disease of thymus gland
CMS Limitations
MRI Chest (con’t)
353.0
brachial plexus lesions
353.3
thoracic root lesions not elsewhere classified
353.8
other nerve root and plexus disorders
391.0 - 391.9 acute rheumatic pericarditis - acute rheumatic heart disease unspecified
398.0
rheumatic myocarditis
414.06
coronary atherosclerosis of native coronary artery of transplanted heart
414.07
coronary atherosclerosis of bypass graft (artery) (vein) of transplanted heart
414.10 - 414.19 aneurysm of heart (wall) - other aneurysm of heart
415.11
iatrogenic pulmonary embolism and infarction
415.12
septic pulmonary embolism
415.19
other pulmonary embolism and infarction
417.0 - 417.9 arteriovenous fistula of pulmonary vessels - unspecified disease of pulmonary circulation
420.0
acute pericarditis in diseases classified elsewhere
420.90-420.99 acute pericarditis unspecified - other acute pericarditis
422.0
acute myocarditis in diseases classified elsewhere
422.90 - 422.99 acute myocarditis unspecified - other acute myocarditis
423.0 - 423.9 hemopericardium - unspecified disease of pericardium
425.0 - 425.9 endomyocardial fibrosis - secondary cardiomyopathy unspecified
440.0
atherosclerosis of aorta
441.00 - 441.9 dissection of aorta aneurysm unspecified site - aortic aneurysm of unspecified site without rupture
442.82
aneurysm of subclavian artery
444.1
embolism and thrombosis of thoracic aorta
446.7
takayasu’s disease
447.0
arteriovenous fistula acquired
447.2
rupture of artery
453.2
embolism and thrombosis of vena cava
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
459.0
hemorrhage unspecified
459.2
compression of vein
492.0
emphysematous bleb
492.8
other emphysema
494.0
bronchiectasis without acute exacerbation
494.1
bronchiectasis with acute exacerbation
508.0 - 508.9 acute pulmonary manifestations due to radiation - respiratory conditions due to unspecified external
agent
510.0
empyema with fistula
510.9
empyema without fistula
511.0 - 511.9 pleurisy without effusion or current tuberculosis - unspecified pleural effusion
512.0 - 512.8 spontaneous tension pneumothorax - other spontaneous pneumothorax
513.0 - 515 abscess of lung - postinflammatory pulmonary fibrosis
518.0 - 518.89 pulmonary collapse - other diseases of lung not elsewhere classified
519.00 - 519.9 tracheostomy complication unspecified - unspecified disease of respiratory system
530.0 - 530.82 achalasia and cardiospasm - esophageal hemorrhage
530.84
tracheoesophageal fistula
530.85 - 530.87 barrett’s esophagus - mechanical complication of esophagostomy
551.20 - 551.8 unspecified ventral hernia with gangrene - hernia of other specified sites with gangrene
552.3
diaphragmatic hernia with obstruction
CMS Limitations
MRI Chest (con’t)
553.3
683
745.0 - 745.9 746.00 - 746.9 747.0 - 747.5 748.3 - 748.9 diaphragmatic hernia without obstruction or gangrene
acute lymphadenitis
common truncus - unspecified defect of septal closure
congenital pulmonary valve anomaly unspecified - unspecified congenital anomaly of heart
patent ductus arteriosus - absence or hypoplasia of umbilical artery
other congenital anomalies of larynx trachea and bronchus - unspecified congenital anomaly of respiratory system
750.3
congenital tracheoesophageal fistula esophageal atresia and stenosis
750.4
other specified congenital anomalies of esophagus
750.6
congenital hiatus hernia
750.8
other specified congenital anomalies of upper alimentary tract
756.2
cervical rib
756.3
other congenital anomalies of ribs and sternum
756.6
congenital anomalies of diaphragm
780.2
syncope and collapse
780.60 - 780.65 fever, unspecified - hypothermia not associated with low environmental temperature
785.50 - 785.6 shock unspecified - enlargement of lymph nodes
786.00
respiratory abnormality unspecified
786.05
shortness of breath
786.1 - 786.3 stridor - hemoptysis
786.50 - 786.6 unspecified chest pain - swelling mass or lump in chest
793.1
nonspecific abnormal findings on radiological and other examination of lung field
793.2
nonspecific abnormal findings on radiological and other examination of other intrathoracic organs
793.80 - 793.89 unspecified abnormal mammogram - other abnormal findings on radiological examination of breast
794.2
nonspecific abnormal results of function study of pulmonary system
794.30
unspecified abnormal function study of cardiovascular system
794.31
nonspecific abnormal electrocardiogram (ecg) (ekg)
794.39
other nonspecific abnormal function study of cardiovascular system
794.5
nonspecific abnormal results of function study of thyroid
860.0 - 860.5 traumatic pneumothorax without open wound into thorax - traumatic pneumohemothorax with open
wound into thorax
861.00 - 861.32 unspecified injury of heart without open wound into thorax - laceration of lung with open wound into
thorax
862.0 - 862.9 injury to diaphragm without open wound into cavity - injury to multiple and unspecified intrathoracic
organs with open wound into cavity
875.0
open wound of chest (wall) without complication
875.1
open wound of chest (wall) complicated
901.0 - 901.89 injury to thoracic aorta - injury to other specified blood vessels of thorax
906.0
late effect of open wound of head neck and trunk
908.0
late effect of internal injury to chest
908.4
late effect of injury to blood vessel of thorax abdomen and pelvis
922.0
contusion of breast
922.1
contusion of chest wall
926.8
crushing injury of multiple sites of trunk
934.0 - 934.9 foreign body in trachea - foreign body in respiratory tree unspecified
935.0 - 935.2 foreign body in mouth - foreign body in stomach
958.0 - 958.4 air embolism as an early complication of trauma - traumatic shock
959.11
other injury of chest wall
959.19
other and unspecified injury of other sites of trunk
CMS Limitations
MRI Chest (con’t)
995.90 - 995.94 systemic inflammatory response syndrome unspecified - systemic inflammatory response syndrome
due to noninfectious process with acute organ dysfunction
996.00 - 996.1 mechanical complications of unspecified cardiac device implant and graft - mechanical complication
of other vascular device implant and graft
996.54
mechanical complication of breast prosthesis
996.60 - 996.62 infection and inflammatory reaction due to unspecified device implant and graft - infection and inflammatory reaction due to other vascular device implant and graft
996.69
infection and inflammatory reaction due to other internal prosthetic device implant and graft
996.70 - 996.72 other complications due to unspecified device implant and graft - other complications due to other
cardiac device implant and graft
996.83
complications of transplanted heart
996.84
complications of transplanted lung
997.1
cardiac complications not elsewhere classified
997.31
ventilator associated pneumonia
997.39
other respiratory complications
998.0
postoperative shock not elsewhere classified
998.11 - 998.6 hemorrhage complicating a procedure - persistent postoperative fistula not elsewhere classified
v10.00 - v10.09 personal history of malignant neoplasm of unspecified site in gastrointestinal tract - personal history of
malignant neoplasm of other sites in gastrointestinal tract
v10.11
personal history of malignant neoplasm of bronchus and lung
v10.12
personal history of malignant neoplasm of trachea
v10.20 - v10.29 personal history of malignant neoplasm of unspecified respiratory organ - personal history of malignant neoplasm of other respiratory and intrathoracic organs
v10.3
personal history of malignant neoplasm of breast
v10.40 - v10.49 personal history of malignant neoplasm of unspecified female genital organ - personal history of malignant neoplasm of other male genital organs
v10.50 - v10.59 personal history of malignant neoplasm of unspecified urinary organ - personal history of malignant
neoplasm of other urinary organs
v10.60 - v10.69 personal history of unspecified leukemia - personal history of other leukemia
v10.71 - v10.79 personal history of lymphosarcoma and reticulosarcoma - personal history of other lymphatic and
hematopoietic neoplasms
v10.81 - v10.89 personal history of malignant neoplasm of bone - personal history of malignant neoplasm of other
sites
v10.9
unspecified personal history of malignant neoplasm
v67.00*
follow-up examination following unspecified surgery
v67.09*
follow-up examination following other surgery
v67.1*
follow-up examination following radiotherapy
v67.2*
follow-up examination following chemotherapy
v71.1*
observation for suspected malignant neoplasm
* non-specific and require an additional ICD-9 code for payment.
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw
LCD # L28723, Effective Date: 03/25/2009
CPT/HCPCS Codes: CPT 70336, CPT 70540, CPT 70542, CPT 70543, CPT 70551, CPT 70552, CPT 70553, CPT 76376,
CPT 76377
ICD-9 codes that SUPPORT medical necessity for magnetic resonance (eg, proton) imaging, temporomandibular
joint(s) (CPT 70336); magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s)
(CPT 70540); magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s) (CPT 70542);
magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast
material(s) and further sequences (CPT 70543); magnetic resonance (eg, proton) imaging, brain (including brain stem);
without contrast material (CPT 70551); magnetic resonance (eg, proton) imaging, brain (including brain stem); with
contrast material(s) (CPT 70552); magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences (CPT 70553); 3D rendering with interpretation
and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not
requiring image postprocessing on an independent workstation (CPT 76376); and 3D rendering with interpretation and
reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring
image postprocessing on an independent workstation (CPT 76377):
140.0
140.1
140.3
140.4
140.5
140.6
140.8
140.9
141.0
141.1
141.2
141.3
141.4
141.5
141.6
141.8
141.9
142.0
142.1
142.2
142.8
142.9
143.0
143.1
143.8
143.9
144.0
144.1
144.8
144.9
145.0
145.1
malignant neoplasm of upper lip vermilion border
malignant neoplasm of lower lip vermilion border
malignant neoplasm of upper lip inner aspect
malignant neoplasm of lower lip inner aspect
malignant neoplasm of lip unspecified inner aspect
malignant neoplasm of commissure of lip
malignant neoplasm of other sites of lip
malignant neoplasm of lip unspecified vermilion border
malignant neoplasm of base of tongue
malignant neoplasm of dorsal surface of tongue
malignant neoplasm of tip and lateral border of tongue
malignant neoplasm of ventral surface of tongue
malignant neoplasm of anterior two-thirds of tongue part unspecified
malignant neoplasm of junctional zone of tongue
malignant neoplasm of lingual tonsil
malignant neoplasm of other sites of tongue
malignant neoplasm of tongue unspecified
malignant neoplasm of parotid gland
malignant neoplasm of submandibular gland
malignant neoplasm of sublingual gland
malignant neoplasm of other major salivary glands
malignant neoplasm of salivary gland unspecified
malignant neoplasm of upper gum
malignant neoplasm of lower gum
malignant neoplasm of other sites of gum
malignant neoplasm of gum unspecified
malignant neoplasm of anterior portion of floor of mouth
malignant neoplasm of lateral portion of floor of mouth
malignant neoplasm of other sites of floor of mouth
malignant neoplasm of floor of mouth part unspecified
malignant neoplasm of cheek mucosa
malignant neoplasm of vestibule of mouth
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
145.2
145.3
145.4
145.5
145.6
145.8
145.9
146.0
146.1
146.2
146.3
146.4
146.5
146.6
146.7
146.8
146.9
147.0
147.1
147.2
147.3
147.8
147.9
148.0
148.1
148.2
148.3
148.8
148.9
149.0
149.1
149.8
149.9
150.0
150.1
150.3
150.8
159.0
160.0
160.1
160.2
160.3
160.4
160.5
160.8
160.9
161.0
161.1
161.2
161.3
malignant neoplasm of hard palate
malignant neoplasm of soft palate
malignant neoplasm of uvula
malignant neoplasm of palate unspecified
malignant neoplasm of retromolar area
malignant neoplasm of other specified parts of mouth
malignant neoplasm of mouth unspecified
malignant neoplasm of tonsil
malignant neoplasm of tonsillar fossa
malignant neoplasm of tonsillar pillars (anterior) (posterior)
malignant neoplasm of vallecula epiglottica
malignant neoplasm of anterior aspect of epiglottis
malignant neoplasm of junctional region of oropharynx
malignant neoplasm of lateral wall of oropharynx
malignant neoplasm of posterior wall of oropharynx
malignant neoplasm of other specified sites of oropharynx
malignant neoplasm of oropharynx unspecified site
malignant neoplasm of superior wall of nasopharynx
malignant neoplasm of posterior wall of nasopharynx
malignant neoplasm of lateral wall of nasopharynx
malignant neoplasm of anterior wall of nasopharynx
malignant neoplasm of other specified sites of nasopharynx
malignant neoplasm of nasopharynx unspecified site
malignant neoplasm of postcricoid region of hypopharynx
malignant neoplasm of pyriform sinus
malignant neoplasm of aryepiglottic fold hypopharyngeal aspect
malignant neoplasm of posterior hypopharyngeal wall
malignant neoplasm of other specified sites of hypopharynx
malignant neoplasm of hypopharynx unspecified site
malignant neoplasm of pharynx unspecified
malignant neoplasm of waldeyer’s ring
malignant neoplasm of other sites within the lip and oral cavity
malignant neoplasm of ill-defined sites within the lip and oral cavity
malignant neoplasm of cervical esophagus
malignant neoplasm of thoracic esophagus
malignant neoplasm of upper third of esophagus
malignant neoplasm of other specified part of esophagus
malignant neoplasm of intestinal tract part unspecified
malignant neoplasm of nasal cavities
malignant neoplasm of auditory tube middle ear and mastoid air cells
malignant neoplasm of maxillary sinus
malignant neoplasm of ethmoidal sinus
malignant neoplasm of frontal sinus
malignant neoplasm of sphenoidal sinus
malignant neoplasm of other accessory sinuses
malignant neoplasm of accessory sinus unspecified
malignant neoplasm of glottis
malignant neoplasm of supraglottis
malignant neoplasm of subglottis
malignant neoplasm of laryngeal cartilages
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
161.8
161.9
162.0
162.2
162.3
162.4
162.5
162.8
162.9
164.0
164.2
164.3
164.8
164.9
165.0
165.8
165.9
170.0
170.1
170.2
170.3
170.9
171.0
171.8
171.9
172.0
172.1
172.2
172.3
172.4
172.6
172.8
173.0
173.1
173.2
173.3
173.4
173.6
176.0
176.1
176.2
176.3
176.5
176.8
190.0
190.1
190.2
190.3
190.4
190.5
malignant neoplasm of other specified sites of larynx
malignant neoplasm of larynx unspecified
malignant neoplasm of trachea
malignant neoplasm of main bronchus
malignant neoplasm of upper lobe bronchus or lung
malignant neoplasm of middle lobe bronchus or lung
malignant neoplasm of lower lobe bronchus or lung
malignant neoplasm of other parts of bronchus or lung
malignant neoplasm of bronchus and lung unspecified
malignant neoplasm of thymus
malignant neoplasm of anterior mediastinum
malignant neoplasm of posterior mediastinum
malignant neoplasm of other parts of mediastinum
malignant neoplasm of mediastinum part unspecified
malignant neoplasm of upper respiratory tract part unspecified
malignant neoplasm of other sites within the respiratory system and intrathoracic organs
malignant neoplasm of ill-defined sites within the respiratory system
malignant neoplasm of bones of skull and face except mandible
malignant neoplasm of mandible
malignant neoplasm of vertebral column excluding sacrum and coccyx
malignant neoplasm of ribs sternum and clavicle
malignant neoplasm of bone and articular cartilage site unspecified
malignant neoplasm of connective and other soft tissue of head face and neck
malignant neoplasm of other specified sites of connective and other soft tissue
malignant neoplasm of connective and other soft tissue site unspecified
malignant melanoma of skin of lip
malignant melanoma of skin of eyelid including canthus
malignant melanoma of skin of ear and external auditory canal
malignant melanoma of skin of other and unspecified parts of face
malignant melanoma of skin of scalp and neck
malignant melanoma of skin of upper limb including shoulder
malignant melanoma of other specified sites of skin
other malignant neoplasm of skin of lip
other malignant neoplasm of skin of eyelid including canthus
other malignant neoplasm of skin of ear and external auditory canal
other malignant neoplasm of skin of other and unspecified parts of face
other malignant neoplasm of scalp and skin of neck
other malignant neoplasm of skin of upper limb including shoulder
kaposi’s sarcoma skin
kaposi’s sarcoma soft tissue
kaposi’s sarcoma palate
kaposi’s sarcoma gastrointestinal sites
kaposi’s sarcoma lymph nodes
kaposi’s sarcoma other specified sites
malignant neoplasm of eyeball except conjunctiva cornea retina and choroid
malignant neoplasm of orbit
malignant neoplasm of lacrimal gland
malignant neoplasm of conjunctiva
malignant neoplasm of cornea
malignant neoplasm of retina
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
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
191.2
malignant neoplasm of temporal lobe
191.3
malignant neoplasm of parietal lobe
191.4
malignant neoplasm of occipital lobe
191.5
malignant neoplasm of ventricles
191.6
malignant neoplasm of cerebellum nos
191.7
malignant neoplasm of brain stem
191.8
malignant neoplasm of other parts of brain
191.9
malignant neoplasm of brain unspecified site
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
193malignant neoplasm of thyroid 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
195.0
malignant neoplasm of head face and neck
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
196.3
secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb
196.8
secondary and unspecified malignant neoplasm of lymph nodes of multiple sites
197.3
secondary malignant neoplasm of other respiratory 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
199.0
disseminated malignant neoplasm
199.2
malignant neoplasm associated with transplant organ
200.01
reticulosarcoma involving lymph nodes of head face and neck
200.02
reticulosarcoma involving intrathoracic lymph nodes
200.04
reticulosarcoma involving lymph nodes of axilla and upper limb
200.08
reticulosarcoma involving lymph nodes of multiple sites
200.11
lymphosarcoma involving lymph nodes of head face and neck
200.12
lymphosarcoma involving intrathoracic lymph nodes
200.14
lymphosarcoma involving lymph nodes of axilla and upper limb
200.18
lymphosarcoma involving lymph nodes of multiple sites
200.21
burkitt’s tumor or lymphoma involving lymph nodes of head face and neck
200.22
burkitt’s tumor or lymphoma involving intrathoracic lymph nodes
200.24
burkitt’s tumor or lymphoma involving lymph nodes of axilla and upper limb
200.28
burkitt’s tumor or lymphoma involving lymph nodes of multiple sites
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
200.30
200.31
200.32
200.33
200.34
200.35
200.36
200.37
200.38
200.40
200.41
200.42
200.43
200.44
200.45
200.46
200.47
200.48
200.50
200.51
200.52
200.53
200.54
200.55
200.56
200.57
200.58
200.60
200.61
200.62
200.63
200.64
200.65
200.66
200.67
200.68
200.70
200.71
200.72
200.73
200.74
200.75
200.76
200.77
200.78
200.81
200.82
200.84
marginal zone lymphoma, unspecified site, extranodal and solid organ sites
marginal zone lymphoma,lymph nodes of head, face, and neck
marginal zone lymphoma,intrathoracic lymph nodes
marginal zone lymphoma, intraabdominal lymph nodes
marginal zone lymphoma, lymph nodes of axilla and upper limb
marginal zone lymphoma, lymph nodes of inguinal region and lower limb
marginal zone lymphoma, intrapelvic lymph nodes
marginal zone lymphoma, spleen
marginal zone lymphoma, lymph nodes of multiple sites
mantle cell lymphoma, unspecified site, extranodal and solid organ sites
mantle cell lymphoma, lymph nodes of head, face, and neck
mantle cell lymphoma, intrathoracic lymph nodes
mantle cell lymphoma, intra-abdominal lymph nodes
mantle cell lymphoma, lymph nodes of axilla and upper limb
mantle cell lymphoma, lymph nodes of inguinal region and lower limb
mantle cell lymphoma, intrapelvic lymph nodes
mantle cell lymphoma, spleen
mantle cell lymphoma, lymph nodes of multiple sites
primary central nervous system lymphoma, unspecified site, extranodal and solid organ sites
primary central nervous system lymphoma, lymph nodes of head, face, and neck
primary central nervous system lymphoma, intrathoracic lymph nodes
primary central nervous system lymphoma, intra-abdominal lymph nodes
primary central nervous system lymphoma, lymph nodes of axilla and upper limb
primary central nervous system lymphoma, lymph nodes of inguinal region and lower limb
primary central nervous system lymphoma, intrapelvic lymph nodes
primary central nervous system lymphoma, spleen
primary central nervous system lymphoma, lymph nodes of multiple sites
anaplastic large cell lymphoma, unspecified site, extranodal and solid organ sites
anaplastic large cell lymphoma, lymph nodes of head, face, and neck
anaplastic large cell lymphoma, intrathoracic lymph nodes
anaplastic large cell lymphoma, intra-abdominal lymph nodes
anaplastic large cell lymphoma, lymph nodes of axilla and upper limb
anaplastic large cell lymphoma, lymph nodes of inguinal region and lower limb
anaplastic large cell lymphoma, intrapelvic lymph nodes
anaplastic large cell lymphoma, spleen
anaplastic large cell lymphoma, lymph nodes of multiple sites
large cell lymphoma, unspecified site, extranodal and solid organ sites
large cell lymphoma, lymph nodes of head, face, and neck
large cell lymphoma, intrathoracic lymph nodes
large cell lymphoma, intra-abdominal lymph nodes
large cell lymphoma, lymph nodes of axilla and upper limb
large cell lymphoma, lymph nodes of inguinal region and lower limb
large cell lymphoma, intrapelvic lymph nodes
large cell lymphoma, spleen
large cell lymphoma, lymph nodes of multiple sites
other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of head face and
neck
other named variants of lymphosarcoma and reticulosarcoma involving intrathoracic lymph nodes
other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of axilla and upper limb
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
200.88
201.01
201.02
201.04
201.08
201.11
201.12
201.14
201.18
201.21
201.22
201.24
201.28
201.41
201.42
201.44
201.48
201.51
201.52
201.54
201.58
201.61
201.62
201.64
201.68
201.71
201.72
201.74
201.78
201.91
201.92
201.94
201.98
202.01
202.02
202.04
202.08
202.11
202.12
202.14
202.18
202.21
202.22
202.24
202.28
202.31
202.32
202.34
202.38
other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of multiple sites
hodgkin’s paragranuloma involving lymph nodes of head face and neck
hodgkin’s paragranuloma involving intrathoracic lymph nodes
hodgkin’s paragranuloma involving lymph nodes of axilla and upper limb
hodgkin’s paragranuloma involving lymph nodes of multiple sites
hodgkin’s granuloma involving lymph nodes of head face and neck
hodgkin’s granuloma involving intrathoracic lymph nodes
hodgkin’s granuloma involving lymph nodes of axilla and upper limb
hodgkin’s granuloma involving lymph nodes of multiple sites
hodgkin’s sarcoma involving lymph nodes of head face and neck
hodgkin’s sarcoma involving intrathoracic lymph nodes
hodgkin’s sarcoma involving lymph nodes of axilla and upper limb
hodgkin’s sarcoma involving lymph nodes of multiple sites
hodgkin’s disease lymphocytic-histiocytic predominance involving lymph nodes of head face and neck
hodgkin’s disease lymphocytic-histiocytic predominance involving intrathoracic lymph nodes
hodgkin’s disease lymphocytic-histiocytic predominance involving lymph nodes of axilla and upper
limb
hodgkin’s disease lymphocytic-histiocytic predominance involving lymph nodes of multiple sites
hodgkin’s disease nodular sclerosis involving lymph nodes of head face and neck
hodgkin’s disease nodular sclerosis involving intrathoracic lymph nodes
hodgkin’s disease nodular sclerosis involving lymph nodes of axilla and upper limb
hodgkin’s disease nodular sclerosis involving lymph nodes of multiple sites
hodgkin’s disease mixed cellularity involving lymph nodes of head face and neck
hodgkin’s disease mixed cellularity involving intrathoracic lymph nodes
hodgkin’s disease mixed cellularity involving lymph nodes of axilla and upper limb
hodgkin’s disease mixed cellularity involving lymph nodes of multiple sites
hodgkin’s disease lymphocytic depletion involving lymph nodes of head face and neck
hodgkin’s disease lymphocytic depletion involving intrathoracic lymph nodes
hodgkin’s disease lymphocytic depletion involving lymph nodes of axilla and upper limb
hodgkin’s disease lymphocytic depletion involving lymph nodes of multiple sites
hodgkin’s disease unspecified type involving lymph nodes of head face and neck
hodgkin’s disease unspecified type involving intrathoracic lymph nodes
hodgkin’s disease unspecified type involving lymph nodes of axilla and upper limb
hodgkin’s disease unspecified type involving lymph nodes of multiple sites
nodular lymphoma involving lymph nodes of head face and neck
nodular lymphoma involving intrathoracic lymph nodes
nodular lymphoma involving lymph nodes of axilla and upper limb
nodular lymphoma involving lymph nodes of multiple sites
mycosis fungoides involving lymph nodes of head face and neck
mycosis fungoides involving intrathoracic lymph nodes
mycosis fungoides involving lymph nodes of axilla and upper limb
mycosis fungoides involving lymph nodes of multiple sites
sezary’s disease involving lymph nodes of head face and neck
sezary’s disease involving intrathoracic lymph nodes
sezary’s disease involving lymph nodes of axilla and upper limb
sezary’s disease involving lymph nodes of multiple sites
malignant histiocytosis involving lymph nodes of head face and neck
malignant histiocytosis involving intrathoracic lymph nodes
malignant histiocytosis involving lymph nodes of axilla and upper limb
malignant histiocytosis involving lymph nodes of multiple sites
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
202.41
202.42
202.44
202.48
202.51
202.52
202.54
202.58
202.61
202.62
202.64
202.68
202.70
202.71
202.72
202.73
202.74
202.75
202.76
202.77
202.78
202.81
202.82
202.84
202.88
202.91
202.92
202.94
202.98
203.00
203.01
203.02
203.80
203.81
203.82
209.30
210.0
210.1
210.2
210.3
210.4
210.5
210.6
210.7
210.8
210.9
leukemic reticuloendotheliosis involving lymph nodes of head face and neck
leukemic reticuloendotheliosis involving intrathoracic lymph nodes
leukemic reticuloendotheliosis involving lymph nodes of axilla and upper arm
leukemic reticuloendotheliosis involving lymph nodes of multiple sites
letterer-siwe disease involving lymph nodes of head face and neck
letterer-siwe disease involving intrathoracic lymph nodes
letterer-siwe disease involving lymph nodes of axilla and upper limb
letterer-siwe disease involving lymph nodes of multiple sites
malignant mast cell tumors involving lymph nodes of head face and neck
malignant mast cell tumors involving intrathoracic lymph nodes
malignant mast cell tumors involving lymph nodes of axilla and upper limb
malignant mast cell tumors involving lymph nodes of multiple sites
peripheral t cell lymphoma, unspecified site, extranodal and solid organ sites
peripheral t cell lymphoma, lymph nodes of head, face, and neck
peripheral t cell lymphoma, intrathoracic lymph nodes
peripheral t cell lymphoma, intra-abdominal lymph nodes
peripheral t cell lymphoma, lymph nodes of axilla and upper limb
peripheral t cell lymphoma, lymph nodes of inguinal region and lower limb
peripheral t cell lymphoma, intrapelvic lymph nodes
peripheral t cell lymphoma, spleen
peripheral t cell lymphoma, lymph nodes of multiple sites
other malignant lymphomas involving lymph nodes of head face and neck
other malignant lymphomas involving intrathoracic lymph nodes
other malignant lymphomas involving lymph nodes of axilla and upper limb
other malignant lymphomas involving lymph nodes of multiple sites
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes
of head face and neck
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving intrathoracic
lymph nodes
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes
of axilla and upper limb
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes
of multiple sites
multiple myeloma, without mention of having achieved remission
multiple myeloma in remission
multiple myeloma, in relapse
other immunoproliferative neoplasms, without mention of having achieved remission
other immunoproliferative neoplasms in remission
other immunoproliferative neoplasms, in relapse
malignant poorly differentiated neuroendocrine carcinoma, any site
benign neoplasm of lip
benign neoplasm of tongue
benign neoplasm of major salivary glands
benign neoplasm of floor of mouth
benign neoplasm of other and unspecified parts of mouth
benign neoplasm of tonsil
benign neoplasm of other parts of oropharynx
benign neoplasm of nasopharynx
benign neoplasm of hypopharynx
benign neoplasm of pharynx unspecified
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
211.0
211.9
212.0
212.1
212.2
212.5
212.6
212.8
212.9
213.0
213.1
213.3
213.9
214.0
214.1
215.0
215.8
216.0
216.1
216.2
216.3
216.4
224.0
224.1
224.2
224.3
224.4
224.5
224.6
224.7
224.8
224.9
225.0
225.1
225.2
225.3
225.4
225.8
225.9
226
227.1
227.3
227.4
227.5
227.6
227.8
228.00
228.01
228.02
228.03
benign neoplasm of esophagus
benign neoplasm of other and unspecified site in the digestive system
benign neoplasm of nasal cavities middle ear and accessory sinuses
benign neoplasm of larynx
benign neoplasm of trachea
benign neoplasm of mediastinum
benign neoplasm of thymus
benign neoplasm of other specified sites of respiratory and intrathoracic organs
benign neoplasm of respiratory and intrathoracic organs site unspecified
benign neoplasm of bones of skull and face
benign neoplasm of lower jaw bone
benign neoplasm of ribs sternum and clavicle
benign neoplasm of bone and articular cartilage site unspecified
lipoma of skin and subcutaneous tissue of face
lipoma of other skin and subcutaneous tissue
other benign neoplasm of connective and other soft tissue of head face and neck
other benign neoplasm of connective and other soft tissue of other specified sites
benign neoplasm of skin of lip
benign neoplasm of eyelid including canthus
benign neoplasm of ear and external auditory canal
benign neoplasm of skin of other and unspecified parts of face
benign neoplasm of scalp and skin of neck
benign neoplasm of eyeball except conjunctiva cornea retina and choroid
benign neoplasm of orbit
benign neoplasm of lacrimal gland
benign neoplasm of conjunctiva
benign neoplasm of cornea
benign neoplasm of retina
benign neoplasm of choroid
benign neoplasm of lacrimal duct
benign neoplasm of other specified parts of eye
benign neoplasm of eye part unspecified
benign neoplasm of brain
benign neoplasm of cranial nerves
benign neoplasm of cerebral meninges
benign neoplasm of spinal cord
benign neoplasm of spinal meninges
benign neoplasm of other specified sites of nervous system
benign neoplasm of nervous system part unspecified
benign neoplasm of thyroid glands
benign neoplasm of parathyroid gland
benign neoplasm of pituitary gland and craniopharyngeal duct
benign neoplasm of pineal gland
benign neoplasm of carotid body
benign neoplasm of aortic body and other paraganglia
benign neoplasm of other endocrine glands and related structures
hemangioma of unspecified site
hemangioma of skin and subcutaneous tissue
hemangioma of intracranial structures
hemangioma of retina
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
228.1
229.0
229.8
230.0
230.1
231.0
231.1
231.8
232.0
232.1
232.2
232.3
232.4
232.8
234.0
234.8
235.0
235.1
235.6
235.7
235.8
237.0
237.1
237.2
237.3
237.4
237.5
237.6
237.70
237.71
237.72
237.9
238.0
238.1
238.2
238.8
239.1
239.2
239.3
239.6
239.7
239.8
240.0
240.9
241.0
241.1
241.9
242.00
242.01
242.10
lymphangioma any site
benign neoplasm of lymph nodes
benign neoplasm of other specified sites
carcinoma in situ of lip oral cavity and pharynx
carcinoma in situ of esophagus
carcinoma in situ of larynx
carcinoma in situ of trachea
carcinoma in situ of other specified parts of respiratory system
carcinoma in situ of skin of lip
carcinoma in situ of eyelid including canthus
carcinoma in situ of skin of ear and external auditory canal
carcinoma in situ of skin of other and unspecified parts of face
carcinoma in situ of scalp and skin of neck
carcinoma in situ of other specified sites of skin
carcinoma in situ of eye
carcinoma in situ of other specified sites
neoplasm of uncertain behavior of major salivary glands
neoplasm of uncertain behavior of lip oral cavity and pharynx
neoplasm of uncertain behavior of larynx
neoplasm of uncertain behavior of trachea bronchus and lung
neoplasm of uncertain behavior of pleura thymus and mediastinum
neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct
neoplasm of uncertain behavior of pineal gland
neoplasm of uncertain behavior of adrenal gland
neoplasm of uncertain behavior of paraganglia
neoplasm of uncertain behavior of other and unspecified endocrine glands
neoplasm of uncertain behavior of brain and spinal cord
neoplasm of uncertain behavior of meninges
neurofibromatosis unspecified
neurofibromatosis type 1 von recklinghausen’s disease
neurofibromatosis type 2 acoustic neurofibromatosis
neoplasm of uncertain behavior of other and unspecified parts of nervous system
neoplasm of uncertain behavior of bone and articular cartilage
neoplasm of uncertain behavior of connective and other soft tissue
neoplasm of uncertain behavior of skin
neoplasm of uncertain behavior of other specified sites
neoplasm of unspecified nature of respiratory system
neoplasm of unspecified nature of bone soft tissue and skin
neoplasm of unspecified nature of breast
neoplasm of unspecified nature of brain
neoplasm of unspecified nature of endocrine glands and other parts of nervous system
neoplasm of unspecified nature of other specified sites
goiter specified as simple
goiter unspecified
nontoxic uninodular goiter
nontoxic multinodular goiter
unspecified nontoxic nodular goiter
toxic diffuse goiter without thyrotoxic crisis or storm
toxic diffuse goiter with thyrotoxic crisis or storm
toxic uninodular goiter without thyrotoxic crisis or storm
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
242.11
242.20
242.21
242.30
242.31
242.40
242.41
245.0
245.1
245.2
245.3
245.4
245.8
245.9
246.0
249.60
249.61
250.60
250.61
250.62
250.63
252.00
252.01
252.02
252.08
252.1
252.8
252.9
253.0
253.1
253.2
253.3
253.4
253.5
253.6
253.7
253.8
253.9
254.0
254.1
254.8
254.9
256.0
258.01
259.3
289.3
294.8
298.9
320.0
toxic uninodular goiter with thyrotoxic crisis or storm
toxic multinodular goiter without thyrotoxic crisis or storm
toxic multinodular goiter with thyrotoxic crisis or storm
toxic nodular goiter unspecified type without thyrotoxic crisis or storm
toxic nodular goiter unspecified type with thyrotoxic crisis or storm
thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
acute thyroiditis
subacute thyroiditis
chronic lymphocytic thyroiditis
chronic fibrous thyroiditis
iatrogenic thyroiditis
other and unspecified chronic thyroiditis
thyroiditis unspecified
disorders of thyrocalcitonin secretion
secondary diabetes mellitus with neurological manifestations, not stated as uncontrolled, or unspecified
secondary diabetes mellitus with neurological manifestations, uncontrolled
diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled
diabetes with neurological manifestations, type i [juvenile type], not stated as uncontrolled
diabetes with neurological manifestations, type ii or unspecified type, uncontrolled
diabetes with neurological manifestations, type i [juvenile type], uncontrolled
hyperparathyroidism, unspecified
primary hyperparathyroidism
secondary hyperparathyroidism, non-renal
other hyperparathyroidism
hypoparathyroidism
other specified disorders of parathyroid gland
unspecified disorder of parathyroid gland
acromegaly and gigantism
other and unspecified anterior pituitary hyperfunction
panhypopituitarism
pituitary dwarfism
other anterior pituitary disorders
diabetes insipidus
other disorders of neurohypophysis
iatrogenic pituitary disorders
other disorders of the pituitary and other syndromes of diencephalohypophyseal origin
unspecified disorder of the pituitary gland and its hypothalamic control
persistent hyperplasia of thymus
abscess of thymus
other specified diseases of thymus gland
unspecified disease of thymus gland
hyperestrogenism
multiple endocrine neoplasia [men] type i
ectopic hormone secretion not elsewhere classified
lymphadenitis unspecified except mesenteric
other persistent mental disorders due to conditions classified elsewhere
unspecified psychosis
hemophilus meningitis
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
320.1
320.2
320.3
320.7
320.81
320.82
320.89
320.9
321.0
321.1
321.2
321.3
321.4
321.8
322.0
322.1
322.2
322.9
323.01
323.02
323.1
323.2
323.41
323.42
323.51
323.52
323.61
323.62
323.63
323.71
323.72
323.81
323.82
323.9
324.0
324.1
324.9
325
326
330.0
330.1
330.2
330.3
330.8
331.0
331.11
331.19
331.2
331.3
331.4
pneumococcal meningitis
streptococcal meningitis
staphylococcal meningitis
meningitis in other bacterial diseases classified elsewhere
anaerobic meningitis
meningitis due to gram-negative bacteria not elsewhere classified
meningitis due to other specified bacteria
meningitis due to unspecified bacterium
cryptococcal meningitis
meningitis in other fungal diseases
meningitis due to viruses not elsewhere classified
meningitis due to trypanosomiasis
meningitis in sarcoidosis
meningitis due to other nonbacterial organisms classified elsewhere
nonpyogenic meningitis
eosinophilic meningitis
chronic meningitis
meningitis unspecified
encephalitis and encephalomyelitis in viral diseases classified elsewhere
myelitis in viral diseases classified elsewhere
encephalitis, myelitis, and encephalomyelitis in rickettsial diseases classified elsewhere
encephalitis, myelitis, and encephalomyelitis in protozoal diseases classified elsewhere
other encephalitis and encephalomyelitis due to infection classified elsewhere
other myelitis due to infection classified elsewhere
encephalitis and encephalomyelitis following immunization procedures
myelitis following immunization procedures
infectious acute disseminated encephalomyelitis (adem)
other postinfectious encephalitis and encephalomyelitis
postinfectious myelitis
toxic encephalitis and encephalomyelitis
toxic myelitis
other causes of encephalitis and encephalomyelitis
other causes of myelitis
unspecified causes of encephalitis, myelitis, and encephalomyelitis
intracranial abscess
intraspinal abscess
intracranial and intraspinal abscess of unspecified site
phlebitis and thrombophlebitis of intracranial venous sinuses
late effects of intracranial abscess or pyogenic infection
leukodystrophy
cerebral lipidoses
cerebral degeneration in generalized lipidoses
cerebral degeneration of childhood in other diseases classified elsewhere
other specified cerebral degenerations in childhood
alzheimer’s disease
pick’s disease
other frontotemporal dementia
senile degeneration of brain
communicating hydrocephalus
obstructive hydrocephalus
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
331.5
331.7
331.81
331.82
331.89
331.9
332.0
332.1
333.0
333.1
333.2
333.3
333.4
333.5
333.6
333.71
333.79
333.82
333.83
333.89
333.90
333.91
333.92
333.93
333.99
334.0
334.1
334.2
334.3
334.4
334.8
334.9
340
341.0
341.1
341.8
341.9
342.00
342.01
342.02
342.10
342.11
342.12
342.80
342.81
342.82
342.90
342.91
342.92
343.0
idiopathic normal pressure hydrocephalus (inph)
cerebral degeneration in diseases classified elsewhere
reye’s syndrome
dementia with lewy bodies
other cerebral degeneration
cerebral degeneration unspecified
paralysis agitans
secondary parkinsonism
other degenerative diseases of the basal ganglia
essential and other specified forms of tremor
myoclonus
tics of organic origin
huntington’s chorea
other choreas
genetic torsion dystonia
athetoid cerebral palsy
other acquired torsion dystonia
orofacial dyskinesia
spasmodic torticollis
other fragments of torsion dystonia
unspecified extrapyramidal disease and abnormal movement disorder
stiff-man syndrome
neuroleptic malignant syndrome
benign shuddering attacks
other extrapyramidal diseases and abnormal movement disorders
friedreich’s ataxia
hereditary spastic paraplegia
primary cerebellar degeneration
other cerebellar ataxia
cerebellar ataxia in diseases classified elsewhere
other spinocerebellar diseases
spinocerebellar disease unspecified
multiple sclerosis
neuromyelitis optica
schilder’s disease
other demyelinating diseases of central nervous system
demyelinating disease of central nervous system unspecified
flaccid hemiplegia and hemiparesis affecting unspecified side
flaccid hemiplegia and hemiparesis affecting dominant side
flaccid hemiplegia and hemiparesis affecting nondominant side
spastic hemiplegia and hemiparesis affecting unspecified side
spastic hemiplegia and hemiparesis affecting dominant side
spastic hemiplegia and hemiparesis affecting nondominant side
other specified hemiplegia and hemiparesis affecting unspecified side
other specified hemiplegia and hemiparesis affecting dominant side
other specified hemiplegia and hemiparesis affecting nondominant side
unspecified hemiplegia and hemiparesis affecting unspecified side
unspecified hemiplegia and hemiparesis affecting dominant side
unspecified hemiplegia and hemiparesis affecting nondominant side
congenital diplegia
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
343.1
343.2
343.3
343.4
343.8
343.9
345.01
345.10
345.11
345.2
345.3
345.40
345.41
345.50
345.51
345.60
345.61
345.70
345.71
345.80
345.81
345.90
345.91
346.90
346.91
346.92
346.93
348.0
348.1
348.2
348.30
348.31
348.39
348.4
348.5
348.8
348.9
349.0
349.1
349.2
349.31
349.39
349.81
349.82
349.89
349.9
congenital hemiplegia
congenital quadriplegia
congenital monoplegia
infantile hemiplegia
other specified infantile cerebral palsy
infantile cerebral palsy unspecified
generalized nonconvulsive epilepsy with intractable epilepsy
generalized convulsive epilepsy without intractable epilepsy
generalized convulsive epilepsy with intractable epilepsy
petit mal status epileptic
grand mal status epileptic
localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures,
without mention of intractable epilepsy
localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures,
with intractable epilepsy
localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures,
without mention of intractable epilepsy
localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, with
intractable epilepsy
infantile spasms without intractable epilepsy
infantile spasms with intractable epilepsy
epilepsia partialis continua without intractable epilepsy
epilepsia partialis continua with intractable epilepsy
other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy
other forms of epilepsy and recurrent seizures, with intractable epilepsy
epilepsy unspecified without intractable epilepsy
epilepsy unspecified with intractable epilepsy
migraine, unspecified, without mention of intractable migraine without mention of status migrainosus
migraine, unspecified, with intractable migraine, so stated, without mention of status migrainosus
migraine, unspecified, without mention of intractable migraine with status migrainosus
migraine, unspecified, with intractable migraine, so stated, with status migrainosus
cerebral cysts
anoxic brain damage
benign intracranial hypertension
encephalopathy unspecified
metabolic encephalopathy
other encephalopathy
compression of brain
cerebral edema
other conditions of brain
unspecified condition of brain
reaction to spinal or lumbar puncture
nervous system complications from surgically implanted device
disorders of meninges not elsewhere classified
accidental puncture or laceration of dura during a procedure
other dural tear
cerebrospinal fluid rhinorrhea
toxic encephalopathy
other specified disorders of nervous system
unspecified disorders of nervous system
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
350.1
350.2
350.8
350.9
351.0
351.1
351.8
351.9
352.0
352.1
352.2
352.3
352.4
352.5
352.6
352.9
353.0
353.5
357.0
358.00
358.01
358.1
359.0
359.1
359.21
359.22
359.29
359.3
360.00
360.01
360.02
360.03
360.04
360.11
360.12
360.13
360.14
360.19
360.20
360.21
360.23
360.24
360.29
360.30
360.31
360.32
360.33
360.34
360.40
360.41
trigeminal neuralgia
atypical face pain
other specified trigeminal nerve disorders
trigeminal nerve disorder unspecified
bell’s palsy
geniculate ganglionitis
other facial nerve disorders
facial nerve disorder unspecified
disorders of olfactory (1st) nerve
glossopharyngeal neuralgia
other disorders of glossopharyngeal (9th) nerve
disorders of pneumogastric (10th) nerve
disorders of accessory (11th) nerve
disorders of hypoglossal (12th) nerve
multiple cranial nerve palsies
unspecified disorder of cranial nerves
brachial plexus lesions
neuralgic amyotrophy
acute infective polyneuritis
myasthenia gravis without (acute) exacerbation
myasthenia gravis with (acute) exacerbation
myasthenic syndromes in diseases classified elsewhere
congenital hereditary muscular dystrophy
hereditary progressive muscular dystrophy
myotonic muscular dystrophy
myotonia congenital
other specified myotonic disorder
periodic paralysis
purulent endophthalmitis unspecified
acute endophthalmitis
panophthalmitis
chronic endophthalmitis
vitreous abscess
sympathetic uveitis
panuveitis
parasitic endophthalmitis unspecified
ophthalmia nodosa
other endophthalmitis
degenerative disorder of globe unspecified
progressive high (degenerative) myopia
siderosis of globe
other metallosis of globe
other degenerative disorders of globe
hypotony of eye unspecified
primary hypotony of eye
ocular fistula causing hypotony
hypotony associated with other ocular disorders
flat anterior chamber of eye
degenerated globe or eye unspecified
blind hypotensive eye
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
360.42
360.43
360.44
360.50
360.51
360.52
360.53
360.54
360.55
360.59
360.60
360.61
360.62
360.63
360.64
360.65
360.69
360.81
360.89
361.00
361.01
361.02
361.03
361.04
361.05
361.06
361.07
361.10
361.11
361.12
361.13
361.14
361.19
361.2
361.30
361.31
361.32
361.33
361.81
361.89
361.9
362.14
362.17
362.18
362.21
362.29
362.30
362.31
362.32
362.33
blind hypertensive eye
hemophthalmos except current injury
leucocoria
foreign body magnetic intraocular unspecified
foreign body magnetic in anterior chamber of eye
foreign body magnetic in iris or ciliary body
foreign body magnetic in lens
foreign body magnetic in vitreous
foreign body magnetic in posterior wall
intraocular foreign body magnetic in other or multiple sites
foreign body intraocular unspecified
foreign body in anterior chamber
foreign body in iris or ciliary body
foreign body in lens
foreign body in vitreous
foreign body in posterior wall of eye
intraocular foreign body in other or multiple sites
luxation of globe
other disorders of globe
retinal detach with retinal defect unspecified
recent retinal detach partial with single defect
recent retinal detach partial with multiple defects
recent retinal detach partial with giant tear
recent retinal detach partial with retinal dialysis
recent retinal detach total or subtotal
old retinal detach partial
old retinal detach total or subtotal
retinoschisis unspecified
flat retinoschisis
bullous retinoschisis
primary retinal cysts
secondary retinal cysts
other retinoschisis and retinal cysts
serous retinal detach
retinal defect unspecified
round hole of retina without detach
horseshoe tear of retina without detach
multiple defects of retina without detach
traction detach of retina
other forms of retinal detach
unspecified retinal detach
retinal microaneurysms nos
other intraretinal microvascular abnormalities
retinal vasculitis
retrolental fibroplasia
other nondiabetic proliferative retinopathy
retinal vascular occlusion unspecified
central retinal artery occlusion
retinal arterial branch occlusion
partial retinal arterial occlusion
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
362.34
368.2
368.30
368.31
368.32
368.33
368.34
368.40
368.41
368.42
368.43
368.44
368.45
368.46
368.47
368.51
368.52
368.53
368.54
368.55
368.59
368.62
368.8
369.00
374.31
374.85
375.12
375.16
375.31
375.32
375.33
375.41
375.42
375.43
375.51
375.52
375.53
375.54
375.55
375.56
375.57
375.61
375.69
375.81
375.89
375.9
376.00
376.01
376.02
376.03
transient retinal arterial occlusion
diplopia
binocular vision disorder unspecified
suppression of binocular vision
simultaneous visual perception without fusion
fusion with defective stereopsis
abnormal retinal correspondence
visual field defect unspecified
scotoma involving central area
scotoma of blind spot area
sector or arcuate visual field defects
other localized visual field defect
generalized visual field contraction or constriction
homonymous bilateral field defects
heteronymous bilateral field defects
protan defect
deutan defect
tritan defect
achromatopsia
acquired color vision deficiencies
other color vision deficiencies
acquired night blindness
other specified visual disturbances
blindness of both eyes impairment level not further specified
paralytic ptosis
vascular anomalies of eyelid
other lacrimal cysts and cystic degeneration
dislocation of lacrimal gland
acute canaliculitis lacrimal
acute dacryocystitis
phlegmonous dacryocystitis
chronic canaliculitis
chronic dacryocystitis
lacrimal mucocele
eversion of lacrimal punctum
stenosis of lacrimal punctum
stenosis of lacrimal canaliculi
stenosis of lacrimal sac
obstruction of nasolacrimal duct neonatal
stenosis of nasolacrimal duct acquired
dacryolith
lacrimal fistula
other changes of lacrimal passages
granuloma of lacrimal passages
other disorders of lacrimal system
unspecified disorder of lacrimal system
acute inflammation of orbit unspecified
orbital cellulitis
orbital periostitis
orbital osteomyelitis
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
376.04
376.10
376.11
376.12
376.13
376.21
376.22
376.30
376.31
376.32
376.33
376.34
376.35
376.36
376.40
376.41
376.42
376.43
376.44
376.45
376.46
376.47
376.50
376.51
376.52
376.6
376.81
376.82
376.89
376.9
377.00
377.01
377.02
377.03
377.04
377.10
377.11
377.12
377.13
377.14
377.15
377.16
377.22
377.23
377.24
377.30
377.31
377.32
377.33
377.34
orbital tenonitis
chronic inflammation of orbit unspecified
orbital granuloma
orbital myositis
parasitic infestation of orbit
thyrotoxic exophthalmos
exophthalmic ophthalmoplegia
exophthalmos unspecified
constant exophthalmos
orbital hemorrhage
orbital edema or congestion
intermittent exophthalmos
pulsating exophthalmos
lateral displacement of globe
deformity of orbit unspecified
hypertelorism of orbit
exostosis of orbit
local deformities of orbit due to bone disease
orbital deformities associated with craniofacial deformities
atrophy of orbit
enlargement of orbit
deformity of orbit due to trauma or surgery
enophthalmos unspecified as to cause
enophthalmos due to atrophy of orbital tissue
enophthalmos due to trauma or surgery
retained (old) foreign body following penetrating wound of orbit
orbital cysts
myopathy of extraocular muscles
other orbital disorders
unspecified disorder of orbit
papilledema unspecified
papilledema associated with increased intracranial pressure
papilledema associated with decreased ocular pressure
papilledema associated with retinal disorder
foster-kennedy syndrome
optic atrophy unspecified
primary optic atrophy
postinflammatory optic atrophy
optic atrophy associated with retinal dystrophies
glaucomatous atrophy (cupping) of optic disc
partial optic atrophy
hereditary optic atrophy
crater-like holes of optic disc
coloboma of optic disc
pseudopapilledema
optic neuritis unspecified
optic papillitis
retrobulbar neuritis (acute)
nutritional optic neuropathy
toxic optic neuropathy
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
377.39
377.41
377.42
377.49
377.51
377.52
377.53
377.54
377.61
377.62
377.63
377.71
377.72
377.73
377.75
377.9
378.11
378.14
378.15
378.18
378.21
378.22
378.23
378.24
378.41
378.42
378.43
378.44
378.45
378.50
378.51
378.52
378.53
378.54
378.55
378.56
378.60
378.61
378.62
378.63
378.71
378.72
378.73
378.81
378.82
378.83
378.84
378.85
378.86
378.87
other optic neuritis
ischemic optic neuropathy
hemorrhage in optic nerve sheaths
other disorders of optic nerve
disorders of optic chiasm associated with pituitary neoplasms and disorders
disorders of optic chiasm associated with other neoplasms
disorders of optic chiasm associated with vascular disorders
disorders of optic chiasm associated with inflammatory disorders
disorders of other visual pathways associated with neoplasms
disorders of other visual pathways associated with vascular disorders
disorders of other visual pathways associated with inflammatory disorders
disorders of visual cortex associated with neoplasms
disorders of visual cortex associated with vascular disorders
disorders of visual cortex associated with inflammatory disorders
cortical blindness
unspecified disorder of optic nerve and visual pathways
monocular exotropia
monocular exotropia with other noncomitancies
alternating exotropia
alternating exotropia with other noncomitancies
intermittent esotropia monocular
intermittent esotropia alternating
intermittent exotropia monocular
intermittent exotropia alternating
esophoria
exophoria
vertical heterophoria
cyclophoria
alternating hyperphoria
paralytic strabismus unspecified
third or oculomotor nerve palsy partial
third or oculomotor nerve palsy total
fourth or trochlear nerve palsy
sixth or abducens nerve palsy
external ophthalmoplegia
total ophthalmoplegia
mechanical strabismus unspecified
brown’s (tendon) sheath syndrome
mechanical strabismus from other musculofascial disorders
limited duction associated with other conditions
duane’s syndrome
progressive external ophthalmoplegia
strabismus in other neuromuscular disorders
palsy of conjugate gaze
spasm of conjugate gaze
convergence insufficiency or palsy
convergence excess or spasm
anomalies of divergence
internuclear ophthalmoplegia
other dissociated deviation of eye movements
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
378.9
379.12
379.13
379.14
379.15
379.16
379.19
379.21
379.22
379.23
379.24
379.25
379.26
379.29
379.31
379.32
379.33
379.34
379.39
379.40
379.41
379.42
379.43
379.45
379.46
379.49
379.50
379.51
379.52
379.53
379.54
379.55
379.56
379.57
379.58
379.59
379.92
380.02
380.03
380.10
381.00
381.01
381.02
381.03
381.04
381.05
381.06
381.10
381.19
381.20
unspecified disorder of eye movements
staphyloma posticum
equatorial staphyloma
anterior staphyloma localized
ring staphyloma
other degenerative disorders of sclera
other scleral disorders
vitreous degeneration
crystalline deposits in vitreous
vitreous hemorrhage
other vitreous opacities
vitreous membranes and strands
vitreous prolapse
other disorders of vitreous
aphakia
subluxation of lens
anterior dislocation of lens
posterior dislocation of lens
other disorders of lens
abnormal pupillary function unspecified
anisocoria
miosis (persistent) not due to miotics
mydriasis (persistent) not due to mydriatics
argyll robertson pupil atypical
tonic pupillary reaction
other anomalies of pupillary function
nystagmus unspecified
congenital nystagmus
latent nystagmus
visual deprivation nystagmus
nystagmus associated with disorders of the vestibular system
dissociated nystagmus
other forms of nystagmus
deficiencies of saccadic eye movements
deficiencies of smooth pursuit movements
other irregularities of eye movements
swelling or mass of eye
chronic perichondritis of pinna
chondritis of pinna
infective otitis externa unspecified
acute nonsuppurative otitis media unspecified
acute serous otitis media
acute mucoid otitis media
acute sanguinous otitis media
acute allergic serous otitis media
acute allergic mucoid otitis media
acute allergic sanguinous otitis media
chronic serous otitis media simple or unspecified
other chronic serous otitis media
chronic mucoid otitis media simple or unspecified
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
381.29
381.3
381.4
381.50
381.51
381.52
381.60
381.61
381.62
381.63
381.7
381.81
381.89
381.9
382.00
382.01
382.02
382.1
382.2
382.3
382.4
382.9
383.00
383.01
383.02
383.1
383.20
383.21
383.22
383.30
383.31
383.32
383.33
383.81
383.89
383.9
385.00
385.01
385.02
385.03
385.09
385.10
385.11
385.12
385.13
385.19
385.21
385.22
385.23
385.24
other chronic mucoid otitis media
other and unspecified chronic nonsuppurative otitis media
nonsuppurative otitis media not specified as acute or chronic
eustachian salpingitis unspecified
acute eustachian salpingitis
chronic eustachian salpingitis
obstruction of eustachian tube unspecified
osseous obstruction of eustachian tube
intrinsic cartilagenous obstruction of eustachian tube
extrinsic cartilagenous obstruction of eustachian tube
patulous eustachian tube
dysfunction of eustachian tube
other disorders of eustachian tube
unspecified eustachian tube disorder
acute suppurative otitis media without spontaneous rupture of eardrum
acute suppurative otitis media with spontaneous rupture of eardrum
acute suppurative otitis media in diseases classified elsewhere
chronic tubotympanic suppurative otitis media
chronic atticoantral suppurative otitis media
unspecified chronic suppurative otitis media
unspecified suppurative otitis media
unspecified otitis media
acute mastoiditis without complications
subperiosteal abscess of mastoid
acute mastoiditis with other complications
chronic mastoiditis
petrositis unspecified
acute petrositis
chronic petrositis
postmastoidectomy complication unspecified
mucosal cyst of postmastoidectomy cavity
recurrent cholesteatoma of postmastoidectomy cavity
granulations of postmastoidectomy cavity
postauricular fistula
other disorders of mastoid
unspecified mastoiditis
tympanosclerosis unspecified as to involvement
tympanosclerosis involving tympanic membrane only
tympanosclerosis involving tympanic membrane and ear ossicles
tympanosclerosis involving tympanic membrane ear ossicles and middle ear
tympanosclerosis involving other combination of structures
adhesive middle ear disease unspecified as to involvement
adhesions of drum head to incus
adhesions of drum head to stapes
adhesions of drum head to promontorium
other middle ear adhesions and combinations
impaired mobility of malleus
impaired mobility of other ear ossicles
discontinuity or dislocation of ear ossicles
partial loss or necrosis of ear ossicles
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
385.30
385.31
385.32
385.33
385.35
385.82
385.83
385.89
385.9
386.00
386.01
386.02
386.03
386.04
386.10
386.11
386.12
386.19
386.2
386.30
386.31
386.32
386.33
386.34
386.35
386.40
386.41
386.42
386.43
386.48
386.50
386.51
386.52
386.53
386.54
386.55
386.56
386.58
386.8
386.9
388.30
388.31
388.32
388.40
388.41
388.42
388.43
388.44
388.5
388.60
cholesteatoma unspecified
cholesteatoma of attic
cholesteatoma of middle ear
cholesteatoma of middle ear and mastoid
diffuse cholesteatosis of middle ear and mastoid
cholesterin granuloma of middle ear
retained foreign body of middle ear
other disorders of middle ear and mastoid
unspecified disorder of middle ear and mastoid
ménière’s disease, unspecified
active ménière’s disease, cochleovestibular
active ménière’s disease, cochlear
active ménière’s disease, vestibular
inactive ménière’s disease
peripheral vertigo unspecified
benign paroxysmal positional vertigo
vestibular neuronitis
other peripheral vertigo
vertigo of central origin
labyrinthitis unspecified
serous labyrinthitis
circumscribed labyrinthitis
suppurative labyrinthitis
toxic labyrinthitis
viral labyrinthitis
labyrinthine fistula unspecified
round window fistula
oval window fistula
semicircular canal fistula
labyrinthine fistula of combined sites
labyrinthine dysfunction unspecified
hyperactive labyrinth unilateral
hyperactive labyrinth bilateral
hypoactive labyrinth unilateral
hypoactive labyrinth bilateral
loss of labyrinthine reactivity unilateral
loss of labyrinthine reactivity bilateral
other forms and combinations of labyrinthine dysfunction
other disorders of labyrinth
unspecified vertiginous syndromes and labyrinthine disorders
tinnitus unspecified
subjective tinnitus
objective tinnitus
abnormal auditory perception unspecified
diplacusis
hyperacusis
impairment of auditory discrimination
auditory recruitment
disorders of acoustic nerve
otorrhea unspecified
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
388.61
388.69
388.70
388.71
388.72
388.8
388.9
389.00
389.01
389.02
389.03
389.04
389.05
389.06
389.08
389.10
389.11
389.12
389.13
389.14
389.15
389.16
389.17
389.18
389.22
415.12
423.3
430
431
432.0
432.1
432.9
433.00
433.01
433.10
433.11
433.20
433.21
433.30
433.31
433.80
433.81
433.90
434.00
434.01
434.10
434.11
434.90
434.91
435.0
cerebrospinal fluid otorrhea
other otorrhea
otalgia unspecified
otogenic pain
referred otogenic pain
other disorders of ear
unspecified disorder of ear
conductive hearing loss unspecified
conductive hearing loss external ear
conductive hearing loss tympanic membrane
conductive hearing loss middle ear
conductive hearing loss inner ear
conductive hearing loss, unilateral
conductive hearing loss, bilateral
conductive hearing loss of combined types
sensorineural hearing loss unspecified
sensory hearing loss, bilateral
neural hearing loss, bilateral
neural hearing loss, unilateral
central hearing loss
sensorineural hearing loss, unilateral
sensorineural hearing loss, asymmetrical
sensory hearing loss, unilateral
sensorineural hearing loss, bilateral
mixed hearing loss, bilateral
septic pulmonary embolism
cardiac tamponade
subarachnoid hemorrhage
intracerebral hemorrhage
nontraumatic extradural hemorrhage
subdural hemorrhage
unspecified intracranial hemorrhage
occlusion and stenosis of basilar artery without cerebral infarction
occlusion and stenosis of basilar artery with cerebral infarction
occlusion and stenosis of carotid artery without cerebral infarction
occlusion and stenosis of carotid artery with cerebral infarction
occlusion and stenosis of vertebral artery without cerebral infarction
occlusion and stenosis of vertebral artery with cerebral infarction
occlusion and stenosis of multiple and bilateral precerebral arteries without cerebral infarction
occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction
occlusion and stenosis of other specified precerebral artery without cerebral infarction
occlusion and stenosis of other specified precerebral artery with cerebral infarction
occlusion and stenosis of unspecified precerebral artery without cerebral infarction
cerebral thrombosis without cerebral infarction
cerebral thrombosis with cerebral infarction
cerebral embolism without cerebral infarction
cerebral embolism with cerebral infarction
cerebral artery occlusion unspecified without cerebral infarction
cerebral artery occlusion unspecified with cerebral infarction
basilar artery syndrome
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
435.1
435.2
435.3
435.8
435.9
437.0
437.1
437.2
437.3
437.4
437.5
437.6
437.7
437.8
437.9
438.0
438.10
438.11
438.12
438.19
438.20
438.21
438.22
438.30
438.31
438.32
438.40
438.41
438.42
438.50
438.51
438.52
438.53
438.6
438.7
438.81
438.82
438.83
438.84
438.85
438.89
438.9
443.21
443.24
461.0
461.1
461.2
461.3
461.8
461.9
vertebral artery syndrome
subclavian steal syndrome
vertebrobasilar artery syndrome
other specified transient cerebral ischemias
unspecified transient cerebral ischemia
cerebral atherosclerosis
other generalized ischemic cerebrovascular disease
hypertensive encephalopathy
cerebral aneurysm nonruptured
cerebral arteritis
moyamoya disease
nonpyogenic thrombosis of intracranial venous sinus
transient global amnesia
other ill-defined cerebrovascular disease
unspecified cerebrovascular disease
cognitive deficits
speech and language deficit unspecified
aphasia
dysphasia
other speech and language deficits
hemiplegia affecting unspecified side
hemiplegia affecting dominant side
hemiplegia affecting nondominant side
monoplegia of upper limb affecting unspecified side
monoplegia of upper limb affecting dominant side
monoplegia of upper limb affecting nondominant side
monoplegia of lower limb affecting unspecified side
monoplegia of lower limb affecting dominant side
monoplegia of lower limb affecting nondominant side
other paralytic syndrome affecting unspecified side
other paralytic syndrome affecting dominant side
other paralytic syndrome affecting nondominant side
other paralytic syndrome bilateral
alterations of sensations
disturbances of vision
apraxia cerebrovascular disease
dysphagia cerebrovascular disease
facial weakness
ataxia
vertigo
other late effects of cerebrovascular disease
unspecified late effects of cerebrovascular disease
dissection of carotid artery
dissection of vertebral artery
acute maxillary sinusitis
acute frontal sinusitis
acute ethmoidal sinusitis
acute sphenoidal sinusitis
other acute sinusitis
acute sinusitis unspecified
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
462
473.0
473.1
473.2
473.3
473.8
473.9
475
476.0
476.1
478.19
478.22
478.24
478.26
478.30
478.31
478.32
478.33
478.34
478.4
519.8
524.00
524.01
524.02
524.03
524.04
524.05
524.06
524.07
524.09
524.10
524.11
524.12
524.19
524.4
524.50
524.51
524.52
524.53
524.54
524.55
524.56
524.57
524.60
524.61
524.62
526.1
526.2
526.3
526.4
acute pharyngitis
chronic maxillary sinusitis
chronic frontal sinusitis
chronic ethmoidal sinusitis
chronic sphenoidal sinusitis
other chronic sinusitis
unspecified sinusitis (chronic)
peritonsillar abscess
chronic laryngitis
chronic laryngotracheitis
other disease of nasal cavity and sinuses
parapharyngeal abscess
retropharyngeal abscess
cyst of pharynx or nasopharynx
unspecified paralysis of vocal cords
partial unilateral paralysis of vocal cords
complete unilateral paralysis of vocal cords
partial bilateral paralysis of vocal cords
complete bilateral paralysis of vocal cords
polyp of vocal cord or larynx
other diseases of respiratory system not elsewhere classified
major anomalies of jaw size unspecified anomaly
major anomalies of jaw size maxillary hyperplasia
major anomalies of jaw size mandibular hyperplasia
major anomalies of jaw size maxillary hypoplasia
major anomalies of jaw size mandibular hypoplasia
major anomalies of jaw size macrogenia
major anomalies of jaw size microgenia
excessive tuberosity of jaw
major anomalies of jaw size other specified anomaly
anomalies of relationship of jaw to cranial base unspecified anomaly
anomalies of relationship of jaw to cranial base maxillary asymmetry
anomalies of relationship of jaw to cranial base other jaw asymmetry
anomalies of relationship of jaw to cranial base other specified anomaly
malocclusion unspecified
dentofacial functional abnormality, unspecified
abnormal jaw closure
limited mandibular range of motion
deviation in opening and closing of the mandible
insufficient anterior guidance
centric occlusion maximum intercuspation discrepancy
non-working side interference
lack of posterior occlusal support
temporomandibular joint disorders unspecified
temporomandibular joint disorders adhesions and ankylosis (bony or fibrous)
temporomandibular joint disorders arthralgia of temporomandibular joint
fissural cysts of jaw
other cysts of jaws
central giant cell (reparative) granuloma
inflammatory conditions of jaw
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
526.5
526.81
526.89
526.9
527.0
527.1
527.2
527.3
527.4
527.5
527.6
527.7
527.8
527.9
528.3
530.86
530.87
683
718.78
718.79
718.98
719.08
723.4
729.2
733.3
733.45
742.0
742.1
742.2
742.3
742.4
742.51
742.53
742.59
742.8
742.9
743.00
743.03
743.06
743.10
743.11
743.12
743.20
743.21
743.22
743.30
743.31
743.32
743.33
743.34
alveolitis of jaw
exostosis of jaw
other specified diseases of the jaws
unspecified disease of the jaws
atrophy of salivary gland
hypertrophy of salivary gland
sialoadenitis
abscess of salivary gland
fistula of salivary gland
sialolithiasis
mucocele of salivary gland
disturbance of salivary secretion
other specified diseases of the salivary glands
unspecified disease of the salivary glands
cellulitis and abscess of oral soft tissues
infection of esophagostomy
mechanical complication of esophagostomy
acute lymphadenitis
developmental dislocation of joint other specified site
developmental dislocation of joint multiple sites
unspecified derangement of joint of other specified sites
effusion of joint of other specified sites
brachial neuritis or radiculitis nos
neuralgia neuritis and radiculitis unspecified
hyperostosis of skull
aseptic necrosis of bone, jaw
encephalocele
microcephalus
congenital reduction deformities of brain
congenital hydrocephalus
other specified congenital anomalies of brain
diastematomyelia
hydromyelia
other specified congenital anomalies of spinal cord
other specified congenital anomalies of nervous system
unspecified congenital anomaly of brain spinal cord and nervous system
clinical anophthalmos unspecified
cystic eyeball congenital
cryptophthalmos
microphthalmos unspecified
simple microphthalmos
microphthalmos associated with other anomalies of eye and adnexa
buphthalmos unspecified
simple buphthalmos
buphthalmos associated with other ocular anomalies
congenital cataract unspecified
congenital capsular and subcapsular cataract
congenital cortical and zonular cataract
congenital nuclear cataract
congenital total and subtotal cataract
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
743.35
743.36
743.37
743.39
743.41
743.42
743.43
743.44
743.45
743.46
743.47
743.48
743.49
743.51
743.52
743.53
743.54
743.55
743.56
743.57
743.58
743.59
743.8
743.9
744.00
744.01
744.02
744.03
744.04
744.05
744.09
744.1
744.21
744.22
744.23
744.24
744.29
744.3
744.41
744.42
744.43
744.46
744.47
744.49
744.5
744.81
744.82
744.83
744.84
744.89
congenital aphakia
congenital anomalies of lens shape
congenital ectopic lens
other congenital cataract and lens anomalies
congenital anomalies of corneal size and shape
congenital corneal opacities interfering with vision
other congenital corneal opacities
specified congenital anomalies of anterior chamber chamber angle and related structures
aniridia
other specified congenital anomalies of iris and ciliary body
specified congenital anomalies of sclera
multiple and combined congenital anomalies of anterior segment
other congenital anomalies of anterior segment
vitreous anomalies congenital
fundus coloboma
chorioretinal degeneration congenital
congenital folds and cysts of posterior segment
congenital macular changes
other retinal changes congenital
specified congenital anomalies of optic disc
vascular anomalies congenital
other congenital anomalies of posterior segment
other specified anomalies of eye congenital
unspecified anomaly of eye congenital
unspecified congenital anomaly of ear with impairment of hearing
congenital absence of external ear
other congenital anomalies of external ear with impairment of hearing
congenital anomaly of middle ear except ossicles
congenital anomalies of ear ossicles
congenital anomalies of inner ear
other congenital anomalies of ear causing impairment of hearing
accessory auricle
absence of ear lobe congenital
macrotia
microtia
specified congenital anomalies of eustachian tube
other congenital anomalies of ear
unspecified congenital anomaly of ear
branchial cleft sinus or fistula
branchial cleft cyst
cervical auricle
preauricular sinus or fistula
preauricular cyst
other branchial cleft cyst or fistula; preauricular sinus
webbing of neck
macrocheilia
microcheilia
macrostomia
microstomia
other specified congenital anomalies of face and neck
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
744.9
747.81
748.0
748.1
748.2
748.3
748.9
754.0
754.1
759.2
780.01
780.02
780.03
780.09
780.1
780.2
780.31
780.32
780.39
780.4
780.53
780.61
780.62
780.64
780.93
781.0
781.1
781.2
781.3
781.4
781.8
781.94
784.0
784.1
784.2
784.3
784.40
784.41
784.49
784.5
784.60
784.61
784.69
784.7
784.8
784.91
785.6
786.1
787.20
787.21
unspecified congenital anomalies of face and neck
congenital anomalies of cerebrovascular system
choanal atresia
other congenital anomalies of nose
web of larynx
other congenital anomalies of larynx trachea and bronchus
unspecified congenital anomaly of respiratory system
congenital musculoskeletal deformities of skull face and jaw
congenital musculoskeletal deformities of sternocleidomastoid muscle
anomalies of other endocrine glands congenital
coma
transient alteration of awareness
persistent vegetative state
alteration of consciousness other
hallucinations
syncope and collapse
febrile convulsions (simple), unspecified
complex febrile convulsions
other convulsions
dizziness and giddiness
hypersomnia with sleep apnea, unspecified
fever presenting with conditions classified elsewhere
postprocedural fever
chills (without fever)
memory loss
abnormal involuntary movements
disturbances of sensation of smell and taste
abnormality of gait
lack of coordination
transient paralysis of limb
neurological neglect syndrome
facial weakness
headache
throat pain
swelling mass or lump in head and neck
aphasia
voice disturbance unspecified
aphonia
other voice disturbance
other speech disturbance
symbolic dysfunction unspecified
alexia and dyslexia
other symbolic dysfunction
epistaxis
hemorrhage from throat
postnasal drip
enlargement of lymph nodes
stridor
dysphagia, unspecified
dysphagia, oral phase
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
787.22
787.23
787.24
787.29
793.0
794.00
794.01
794.02
794.09
800.00
800.01
800.02
800.03
800.04
800.05
800.06
800.09
800.10
800.11
800.12
800.13
800.14
800.15
800.16
800.19
800.20
800.21
800.22
800.23
800.24
800.25
800.26
dysphagia, oropharyngeal phase
dysphagia, pharyngeal phase
dysphagia, pharyngoesophageal phase
other dysphagia
nonspecific abnormal findings on radiological and other examination of skull and head
unspecified abnormal function study of brain and central nervous system
nonspecific abnormal echoencephalogram
nonspecific abnormal electroencephalogram (eeg)
other nonspecific abnormal results of function study of brain and central nervous system
closed fracture of vault of skull without intracranial injury with state of consciousness unspecified
closed fracture of vault of skull without intracranial injury with no loss of consciousness
closed fracture of vault of skull without intracranial injury with brief (less than one hour) loss of consciousness
closed fracture of vault of skull without intracranial injury with moderate (1-24 hours) loss of consciousness
closed fracture of vault of skull without intracranial injury with prolonged (more than 24 hours) loss of
consciousness and return to pre-existing conscious level
closed fracture of vault of skull without intracranial injury with prolonged (more than 24 hours) loss of
consciousness without return to pre-existing conscious level
closed fracture of vault of skull without intra cranial injury with loss of consciousness of unspecified
duration
closed fracture of vault of skull without intracranial injury with concussion unspecified
closed fracture of vault of skull with cerebral laceration and contusion with state of consciousness unspecified
closed fracture of vault of skull with cerebral laceration and contusion with no loss of consciousness
closed fracture of vault of skull with cerebral laceration and contusion with brief (less than one hour)
loss of consciousness
closed fracture of vault of skull with cerebral laceration and contusion with moderate (1-24 hours) loss
of consciousness
closed fracture of vault of skull with cerebral laceration and contusion with prolonged (more than 24
hours) loss of consciousness and return to pre-existing conscious level
closed fracture of vault of skull with cerebral laceration and contusion with prolonged (more than 24
hours) loss of consciousness without return to pre-existing conscious level
closed fracture of vault of skull with cerebral laceration and contusion with loss of consciousness of
unspecified duration
closed fracture of vault of skull with cerebral laceration and contusion with concussion unspecified
closed fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with state of
consciousness unspecified
closed fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with no loss of
consciousness
closed fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with brief (less
than one hour) loss of consciousness
closed fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with moderate
(1-24 hours) loss of consciousness
closed fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
closed fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
closed fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with loss of
consciousness of unspecified duration
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
800.29
800.30
800.31
800.32
800.33
800.34
800.35
800.36
800.39
800.40
800.41
800.42
800.43
800.44
800.45
800.46
800.49
800.50
800.51
800.52
800.53
800.54
800.55
800.56
800.59
800.60
800.61
closed fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with concussion unspecified
closed fracture of vault of skull with other and unspecified intracranial hemorrhage with state of consciousness unspecified
closed fracture of vault of skull with other and unspecified intracranial hemorrhage with no loss of consciousness
closed fracture of vault of skull with other and unspecified intracranial hemorrhage with brief (less
than one hour) loss of consciousness
closed fracture of vault of skull with other and unspecified intracranial hemorrhage with moderate (124 hours) loss of consciousness
closed fracture of vault of skull with other and unspecified intracranial hemorrhage with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
closed fracture of vault of skull with other and unspecified intracranial hemorrhage with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
closed fracture of vault of skull with other and unspecified intracranial hemorrhage with loss of consciousness of unspecified duration
closed fracture of vault of skull with other and unspecified intracranial hemorrhage with concussion
unspecified
closed fracture of vault of skull with intracranial injury of other and unspecified nature with state of
consciousness unspecified
closed fracture of vault of skull with intracranial injury of other and unspecified nature with no loss of
consciousness
closed fracture of vault of skull with intracranial injury of other and unspecified nature with brief (less
than one hour) loss of consciousness
closed fracture of vault of skull with intracranial injury of other and unspecified nature with moderate
(1-24 hours) loss of consciousness
closed fracture of vault of skull with intracranial injury of other and unspecified nature with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
closed fracture of vault of skull with intracranial injury of other and unspecified nature with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
closed fracture of vault of skull with intracranial injury of other and unspecified nature with loss of consciousness of unspecified duration
closed fracture of vault of skull with intracranial injury of other and unspecified nature with concussion
unspecified
open fracture of vault of skull without intracranial injury with state of consciousness unspecified
open fracture of vault of skull without intracranial injury with no loss of consciousness
open fracture of vault of skull without intracranial injury with brief (less than one hour) loss of consciousness
open fracture of vault of skull without intracranial injury with moderate (1-24 hours) loss of consciousness
open fracture of vault of skull without intracranial injury with prolonged (more than 24 hours) loss of
consciousness and return to pre-existing conscious level
open fracture of vault of skull without intracranial injury with prolonged (more than 24 hours) loss of
consciousness without return to pre-existing conscious level
open fracture of vault of skull without intracranial injury with loss of consciousness of unspecified duration
open fracture of vault of skull without intracranial injury with concussion unspecified
open fracture of vault of skull with cerebral laceration and contusion with state of consciousness unspecified
open fracture of vault of skull with cerebral laceration and contusion with no loss of consciousness
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
800.62
800.63
800.64
800.65
800.66
800.69
800.70
800.71
800.72
800.73
800.74
800.75
800.76
800.79
800.80
800.81
800.82
800.83
800.84
800.85
800.86
800.89
800.90
800.91
800.92
open fracture of vault of skull with cerebral laceration and contusion with brief (less than one hour)
loss of consciousness
open fracture of vault of skull with cerebral laceration and contusion with moderate (1-24 hours) loss
of consciousness
open fracture of vault of skull with cerebral laceration and contusion with prolonged (more than 24
hours) loss of consciousness and return to pre-existing conscious level
open fracture of vault of skull with cerebral laceration and contusion with prolonged (more than 24
hours) loss of consciousness without return to pre-existing conscious level
open fracture of vault of skull with cerebral laceration and contusion with loss of consciousness of unspecified duration
open fracture of vault of skull with cerebral laceration and contusion with concussion unspecified
open fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with state of
consciousness unspecified
open fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with no loss of
consciousness
open fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with brief (less
than one hour) loss of consciousness
open fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with moderate
(1-24 hours) loss of consciousness
open fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
open fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
open fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with loss of consciousness of unspecified duration
open fracture of vault of skull with subarachnoid subdural and extradural hemorrhage with concussion
unspecified
open fracture of vault of skull with other and unspecified intracranial hemorrhage with state of consciousness unspecified
open fracture of vault of skull with other and unspecified intracranial hemorrhage with no loss of consciousness
open fracture of vault of skull with other and unspecified intracranial hemorrhage with brief (less than
one hour) loss of consciousness
open fracture of vault of skull with other and unspecified intracranial hemorrhage with moderate (1-24
hours) loss of consciousness
open fracture of vault of skull with other and unspecified intracranial hemorrhage with prolonged
(more than 24 hours)loss of consciousness and return to pre-existing conscious level
open fracture of vault of skull with other and unspecified intracranial hemorrhage with prolonged
(more than 24 hours)loss of consciousness without return to pre-existing conscious level
open fracture of vault of skull with other and unspecified intracranial hemorrhage with loss of consciousness of unspecified duration
open fracture of vault of skull with other and unspecified intracranial hemorrhage with concussion
unspecified
open fracture of vault of skull with intracranial injury of other and unspecified nature with state of consciousness unspecified
open fracture of vault of skull with intracranial injury of other and unspecified nature with no loss of
consciousness
open fracture of vault of skull with intracranial injury of other and unspecified nature with brief (less
than one hour) loss of consciousness
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
800.93
800.94
800.95
800.96
800.99
801.00
801.01
801.02
801.03
801.04
801.05
801.06
801.09
801.10
801.11
801.12
801.13
801.14
801.15
801.16
801.19
801.20
801.21
801.22
801.23
801.24
801.25
open fracture of vault of skull with intracranial injury of other and unspecified nature with moderate (124 hours) loss of consciousness
open fracture of vault of skull with intracranial injury of other and unspecified nature with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
open fracture of vault of skull with intracranial injury of other and unspecified nature with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
open fracture of vault of skull with intracranial injury of other and unspecified nature with loss of consciousness of unspecified duration
open fracture of vault of skull with intracranial injury of other and unspecified nature with concussion
unspecified
closed fracture of base of skull without intra cranial injury with state of consciousness unspecified
closed fracture of base of skull without intra cranial injury with no loss of consciousness
closed fracture of base of skull without intra cranial injury with brief (less than one hour) loss of consciousness
closed fracture of base of skull without intra cranial injury with moderate (1-24 hours) loss of consciousness
closed fracture of base of skull without intra cranial injury with prolonged (more than 24 hours) loss of
consciousness and return to pre-existing conscious level
closed fracture of base of skull without intra cranial injury with prolonged (more than 24 hours) loss of
consciousness without return to pre-existing conscious level
closed fracture of base of skull without intra cranial injury with loss of consciousness of unspecified
duration
closed fracture of base of skull without intra cranial injury with concussion unspecified
closed fracture of base of skull with cerebral laceration and contusion with state of consciousness unspecified
closed fracture of base of skull with cerebral laceration and contusion with no loss of consciousness
closed fracture of base of skull with cerebral laceration and contusion with brief (less than one hour)
loss of consciousness
closed fracture of base of skull with cerebral laceration and contusion with moderate (1-24 hours) loss
of consciousness
closed fracture of base of skull with cerebral laceration and contusion with prolonged (more than 24
hours) loss of consciousness and return to pre-existing conscious level
closed fracture of base of skull with cerebral laceration and contusion with prolonged (more than 24
hours) loss of consciousness without return to pre-existing conscious level
closed fracture of base of skull with cerebral laceration and contusion with loss of consciousness of
unspecified duration
closed fracture of base of skull with cerebral laceration and contusion with concussion unspecified
closed fracture of base of skull with subarachnoid subdural and extradural hemorrhage with state of
consciousness unspecified
closed fracture of base of skull with subarachnoid subdural and extradural hemorrhage with no loss of
consciousness
closed fracture of base of skull with subarachnoid subdural and extradural hemorrhage with brief (less
than one hour) loss of consciousness
closed fracture of base of skull with subarachnoid subdural and extradural hemorrhage with moderate
(1-24 hours) loss of consciousness
closed fracture of base of skull with subarachnoid subdural and extradural hemorrhage with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
closed fracture of base of skull with subarachnoid subdural and extradural hemorrhage with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
801.26
801.29
801.30
801.31
801.32
801.33
801.34
801.35
801.36
801.39
801.40
801.41
801.42
801.43
801.44
801.45
801.46
801.49
801.50
801.51
801.52
801.53
801.54
801.55
801.56
801.59
closed fracture of base of skull with subarachnoid subdural and extradural hemorrhage with loss of
consciousness of unspecified duration
closed fracture of base of skull with subarachnoid subdural and extradural hemorrhage with concussion unspecified
closed fracture of base of skull with other and unspecified intracranial hemorrhage with state of consciousness unspecified
closed fracture of base of skull with other and unspecified intracranial hemorrhage with no loss of consciousness
closed fracture of base of skull with other and unspecified intracranial hemorrhage with brief (less than
one hour) loss of consciousness
closed fracture of base of skull with other and unspecified intracranial hemorrhage with moderate (124 hours) loss of consciousness
closed fracture of base of skull with other and unspecified intracranial hemorrhage with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
closed fracture of base of skull with other and unspecified intracranial hemorrhage with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
closed fracture of base of skull with other and unspecified intracranial hemorrhage with loss of consciousness of unspecified duration
closed fracture of base of skull with other and unspecified intracranial hemorrhage with concussion
unspecified
closed fracture of base of skull with intracranial injury of other and unspecified nature with state of
consciousness unspecified
closed fracture of base of skull with intracranial injury of other and unspecified nature with no loss of
consciousness
closed fracture of base of skull with intracranial injury of other and unspecified nature with brief (less
than one hour) loss of consciousness
closed fracture of base of skull with intracranial injury of other and unspecified nature with moderate
(1-24 hours) loss of consciousness
closed fracture of base of skull with intracranial injury of other and unspecified nature with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
closed fracture of base of skull with intracranial injury of other and unspecified nature with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
closed fracture of base of skull with intracranial injury of other and unspecified nature with loss of consciousness of unspecified duration
closed fracture of base of skull with intracranial injury of other and unspecified nature with concussion
unspecified
open fracture of base of skull without intracranial injury with state of consciousness unspecified
open fracture of base of skull without intracranial injury with no loss of consciousness
open fracture of base of skull without intracranial injury with brief (less than one hour) loss of consciousness
open fracture of base of skull without intracranial injury with moderate (1-24 hours) loss of consciousness
open fracture of base of skull without intracranial injury with prolonged (more than 24 hours) loss of
consciousness and return to pre-existing conscious level
open fracture of base of skull without intracranial injury with prolonged (more than 24 hours) loss of
consciousness without return to pre-existing conscious level
open fracture of base of skull without intracranial injury with loss of consciousness of unspecified duration
open fracture of base of skull without intracranial injury with concussion unspecified
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
801.60
801.61
801.62
801.63
801.64
801.65
801.66
801.69
801.70
801.71
801.72
801.73
801.74
801.75
801.76
801.79
801.80
801.81
801.82
801.83
801.84
801.85
801.86
801.89
801.90
801.91
open fracture of base of skull with cerebral laceration and contusion with state of consciousness unspecified
open fracture of base of skull with cerebral laceration and contusion with no loss of consciousness
open fracture of base of skull with cerebral laceration and contusion with brief (less than one hour)
loss of consciousness
open fracture of base of skull with cerebral laceration and contusion with moderate (1-24 hours) loss of
consciousness
open fracture of base of skull with cerebral laceration and contusion with prolonged (more than 24
hours) loss of consciousness and return to pre-existing conscious level
open fracture of base of skull with cerebral laceration and contusion with prolonged (more than 24
hours) loss of consciousness without return to pre-existing conscious level
open fracture of base of skull with cerebral laceration and contusion with loss of consciousness of unspecified duration
open fracture of base of skull with cerebral laceration and contusion with concussion unspecified
open fracture of base of skull with subarachnoid subdural and extradural hemorrhage with state of
consciousness unspecified
open fracture of base of skull with subarachnoid subdural and extradural hemorrhage with no loss of
consciousness
open fracture of base of skull with subarachnoid subdural and extradural hemorrhage with brief (less
than one hour) loss of consciousness
open fracture of base of skull with subarachnoid subdural and extradural hemorrhage with moderate
(1-24 hours) loss of consciousness
open fracture of base of skull with subarachnoid subdural and extradural hemorrhage with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
open fracture of base of skull with subarachnoid subdural and extradural hemorrhage with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
open fracture of base of skull with subarachnoid subdural and extradural hemorrhage with loss of consciousness of unspecified duration
open fracture of base of skull with subarachnoid subdural and extradural hemorrhage with concussion
unspecified
open fracture of base of skull with other and unspecified intracranial hemorrhage with state of consciousness unspecified
open fracture of base of skull with other and unspecified intracranial hemorrhage with no loss of consciousness
open fracture of base of skull with other and unspecified intracranial hemorrhage with brief (less than
one hour) loss of consciousness
open fracture of base of skull with other and unspecified intracranial hemorrhage with moderate (1-24
hours) loss of consciousness
open fracture of base of skull with other and unspecified intracranial hemorrhage with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
open fracture of base of skull with other and unspecified intracranial hemorrhage with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
open fracture of base of skull with other and unspecified intracranial hemorrhage with loss of consciousness of unspecified duration
open fracture of base of skull with other and unspecified intracranial hemorrhage with concussion unspecified
open fracture of base of skull with intracranial injury of other and unspecified nature with state of consciousness unspecified
open fracture of base of skull with intracranial injury of other and unspecified nature with no loss of
consciousness
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
801.92
801.93
801.94
801.95
801.96
801.99
802.4
802.5
802.6
802.7
802.8
803.00
803.01
803.02
803.03
803.04
803.05
803.06
803.09
803.10
803.11
803.12
803.13
803.14
803.15
803.16
803.19
803.20
803.21
803.22
803.23
open fracture of base of skull with intracranial injury of other and unspecified nature with brief (less
than one hour) loss of consciousness
open fracture of base of skull with intracranial injury of other and unspecified nature with moderate (124 hours) loss of consciousness
open fracture of base of skull with intracranial injury of other and unspecified nature with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
open fracture of base of skull with intracranial injury of other and unspecified nature with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
open fracture of base of skull with intracranial injury of other and unspecified nature with loss of consciousness of unspecified duration
open fracture of base of skull with intracranial injury of other and unspecified nature with concussion
unspecified
closed fracture of malar and maxillary bones
open fracture of malar and maxillary bones
closed fracture of orbital floor (blow-out)
open fracture of orbital floor (blow-out)
closed fracture of other facial bones
other closed skull fracture without intracranial injury with state of consciousness unspecified
other closed skull fracture without intracranial injury with no loss of consciousness
other closed skull fracture without intracranial injury with brief (less than one hour) loss of consciousness
other closed skull fracture without intracranial injury with moderate (1-24 hours) loss of consciousness
other closed skull fracture without intracranial injury with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level
other closed skull fracture without intracranial injury with prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level
other closed skull fracture without intracranial injury with loss of consciousness of unspecified duration
other closed skull fracture without intracranial injury with concussion unspecified
other closed skull fracture with cerebral laceration and contusion with state of consciousness unspecified
other closed skull fracture with cerebral laceration and contusion with no loss of consciousness
other closed skull fracture with cerebral laceration and contusion with brief (less than one hour) loss of
consciousness
other closed skull fracture with cerebral laceration and contusion with moderate (1-24 hours) loss of
consciousness
other closed skull fracture with cerebral laceration and contusion with prolonged (more than 24 hours)
loss of consciousness and return to pre-existing conscious level
other closed skull fracture with cerebral laceration and contusion with prolonged (more than 24 hours)
loss of consciousness without return to pre-existing conscious level
other closed skull fracture with cerebral laceration and contusion with loss of consciousness of unspecified duration
other closed skull fracture with cerebral laceration and contusion with concussion unspecified
other closed skull fracture with subarachnoid subdural and extradural hemorrhage with state of consciousness unspecified
other closed skull fracture with subarachnoid subdural and extradural hemorrhage with no loss of consciousness
other closed skull fracture with subarachnoid subdural and extradural hemorrhage with brief (less than
one hour) loss of consciousness
other closed skull fracture with subarachnoid subdural and extradural hemorrhage with moderate (1-24
hours) loss of consciousness
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
803.24
803.25
803.26
803.29
803.30
803.31
803.32
803.33
803.34
803.35
803.36
803.39
803.40
803.41
803.42
803.43
803.44
803.45
803.46
803.49
803.50
803.51
803.52
803.53
803.54
803.55
803.56
other closed skull fracture with subarachnoid subdural and extradural hemorrhage with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
other closed skull fracture with subarachnoid subdural and extradural hemorrhage with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
other closed skull fracture with subarachnoid subdural and extradural hemorrhage with loss of consciousness of unspecified duration
other closed skull fracture with subarachnoid subdural and extradural hemorrhage with concussion
unspecified
other closed skull fracture with other and unspecified intracranial hemorrhage with state of unconsciousness unspecified
other closed skull fracture with other and unspecified intracranial hemorrhage with no loss of consciousness
other closed skull fracture with other and unspecified intracranial hemorrhage with brief (less than one
hour) loss of consciousness
other closed skull fracture with other and unspecified intracranial hemorrhage with moderate (1-24
hours) loss of consciousness
other closed skull fracture with other and unspecified intracranial hemorrhage with prolonged (more
than 24 hours) loss of consciousness and return to pre-existing conscious level
other closed skull fracture with other and unspecified intracranial hemorrhage with prolonged (more
than 24 hours) loss of consciousness without return to pre-existing conscious level
other closed skull fracture with other and unspecified intracranial hemorrhage with loss of consciousness of unspecified duration
other closed skull fracture with other and unspecified intracranial hemorrhage with concussion unspecified
other closed skull fracture with intracranial injury of other and unspecified nature with state of consciousness unspecified
other closed skull fracture with intracranial injury of other and unspecified nature with no loss of consciousness
other closed skull fracture with intracranial injury of other and unspecified nature with brief (less than
one hour) loss of consciousness
other closed skull fracture with intracranial injury of other and unspecified nature with moderate (1-24
hours) loss of consciousness
other closed skull fracture with intracranial injury of other and unspecified nature with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
other site of closed skull fracture with intracranial injury of other and unspecified nature with prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level
other site of closed skull fracture with intracranial injury of other and unspecified nature with loss of
consciousness of unspecified duration
other site of closed skull fracture with intracranial injury of other and unspecified nature with concussion unspecified
other open skull fracture without injury with state of consciousness unspecified
other open skull fracture without intracranial injury with no loss of consciousness
other open skull fracture without intracranial injury with brief (less than one hour) loss of consciousness
other open skull fracture without intracranial injury with moderate (1-24 hours) loss of consciousness
other open skull fracture without intracranial injury with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level
other open skull fracture without intracranial injury with prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level
other open skull fracture without intracranial injury with loss of consciousness of unspecified duration
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
803.59
803.60
803.61
803.62
803.63
803.64
803.65
803.66
803.69
803.70
803.71
803.72
803.73
803.74
803.75
803.76
803.79
803.80
803.81
803.82
803.83
803.84
803.85
803.86
803.89
803.90
other open skull fracture without intracranial injury with concussion unspecified
other open skull fracture with cerebral laceration and contusion with state of consciousness unspecified
other open skull fracture with cerebral laceration and contusion with no loss of consciousness
other open skull fracture with cerebral laceration and contusion with brief (less than one hour) loss of
consciousness
other open skull fracture with cerebral laceration and contusion with moderate (1-24 hours) loss of
consciousness
other open skull fracture with cerebral laceration and contusion with prolonged (more than 24 hours)
loss of consciousness and return to pre-existing conscious level
other open skull fracture with cerebral laceration and contusion with prolonged (more than 24 hours)
loss of consciousness without return to pre-existing conscious level
other open skull fracture with cerebral laceration and contusion with loss of consciousness of unspecified duration
other open skull fracture with cerebral laceration and contusion with concussion unspecified
other open skull fracture with subarachnoid subdural and extradural hemorrhage with state of consciousness unspecified
other open skull fracture with subarachnoid subdural and extradural hemorrhage with no loss of consciousness
other open skull fracture with subarachnoid subdural and extradural hemorrhage with brief (less than
one hour) loss of consciousness
other open skull fracture with subarachnoid subdural and extradural hemorrhage with moderate (1-24
hours) loss of consciousness
other open skull fracture with subarachnoid subdural and extradural hemorrhage with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
other open skull fracture with subarachnoid subdural and extradural hemorrhage with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
other open skull fracture with subarachnoid subdural and extradural hemorrhage with loss of consciousness of unspecified duration
other open skull fracture with subarachnoid subdural and extradural hemorrhage with concussion unspecified
other open skull fracture with other and unspecified intracranial hemorrhage with state of consciousness unspecified
other open skull fracture with other and unspecified intracranial hemorrhage with no loss of consciousness
other open skull fracture with other and unspecified intracranial hemorrhage with brief (less than one
hour) loss of consciousness
other open skull fracture with other and unspecified intracranial hemorrhage with moderate (1-24
hours) loss of consciousness
other open skull fracture with other and unspecified intracranial hemorrhage with prolonged (more
than 24 hours) loss of consciousness and return to pre-existing conscious level
other open skull fracture with other and unspecified intracranial hemorrhage with prolonged (more
than 24 hours) loss of consciousness without return to pre-existing conscious level
other open skull fracture with other and unspecified intracranial hemorrhage with loss of consciousness of unspecified duration
other open skull fracture with other and unspecified intracranial hemorrhage with concussion unspecified
other open skull fracture with intracranial injury of other and unspecified nature with state of consciousness unspecified
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
803.91
803.92
803.93
803.94
803.95
803.96
803.99
804.00
804.01
804.02
804.03
804.04
804.05
804.06
804.09
804.10
804.11
804.12
804.13
804.14
804.15
804.16
804.19
804.20
804.21
other open skull fracture with intracranial injury of other and unspecified nature with no loss of consciousness
other open skull fracture with intracranial injury of other and unspecified nature with brief (less than
one hour) loss of consciousness
other open skull fracture with intracranial injury of other and unspecified nature with moderate (1-24
hours) loss of consciousness
other open skull fracture with intracranial injury of other and unspecified nature with prolonged (more
than 24 hours) loss of consciousness and return to pre-existing conscious level
other open skull fracture with intracranial injury of other and unspecified nature with prolonged (more
than 24 hours) loss of consciousness without return to pre-existing conscious level
other open skull fracture with intracranial injury of other and unspecified nature with loss of consciousness of unspecified duration
other open skull fracture with intracranial injury of other and unspecified nature with concussion unspecified
closed fractures involving skull or face with other bones without intracranial injury with state of consciousness unspecified
closed fractures involving skull or face with other bones without intracranial injury with no loss of consciousness
closed fractures involving skull or face with other bones without intracranial injury with brief (less than
one hour) loss of consciousness
closed fractures involving skull or face with other bones without intracranial injury with moderate (1-24
hours) loss of consciousness
closed fractures involving skull or face with other bones without mention or intracranial injury with
prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level
closed fractures involving skull of face with other bones without intracranial injury with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
closed fractures involving skull of face with other bones without intracranial injury with loss of consciousness of unspecified duration
closed fractures involving skull of face with other bones without intracranial injury with concussion
unspecified
closed fractures involving skull or face with other bones with cerebral laceration and contusion with
state of consciousness unspecified
closed fractures involving skull or face with other bones with cerebral laceration and contusion with no
loss of consciousness
closed fractures involving skull or face with other bones with cerebral laceration and contusion with
brief (less than one hour) loss of consciousness
closed fractures involving skull or face with other bones with cerebral laceration and contusion with
moderate (1-24 hours) loss of consciousness
closed fractures involving skull or face with other bones with cerebral laceration and contusion with
prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level
closed fractures involving skull or face with other bones with cerebral laceration and contusion with
prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level
closed fractures involving skull or face with other bones with cerebral laceration and contusion with
loss of consciousness of unspecified duration
closed fractures involving skull or face with other bones with cerebral laceration and contusion with
concussion unspecified
closed fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with state of consciousness unspecified
closed fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with no loss of consciousness
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
804.22
804.23
804.24
804.25
804.26
804.29
804.30
804.31
804.32
804.33
804.34
804.35
804.36
804.39
804.40
804.41
804.42
804.43
804.44
804.45
804.46
804.49
closed fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with brief (less than one hour) loss of consciousness
closed fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with moderate (1-24 hours) loss of consciousness
closed fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with prolonged (more than 24 hours) loss of consciousness and return to pre-existing
conscious level
closed fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with prolonged (more than 24 hours) loss of consciousness without return to pre-existing
conscious level
closed fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with loss of consciousness of unspecified duration
closed fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with concussion unspecified
closed fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with state of consciousness unspecified
closed fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with no loss of consciousness
closed fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with brief (less than one hour) loss of consciousness
closed fractures involving skull or face with other bones with other and unspecified intracranial hemorrrhage with moderate (1-24 hours) loss of consciousness
closed fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with prolonged (more than 24 hours) loss of consciousness and return to pre- existing conscious
level
closed fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with prolonged (more than 24 hours) loss of consciousness without return to pre-existing
conscious level
closed fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with loss of consciousness of unspecified duration
closed fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with concussion unspecified
closed fractures involving skull or face with other bones with intracranial injury of other and unspecified nature with state of consciousness unspecified
closed fractures involving skull or face with other bones with intracranial injury of other and unspecified nature with no loss of consciousness
closed fractures involving skull or face with other bones with intracranial injury of other and unspecified nature with brief (less than one hour) loss of consciousness
closed fractures involving skull or face with other bones with intracranial injury of other and unspecified nature with moderate (1-24 hours) loss of consciousness
closed fractures involving skull or face with other bones with intracranial injury of other and unspecified nature with prolonged (more than 24 hours) loss of consciousness and return to pre-existing
conscious level
closed fractures involving skull or face with other bones with intracranial injury of other and unspecified nature with prolonged (more than 24 hours) loss of consciousness without return to pre-existing
conscious level
closed fractures involving skull or face with other bones with intracranial injury of other and unspecified nature with loss of consciousness of unspecified duration
closed fractures involving skull or face with other bones with intracranial injury of other and unspecified nature with concussion unspecified
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
804.50
804.51
804.52
804.53
804.54
804.55
804.56
804.59
804.60
804.61
804.62
804.63
804.64
804.65
804.66
804.69
804.70
804.71
804.72
804.73
804.74
804.75
804.76
804.79
open fractures involving skull or face with other bones without intracranial injury with state of consciousness unspecified
open fractures involving skull or face with other bones without intracranial injury with no loss of consciousness
open fractures involving skull or face with other bones without intracranial injury with brief (less than
one hour) loss of consciousness
open fractures involving skull or face with other bones without intracranial injury with moderate (1-24
hours) loss of consciousness
open fractures involving skull or face with other bones without intracranial injury with prolonged (more
than 24 hours) loss of consciousness and return to pre-existing conscious level
open fractures involving skull or face with other bones without intracranial injury with prolonged (more
than 24 hours) loss of consciousness without return to pre-existing conscious level
open fractures involving skull or face with other bones without intracranial injury with loss of consciousness of unspecified duration
open fractures involving skull or face with other bones without intracranial injury with concussion unspecified
open fractures involving skull or face with other bones with cerebral laceration and contusion with
state of consciousness unspecified
open fractures involving skull or face with other bones with cerebral laceration and contusion with no
loss of consciousness
open fractures involving skull or face with other bones with cerebral laceration and contusion with
brief (less than one hour) loss of consciousness
open fractures involving skull or face with other bones with cerebral laceration and contusion with
moderate (1-24 hours) loss of consciousness
open fractures involving skull or face with other bones with cerebral laceration and contusion with
prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level
open fractures involving skull or face with other bones with cerebral laceration and contusion with
prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level
open fractures involving skull or face with other bones with cerebral laceration and contusion with loss
of consciousness of unspecified duration
open fractures involving skull or face with other bones with cerebral laceration and contusion with
concussion unspecified
open fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with state of consciousness unspecified
open fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with no loss of consciousness
open fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with brief (less than one hour) loss of consciousness
open fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with moderate (1-24 hours) loss of consciousness
open fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with prolonged (more than 24 hours) loss of consciousness and return to pre-existing
conscious level
open fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with prolonged (more than 24 hours) loss of consciousness without return to pre-existing
conscious level
open fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with loss of consciousness of unspecified duration
open fractures involving skull or face with other bones with subarachnoid subdural and extradural
hemorrhage with concussion unspecified
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
804.80
804.81
804.82
804.83
804.84
804.85
804.86
830.0
830.1
847.0
850.0
850.11
850.12
850.2
850.3
850.4
850.5
850.9
851.00
851.01
851.02
851.03
851.04
851.05
851.06
851.09
851.10
851.11
851.12
851.13
851.14
851.15
open fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with state of consciousness unspecified
open fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with no loss of consciousness
open fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with brief (less than one hour) loss of consciousness
open fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with moderate (1-24 hours) loss of consciousness
open fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious
level
open fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with prolonged (more than 24 hours) loss consciousness without return to pre-existing conscious level
open fractures involving skull or face with other bones with other and unspecified intracranial hemorrhage with loss of consciousness of unspecified duration
closed dislocation of jaw
open dislocation of jaw
neck sprain
concussion with no loss of consciousness
concussion with loss of consciousness of 30 minutes or less
concussion with loss of consciousness from 31 to 59 minutes
concussion with moderate loss of consciousness
concussion with prolonged loss of consciousness and return to pre-existing conscious level
concussion with prolonged loss of consciousness without return to pre-existing conscious level
concussion with loss of consciousness of unspecified duration
concussion unspecified
cortex (cerebral) contusion without open intracranial wound state of consciousness unspecified
cortex (cerebral) contusion without open intracranial wound with no loss of consciousness
cortex (cerebral) contusion without open intracranial wound with brief (less than one hour) loss of
consciousness
cortex (cerebral) contusion without open intracranial wound with moderate (1-24 hours) loss of consciousness
cortex (cerebral) contusion without open intracranial wound with prolonged (more than 24 hours) loss
of consciousness and return to pre-exisiting conscious level
cortex (cerebral) contusion without open intracranial wound with prolonged (more than 24 hours) loss
of consciousness without return to pre-existing conscious level
cortex (cerebral) contusion without open intracranial wound with loss of consciousness of unspecified
duration
cortex (cerebral) contusion without open intracranial wound with concussion unspecified
cortex (cerebral) contusion with open intracranial wound without specific state of consciousness
cortex (cerebral) contusion with open intracranial wound with no loss of consciousness
cortex (cerebral) contusion with open intracranial wound with brief (less than one hour) loss of consciousness
cortex (cerebral) contusion with open intracranial wound with moderate (1-24 hours) loss of consciousness
cortex (cerebral) contusion with open intracranial wound with prolonged (more than 24 hours) loss of
consciousness and return to pre-existing conscious level
cortex (cerebral) contusion with open intracranial wound with prolonged (more than 24 hours) loss of
consciousness without return to pre-existing conscious level
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
851.16
851.19
851.20
851.21
851.22
851.23
851.24
851.25
851.26
851.29
851.30
851.31
851.32
851.33
851.34
851.35
851.36
851.39
851.40
851.41
851.42
851.43
851.44
851.45
851.46
851.49
851.50
851.51
851.52
851.53
cortex (cerebral) contusion with open intracranial wound with loss of consciousness of unspecified
duration
cortex (cerebral) contusion with open intracranial wound with concussion unspecified
cortex (cerebral) laceration without open intracranial wound with state of consciousness unspecified
cortex (cerebral) laceration without open intracranial wound with no loss of consciousness
cortex (cerebral) laceration without open intracranial wound with brief (less than one hour) loss of
consciousness
cortex (cerebral) laceration without open intracranial wound with moderate (1-24 hours) loss of consciousness
cortex (cerebral) laceration without open intracranial wound with prolonged (more than 24 hours) loss
of consciousness and return to pre-existing conscious level
cortex (cerebral) laceration without open intracranial wound with prolonged (more than 24 hours) loss
of consciousness without return to pre-existing conscious level
cortex (cerebral) laceration without open intracranial wound with loss of consciousness of unspecified
duration
cortex (cerebral) laceration without open intracranial wound with concussion unspecified
cortex (cerebral) laceration with open intracranial wound with state of consciousness unspecified
cortex (cerebral) laceration with open intracranial wound with no loss of consciousness
cortex (cerebral) laceration with open intracranial wound with brief (less than one hour) loss of consciousness
cortex (cerebral) laceration with open intracranial wound with moderate (1-24 hours) loss of consciousness
cortex (cerebral) laceration with open intracranial wound with prolonged (more than 24 hours) loss of
consciousness and return to pre-existing conscious level
cortex (cerebral) laceration with open intracranial wound with prolonged (more than 24 hours) loss of
consciousness without return to pre-existing conscious level
cortex (cerebral) laceration with open intracranial wound with loss of consciousness of unspecified
duration
cortex (cerebral) laceration with open intracranial wound with concussion unspecified
cerebellar or brain stem contusion without open intracranial wound with state of consciousness unspecified
cerebellar or brain stem contusion without open intracranial wound with no loss of consciousness
cerebellar or brain stem contusion without open intracranial wound with brief (less than one hour) loss
of consciousness
cerebellar or brain stem contusion without open intracranial wound with moderate (1-24 hours) loss of
consciousness
cerebellar or brain stem contusion without open intracranial wound with prolonged (more than 24
hours) loss consciousness and return to pre-existing conscious level
cerebellar or brain stem contusion without open intracranial wound with prolonged (more than 24
hours) loss of consciousness without return to pre-existing conscious level
cerebellar or brain stem contusion without open intracranial wound with loss of consciousness of unspecified duration
cerebellar or brain stem contusion without open intracranial wound with concussion unspecified
cerebellar or brain stem contusion with open intracranial wound with state of consciousness unspecified
cerebellar or brain stem contusion with open intracranial wound with no loss of consciousness
cerebellar or brain stem contusion with open intracranial wound with brief (less than one hour) loss of
consciousness
cerebellar or brain stem contusion with open intracranial wound with moderate (1-24 hours) loss of
consciousness
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
851.54
851.55
851.56
851.59
851.60
851.61
851.62
851.63
851.64
851.65
851.66
851.69
851.70
851.71
851.72
851.73
851.74
851.75
851.76
851.79
851.80
851.81
851.82
851.83
851.84
851.85
851.86
cerebellar or brain stem contusion with open intracranial wound with prolonged (more than 24 hours)
loss of consciousness and return to pre-existing conscious level
cerebellar or brain stem contusion with open intracranial wound with prolonged (more than 24 hours)
loss of consciousness without return to pre-existing conscious level
cerebellar or brain stem contusion with open intracranial wound with loss of consciousness of unspecified duration
cerebellar or brain stem contusion with open intracranial wound with concussion unspecified
cerebellar or brain stem laceration without open intracranial wound with state of consciousness unspecified
cerebellar or brain stem laceration without open intracranial wound with no loss of consciousness
cerebellar or brain stem laceration without open intracranial wound with brief (less than 1 hour) loss of
consciousness
cerebellar or brain stem laceration without open intracranial wound with moderate (1-24 hours) loss of
consciousness
cerebellar or brain stem laceration without open intracranial wound with prolonged (more than 24
hours) loss of consciousness and return to pre-existing conscious level
cerebellar or brain stem laceration without open intracranial wound with prolonged (more than 24
hours) loss of consciousness without return to pre-existing conscious level
cerebellar or brain stem laceration without open intracranial wound with loss of consciousness of unspecified duration
cerebellar or brain stem laceration without open intracranial wound with concussion unspecified
cerebellar or brain stem laceration with open intracranial wound with state of consciousness unspecified
cerebellar or brain stem laceration with open intracranial wound with no loss of consciousness
cerebellar or brain stem laceration with open intracranial wound with brief (less than one hour) loss of
consciousness
cerebellar or brain stem laceration with open intracranial wound with moderate (1-24 hours) loss of
consciousness
cerebellar or brain stem laceration with open intracranial wound with prolonged (more than 24 hours)
loss of consciousness and return to pre-existing conscious level
cerebellar or brain stem laceration with open intracranial wound with prolonged (more than 24 hours)
loss of consciousness without return to pre-existing conscious level
cerebellar or brain stem laceration with open intracranial wound with loss of consciousness of unspecified duration
cerebellar or brain stem laceration with open intracranial wound with concussion unspecified
other and unspecified cerebral laceration and contusion without open intracranial wound with state of
consciousness unspecified
other and unspecified cerebral laceration and contusion without open intracranial wound with no loss
of consciousness
other and unspecified cerebral laceration and contusion without open intracranial wound with brief
(less than one hour) loss of consciousness
other and unspecified cerebral laceration and contusion without open intracranial wound with moderate (1-24 hours) loss of consciousness
other and unspecified cerebral laceration and contusion without open intracranial wound with prolonged (more than 24 hours) loss of consciousness and return to pre- existing conscious level
other and unspecified cerebral laceration and contusion without open intracranial wound with prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level
other and unspecified cerebral laceration and contusion without open intracranial wound with loss of
consciousness of unspecified duration
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
851.89
851.90
851.91
851.92
851.93
851.94
851.95
851.96
851.99
852.00
852.01
852.02
852.03
852.04
852.05
852.06
852.09
852.10
852.11
852.12
852.13
852.14
852.15
852.16
852.19
852.20
other and unspecified cerebral laceration and contusion without open intracranial wound with concussion unspecified
other and unspecified cerebral laceration and contusion with open intracranial wound with state of
consciousness unspecified
other and unspecified cerebral laceration and contusion with open intracranial wound with no loss of
consciousness
other and unspecified cerebral laceration and contusion with open intracranial wound with brief (less
than one hour) loss of consciousness
other and unspecified cerebral laceration and contusion with open intracranial wound with moderate
(1-24 hours) loss of consciousness
other and unspecified cerebral laceration and contusion with open intracranial wound with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
other and unspecified cerebral laceration and contusion with open intracranial wound with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
other and unspecified cerebral laceration and contusion with open intracranial wound with loss of consciousness of unspecified duration
other and unspecified cerebral laceration and contusion with open intracranial wound with concussion
unspecified
subarachnoid hemorrhage following injury without open intracranial wound with state of consciousness unspecified
subarachnoid hemorrhage following injury without open intracranial wound with no loss of consciousness
subarachnoid hemorrhage following injury without open intracranial wound with brief (less than one
hour) loss of consciousness
subarachnoid hemorrhage following injury without open intracranial wound with moderate (1-24
hours) loss of consciousness
subarachnoid hemorrhage following injury without open intracranial wound with prolonged (more
than 24 hours) loss of consciousness and return to pre-existing conscious level
subarachnoid hemorrhage following injury without open intracranial wound with prolonged (more
than 24 hours) loss of consciousness without return to pre-existing conscious level
subarachnoid hemorrhage following injury without open intracranial wound with loss of consciousness
of unspecified duration
subarachnoid hemorrhage following injury without open intracranial wound with concussion unspecified
subarachnoid hemorrhage following injury with open intracranial wound with state of consciousness
unspecified
subarachnoid hemorrhage following injury with open intracranial wound with no loss of consciousness
subarachnoid hemorrhage following injury with open intracranial wound with brief (less than one hour)
loss of consciousness
subarachnoid hemorrhage following injury with open intracranial wound with moderate (1-24 hours)
loss of consciousness
subarachnoid hemorrhage following injury with open intracranial wound with prolonged (more than 24
hours) loss of consciousness and return to pre-existing conscious level
subarachnoid hemorrhage following injury with open intracranial wound with prolonged (more than 24
hours) loss of consciousness without return to pre-existing conscious level
subarachnoid hemorrhage following injury with open intracranial wound with loss of consciousness of
unspecified duration
subarachnoid hemorrhage following injury with open intracranial wound with concussion unspecified
subdural hemorrhage following injury without open intracranial wound with state of consciousness
unspecified
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
852.21
852.22
852.23
852.24
852.25
852.26
852.29
852.30
852.31
852.32
852.33
852.34
852.35
852.36
852.39
852.40
852.41
852.42
852.43
852.44
852.45
852.46
852.49
852.50
852.51
852.52
852.53
852.54
subdural hemorrhage following injury without open intracranial wound with no loss of consciousness
subdural hemorrhage following injury without open intracranial wound with brief (less than one hour)
loss of consciousness
subdural hemorrhage following injury without open intracranial wound with moderate (1-24 hours) loss
of consciousness
subdural hemorrhage following injury without open intracranial wound with prolonged (more than 24
hours) loss of consciousness and return to pre-existing conscious level
subdural hemorrhage following injury without open intracranial wound with prolonged (more than 24
hours) loss of consciousness without return to pre-existing conscious level
subdural hemorrhage following injury without open intracranial wound with loss of consciousness of
unspecified duration
subdural hemorrhage following injury without open intracranial wound with concussion unspecified
subdural hemorrhage following injury with open intracranial wound with state of consciousness unspecified
subdural hemorrhage following injury with open intracranial wound with no loss of consciousness
subdural hemorrhage following injury with open intracranial wound with brief (less than one hour) loss
of consciousness
subdural hemorrhage following injury with open intracranial wound with moderate (1-24 hours) loss of
consciousness
subdural hemorrhage following injury with open intracranial wound with prolonged (more than 24
hours) loss of consciousness and return to pre-existing conscious level
subdural hemorrhage following injury with open intracranial wound with prolonged (more than 24
hours) loss of consciousness without return to pre-existing conscious level
subdural hemorrhage following injury with open intracranial wound with loss of consciousness of unspecified duration
subdural hemorrhage following injury with open intracranial wound with concussion unspecified
extradural hemorrhage following injury without open intracranial wound with state of consciousness
unspecified
extradural hemorrhage following injury without open intracranial wound with no loss of consciousness
extradural hemorrhage following injury without open intracranial wound with brief (less than 1 hour)
loss of consciousness
extradural hemorrhage following injury without open intracranial wound with moderate (1-24 hours)
loss of consciousness
extradural hemorrhage following injury without open intracranial wound with prolonged (more than 24
hours) loss of consciousness and return to pre-existing conscious level
extradural hemorrhage following injury without open intracranial wound with prolonged (more than 24
hours) loss of consciousness without return to pre-existing conscious level
extradural hemorrhage following injury without open intracranial wound with loss of consciousness of
unspecified duration
extradural hemorrhage following injury without open intracranial wound with concussion unspecified
extradural hemorrhage following injury with open intracranial wound with state of consciousness unspecified
extradural hemorrhage following injury with open intracranial wound with no loss of consciousness
extradural hemorrhage following injury with open intracranial wound with brief (less than one hour)
loss of consciousness
extradural hemorrhage following injury with open intracranial wound with moderate (1-24 hours) loss
of consciousness
extradural hemorrhage following injury with open intracranial wound with prolonged (more than 24
hours) loss of consciousness and return to pre-existing conscious level
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
852.55
852.56
852.59
853.00
853.01
853.02
853.03
853.04
853.05
853.06
853.09
853.10
853.11
853.12
853.13
853.14
853.15
853.16
853.19
854.00
854.01
854.02
854.03
854.04
854.05
extradural hemorrhage following injury with open intracranial wound with prolonged (more than 24
hours) loss of consciousness without return to pre-existing conscious level
extradural hemorrhage following injury with open intracranial wound with loss of consciousness of
unspecified duration
extradural hemorrhage following injury with open intracranial wound with concussion unspecified
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
state of consciousness unspecified
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
no loss of consciousness
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
brief (less than one hour) loss of consciousness
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
moderate (1-24 hours) loss of consciousness
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
prolonged (more than 24 hours) loss of consciousness and return to pre- existing conscious level
other and unspecified intracranial hemorrhage following injury. without open intracranial wound with
prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
loss of consciousness of unspecified duration
other and unspecified intracranial hemorrhage following injury without open intracranial wound with
concussion unspecified
other and unspecified intracranial hemorrhage following injury with open intracranial wound with state
of consciousness unspecified
other and unspecified intracranial hemorrhage following injury with open intracranial wound with no
loss of consciousness
other and unspecified intracranial hemorrhage following injury with open intracranial wound with brief
(less than one hour) loss of consciousness
other and unspecified intracranial hemorrhage following injury with open intracranial wound with
moderate (1-24 hours) loss of consciousness
other and unspecified intracranial hemorrhage following injury with open intracranial wound with prolonged( more than 24 hours) loss of consciousness and return to pre-existing conscious level
other and unspecified intracranial hemorrhage following injury with open intracranial wound with prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level
other and unspecified intracranial hemorrhage following injury with open intracranial wound with loss
of consciousness of unspecified duration
other and unspecified intracranial hemorrhage following injury with open intracranial wound with concussion unspecified
intracranial injury of other and unspecified nature without open intracranial wound with state of consciousness unspecified
intracranial injury of other and unspecified nature without open intracranial wound with no loss of consciousness
intracranial injury of other and unspecified nature without open intracranial wound with brief (less than
one hour) loss of consciousness
intracranial injury of other and unspecified nature without open intracranial wound with moderate (124 hours) loss of consciousness
intracranial injury of other and unspecified nature without open intracranial wound with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing conscious level
intracranial injury of other and unspecified nature without open intracranial wound with prolonged
(more than 24 hours) loss of consciousness without return to pre-existing conscious level
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
854.06
854.09
854.10
854.11
854.12
854.13
854.14
854.15
854.16
854.19
870.4
871.1
871.2
871.3
871.6
873.40
873.41
873.42
873.44
873.49
873.50
873.51
873.52
873.54
873.59
920
921.1
921.2
921.3
921.9
925.1
925.2
933.0
933.1
950.0
950.1
950.2
950.3
950.9
951.0
intracranial injury of other and unspecified nature without open intracranial wound with loss of consciousness of unspecified duration
intracranial injury of other and unspecified nature without open intracranial wound with concussion
unspecified
intracranial injury of other and unspecified nature with open intracranial wound with state of consciousness unspecified
intracranial injury of other and unspecified nature with open intracranial wound with no loss of consciousness
intracranial injury of other and unspecified nature with open intracranial wound with brief (less than
one hour) loss of consciousness
intracranial injury of other and unspecified nature with open intracranial wound with moderate (1-24
hours) loss of consciousness
intracranial injury of other and unspecified nature with open intracranial wound with prolonged (more
than 24 hours) loss of consciousness and return to pre-existing conscious level
intracranial injury of other and unspecified nature with open intracranial wound with prolonged (more
than 24 hours) loss of consciousness without return to pre-existing conscious level
intracranial injury of other and unspecified nature with open intracranial wound with loss of consciousness of unspecified duration
intracranial injury of other and unspecified nature with open intracranial wound with concussion unspecified
penetrating wound of orbit with foreign body
ocular laceration with prolapse or exposure of intraocular tissue
rupture of eye with partial loss of intraocular tissue
avulsion of eye
penetration of eyeball with (nonmagnetic) foreign body
open wound of face unspecified site uncomplicated
open wound of cheek uncomplicated
open wound of forehead uncomplicated
open wound of jaw uncomplicated
open wound of other and multiple sites uncomplicated
open wound of face unspecified site complicated
open wound of cheek complicated
open wound of forehead complicated
open wound of jaw complicated
open wound of other and multiple sites complicated
contusion of face scalp and neck except eye(s)
contusion of eyelids and periocular area
contusion of orbital tissues
contusion of eyeball
unspecified contusion of eye
crushing injury of face and scalp
crushing injury of neck
foreign body in pharynx
foreign body in larynx
optic nerve injury
injury to optic chiasm
injury to optic pathways
injury to visual cortex
injury to unspecified optic nerve and pathways
injury to oculomotor nerve
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
951.1
951.2
951.3
951.4
951.5
951.6
951.7
951.8
996.40
996.49
998.31
998.33
v10.01
v10.02
v10.12
v10.21
v10.22
v10.81
v10.82
v10.83
v10.84
v10.85
v10.87
v67.00
v67.09
v67.1
v67.2
v71.1
injury to trochlear nerve
injury to trigeminal nerve
injury to abducens nerve
injury to facial nerve
injury to acoustic nerve
injury to accessory nerve
injury to hypoglossal nerve
injury to other specified cranial nerves
unspecified mechanical complication of internal orthopedic device, implant, and graft
other mechanical complication of other internal orthopedic device, implant, and graft
disruption of internal operation (surgical) wound
disruption of traumatic injury wound repair
personal history of malignant neoplasm of tongue
personal history of malignant neoplasm of other and unspecified parts of oral cavity and pharynx
personal history of malignant neoplasm of trachea
personal history of malignant neoplasm of larynx
personal history of malignant neoplasm of nasal cavities middle ear and accessory sinuses
personal history of malignant neoplasm of bone
personal history of malignant melanoma of skin
personal history of other malignant neoplasm of skin
personal history of malignant neoplasm of eye
personal history of malignant neoplasm of brain
personal history of malignant neoplasm of thyroid
follow-up examination following unspecified surgery
follow-up examination following other surgery
follow-up examination following radiotherapy
follow-up examination following chemotherapy
observation for suspected malignant neoplasm
mri cpt codes: 71550, 71551, 71552, 76376 & 76377*)*note: for the purposes of this lcd, cpt code 76376 or 76377 is allowed only when billed in conjunction with another mri procedure code. see item 3(c) in the “limitations” section above.
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 upper 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 site
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 of stomach 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 site
158.0
malignant neoplasm of retroperitoneum
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
162.0
162.2
162.3
162.4
162.5
162.8
162.9
163.0
163.1
163.8
163.9
164.0
164.1
164.2
164.3
164.8
164.9
165.0
165.8
165.9
170.2
170.3
171.4
171.8
172.0
172.8
172.9
173.5
174.0
174.1
174.2
174.3
174.4
174.5
174.6
174.8
174.9
175.0
175.9
176.0
176.1
176.3
176.4
176.5
176.8
193
194.1
194.8
195.1
196.1
malignant neoplasm of trachea
malignant neoplasm of main bronchus
malignant neoplasm of upper lobe bronchus or lung
malignant neoplasm of middle lobe bronchus or lung
malignant neoplasm of lower lobe bronchus or lung
malignant neoplasm of other parts of bronchus or lung
malignant neoplasm of bronchus and lung unspecified
malignant neoplasm of parietal pleura
malignant neoplasm of visceral pleura
malignant neoplasm of other specified sites of pleura
malignant neoplasm of pleura unspecified
malignant neoplasm of thymus
malignant neoplasm of heart
malignant neoplasm of anterior mediastinum
malignant neoplasm of posterior mediastinum
malignant neoplasm of other parts of mediastinum
malignant neoplasm of mediastinum part unspecified
malignant neoplasm of upper respiratory tract part unspecified
malignant neoplasm of other sites within the respiratory system and intrathoracic organs
malignant neoplasm of ill-defined sites within the respiratory system
malignant neoplasm of vertebral column excluding sacrum and coccyx
malignant neoplasm of ribs sternum and clavicle
malignant neoplasm of connective and other soft tissue of thorax
malignant neoplasm of other specified sites of connective and other soft tissue
malignant melanoma of skin of lip
malignant melanoma of other specified sites of skin
melanoma of skin site unspecified
other malignant neoplasm of skin of trunk except scrotum
malignant neoplasm of nipple and areola of female breast
malignant neoplasm of central portion of female breast
malignant neoplasm of upper-inner quadrant of female breast
malignant neoplasm of lower-inner quadrant of female breast
malignant neoplasm of upper-outer quadrant of female breast
malignant neoplasm of lower-outer quadrant of female breast
malignant neoplasm of axillary tail of female breast
malignant neoplasm of other specified sites of female breast
malignant neoplasm of breast (female) unspecified site
malignant neoplasm of nipple and areola of male breast
malignant neoplasm of other and unspecified sites of male breast
kaposi’s sarcoma skin
kaposi’s sarcoma soft tissue
kaposi’s sarcoma gastrointestinal sites
kaposi’s sarcoma lung
kaposi’s sarcoma lymph nodes
kaposi’s sarcoma other specified sites
malignant neoplasm of thyroid gland
malignant neoplasm of parathyroid gland
malignant neoplasm of other endocrine glands and related structures
malignant neoplasm of thorax
secondary and unspecified malignant neoplasm of intrathoracic lymph nodes
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
197.0
197.1
197.2
197.3
199.0
199.1
199.2
200.00
200.02
200.10
200.12
200.20
200.22
200.30
200.31
200.32
200.33
200.34
200.35
200.36
200.37
200.38
200.40
200.41
200.42
200.43
200.44
200.45
200.46
200.47
200.48
200.50
200.51
200.52
200.53
200.54
200.55
200.56
200.57
200.58
200.60
200.61
200.62
200.63
200.64
200.65
200.66
200.67
200.68
200.70
secondary malignant neoplasm of lung
secondary malignant neoplasm of mediastinum
secondary malignant neoplasm of pleura
secondary malignant neoplasm of other respiratory organs
disseminated malignant neoplasm
other malignant neoplasm of unspecified site
malignant neoplasm associated with transplant organ
reticulosarcoma unspecified site
reticulosarcoma involving intrathoracic lymph nodes
lymphosarcoma unspecified site
lymphosarcoma involving intrathoracic lymph nodes
burkitt’s tumor or lymphoma unspecified site
burkitt’s tumor or lymphoma involving intrathoracic lymph nodes
marginal zone lymphoma, unspecified site, extranodal and solid organ sites
marginal zone lymphoma,lymph nodes of head, face, and neck
marginal zone lymphoma,intrathoracic lymph nodes
marginal zone lymphoma, intraabdominal lymph nodes
marginal zone lymphoma, lymph nodes of axilla and upper limb
marginal zone lymphoma, lymph nodes of inguinal region and lower limb
marginal zone lymphoma, intrapelvic lymph nodes
marginal zone lymphoma, spleen
marginal zone lymphoma, lymph nodes of multiple sites
mantle cell lymphoma, unspecified site, extranodal and solid organ sites
mantle cell lymphoma, lymph nodes of head, face, and neck
mantle cell lymphoma, intrathoracic lymph nodes
mantle cell lymphoma, intra-abdominal lymph nodes
mantle cell lymphoma, lymph nodes of axilla and upper limb
mantle cell lymphoma, lymph nodes of inguinal region and lower limb
mantle cell lymphoma, intrapelvic lymph nodes
mantle cell lymphoma, spleen
mantle cell lymphoma, lymph nodes of multiple sites
primary central nervous system lymphoma, unspecified site, extranodal and solid organ sites
primary central nervous system lymphoma, lymph nodes of head, face, and neck
primary central nervous system lymphoma, intrathoracic lymph nodes
primary central nervous system lymphoma, intra-abdominal lymph nodes
primary central nervous system lymphoma, lymph nodes of axilla and upper limb
primary central nervous system lymphoma, lymph nodes of inguinal region and lower limb
primary central nervous system lymphoma, intrapelvic lymph nodes
primary central nervous system lymphoma, spleen
primary central nervous system lymphoma, lymph nodes of multiple sites
anaplastic large cell lymphoma, unspecified site, extranodal and solid organ sites
anaplastic large cell lymphoma, lymph nodes of head, face, and neck
anaplastic large cell lymphoma, intrathoracic lymph nodes
anaplastic large cell lymphoma, intra-abdominal lymph nodes
anaplastic large cell lymphoma, lymph nodes of axilla and upper limb
anaplastic large cell lymphoma, lymph nodes of inguinal region and lower limb
anaplastic large cell lymphoma, intrapelvic lymph nodes
anaplastic large cell lymphoma, spleen
anaplastic large cell lymphoma, lymph nodes of multiple sites
large cell lymphoma, unspecified site, extranodal and solid organ sites
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
200.71
200.72
200.73
200.74
200.75
200.76
200.77
200.78
200.80
200.82
201.00
201.02
201.10
201.12
201.20
201.22
201.40
201.42
201.50
201.52
201.60
201.62
201.70
201.72
201.98
202.00
202.02
202.10
202.12
202.20
202.22
202.30
202.32
202.40
202.42
202.50
202.52
202.60
202.62
202.70
202.71
202.72
202.73
202.74
202.75
202.76
202.77
202.78
202.80
202.82
large cell lymphoma, lymph nodes of head, face, and neck
large cell lymphoma, intrathoracic lymph nodes
large cell lymphoma, intra-abdominal lymph nodes
large cell lymphoma, lymph nodes of axilla and upper limb
large cell lymphoma, lymph nodes of inguinal region and lower limb
large cell lymphoma, intrapelvic lymph nodes
large cell lymphoma, spleen
large cell lymphoma, lymph nodes of multiple sites
other named variants of lymphosarcoma and reticulosarcoma unspecified site
other named variants of lymphosarcoma and reticulosarcoma involving intrathoracic lymph nodes
hodgkin’s paragranuloma unspecified site
hodgkin’s paragranuloma involving intrathoracic lymph nodes
hodgkin’s granuloma unspecified site
hodgkin’s granuloma involving intrathoracic lymph nodes
hodgkin’s sarcoma unspecified site
hodgkin’s sarcoma involving intrathoracic lymph nodes
hodgkin’s disease lymphocytic-histiocytic predominance unspecified site
hodgkin’s disease lymphocytic-histiocytic predominance involving intrathoracic lymph nodes
hodgkin’s disease nodular sclerosis unspecified site
hodgkin’s disease nodular sclerosis involving intrathoracic lymph nodes
hodgkin’s disease mixed cellularity unspecified site
hodgkin’s disease mixed cellularity involving intrathoracic lymph nodes
hodgkin’s disease lymphocytic depletion unspecified site
hodgkin’s disease lymphocytic depletion involving intrathoracic lymph nodes
hodgkin’s disease unspecified type involving lymph nodes of multiple sites
nodular lymphoma unspecified site
nodular lymphoma involving intrathoracic lymph nodes
mycosis fungoides unspecified site
mycosis fungoides involving intrathoracic lymph nodes
sezary’s disease unspecified site
sezary’s disease involving intrathoracic lymph nodes
malignant histiocytosis unspecified site
malignant histiocytosis involving intrathoracic lymph nodes
leukemic reticuloendotheliosis unspecified site
leukemic reticuloendotheliosis involving intrathoracic lymph nodes
letterer-siwe disease unspecified site
letterer-siwe disease involving intrathoracic lymph nodes
malignant mast cell tumors unspecified site
malignant mast cell tumors involving intrathoracic lymph nodes
peripheral t cell lymphoma, unspecified site, extranodal and solid organ sites
peripheral t cell lymphoma, lymph nodes of head, face, and neck
peripheral t cell lymphoma, intrathoracic lymph nodes
peripheral t cell lymphoma, intra-abdominal lymph nodes
peripheral t cell lymphoma, lymph nodes of axilla and upper limb
peripheral t cell lymphoma, lymph nodes of inguinal region and lower limb
peripheral t cell lymphoma, intrapelvic lymph nodes
peripheral t cell lymphoma, spleen
peripheral t cell lymphoma, lymph nodes of multiple sites
other malignant lymphomas unspecified site
other malignant lymphomas involving intrathoracic lymph nodes
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
202.88
203.00
203.01
203.02
203.80
203.81
203.82
209.20
209.21
209.22
209.23
209.30
209.60
209.61
209.62
209.63
211.0
211.1
212.2
212.3
212.4
212.5
212.6
212.7
212.8
212.9
213.3
213.4
213.9
214.1
214.2
215.0
215.4
215.7
216.5
216.8
217
226
227.1
227.6
227.8
228.00
228.01
228.09
228.1
229.0
229.8
230.1
230.2
231.1
other malignant lymphomas involving lymph nodes of multiple sites
multiple myeloma, without mention of having achieved remission
multiple myeloma in remission
multiple myeloma, in relapse
other immunoproliferative neoplasms, without mention of having achieved remission
other immunoproliferative neoplasms in remission
other immunoproliferative neoplasms, in relapse
malignant carcinoid tumor of unknown primary site
malignant carcinoid tumor of the bronchus and lung
malignant carcinoid tumor of the thymus
malignant carcinoid tumor of the stomach
malignant poorly differentiated neuroendocrine carcinoma, any site
benign carcinoid tumor of unknown primary site
benign carcinoid tumor of the bronchus and lung
benign carcinoid tumor of the thymus
benign carcinoid tumor of the stomach
benign neoplasm of esophagus
benign neoplasm of stomach
benign neoplasm of trachea
benign neoplasm of bronchus and lung
benign neoplasm of pleura
benign neoplasm of mediastinum
benign neoplasm of thymus
benign neoplasm of heart
benign neoplasm of other specified sites of respiratory and intrathoracic organs
benign neoplasm of respiratory and intrathoracic organs site unspecified
benign neoplasm of ribs sternum and clavicle
benign neoplasm of scapula and long bones of upper limb
benign neoplasm of bone and articular cartilage site unspecified
lipoma of other skin and subcutaneous tissue
lipoma of intrathoracic organs
other benign neoplasm of connective and other soft tissue of head face and neck
other benign neoplasm of connective and other soft tissue of thorax
other benign neoplasm of connective and other soft tissue of trunk unspecified
benign neoplasm of skin of trunk except scrotum
benign neoplasm of other specified sites of skin
benign neoplasm of breast
benign neoplasm of thyroid glands
benign neoplasm of parathyroid gland
benign neoplasm of aortic body and other paraganglia
benign neoplasm of other endocrine glands and related structures
hemangioma of unspecified site
hemangioma of skin and subcutaneous tissue
hemangioma of other sites
lymphangioma any site
benign neoplasm of lymph nodes
benign neoplasm of other specified sites
carcinoma in situ of esophagus
carcinoma in situ of stomach
carcinoma in situ of trachea
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
231.2
231.8
231.9
232.5
232.8
233.0
235.7
235.8
235.9
237.3
237.70
237.71
238.0
238.1
238.2
238.3
238.5
238.6
238.79
238.8
239.0
239.1
239.2
239.3
240.0
240.9
241.0
241.1
241.9
242.00
242.01
242.10
242.11
242.20
242.21
242.30
242.31
242.40
242.41
242.80
242.81
242.90
242.91
243
244.0
244.1
244.2
244.3
244.8
244.9
carcinoma in situ of bronchus and lung
carcinoma in situ of other specified parts of respiratory system
carcinoma in situ of respiratory system part unspecified
carcinoma in situ of skin of trunk except scrotum
carcinoma in situ of other specified sites of skin
carcinoma in situ of breast
neoplasm of uncertain behavior of trachea bronchus and lung
neoplasm of uncertain behavior of pleura thymus and mediastinum
neoplasm of uncertain behavior of other and unspecified respiratory organs
neoplasm of uncertain behavior of paraganglia
neurofibromatosis unspecified
neurofibromatosis type 1 von recklinghausen’s disease
neoplasm of uncertain behavior of bone and articular cartilage
neoplasm of uncertain behavior of connective and other soft tissue
neoplasm of uncertain behavior of skin
neoplasm of uncertain behavior of breast
neoplasm of uncertain behavior of histiocytic and mast cells
neoplasm of uncertain behavior of plasma cells
other lymphatic and hematopoietic tissues
neoplasm of uncertain behavior of other specified sites
neoplasm of unspecified nature of digestive system
neoplasm of unspecified nature of respiratory system
neoplasm of unspecified nature of bone soft tissue and skin
neoplasm of unspecified nature of breast
goiter specified as simple
goiter unspecified
nontoxic uninodular goiter
nontoxic multinodular goiter
unspecified nontoxic nodular goiter
toxic diffuse goiter without thyrotoxic crisis or storm
toxic diffuse goiter with thyrotoxic crisis or storm
toxic uninodular goiter without thyrotoxic crisis or storm
toxic uninodular goiter with thyrotoxic crisis or storm
toxic multinodular goiter without thyrotoxic crisis or storm
toxic multinodular goiter with thyrotoxic crisis or storm
toxic nodular goiter unspecified type without thyrotoxic crisis or storm
toxic nodular goiter unspecified type with thyrotoxic crisis or storm
thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm
thyrotoxicosis of other specified origin without thyrotoxic crisis or storm
thyrotoxicosis of other specified origin with thyrotoxic crisis or storm
thyrotoxicosis without goiter or other cause and without thyrotoxic crisis or storm
thyrotoxicosis without goiter or other cause with thyrotoxic crisis or storm
congenital hypothyroidism
postsurgical hypothyroidism
other postablative hypothyroidism
iodine hypothyroidism
other iatrogenic hypothyroidism
other specified acquired hypothyroidism
unspecified acquired hypothyroidism
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
245.0
245.1
245.2
245.3
245.4
245.8
245.9
246.0
246.1
246.2
246.3
246.8
246.9
254.0
254.1
254.8
254.9
273.4
277.02
353.0
353.3
353.8
358.00
358.01
391.0
391.1
391.2
391.8
391.9
398.0
414.10
414.11
414.19
415.11
415.12
415.19
417.0
417.1
417.8
417.9
420.0
420.90
420.91
420.99
422.0
422.90
422.91
422.92
422.93
422.99
acute thyroiditis
subacute thyroiditis
chronic lymphocytic thyroiditis
chronic fibrous thyroiditis
iatrogenic thyroiditis
other and unspecified chronic thyroiditis
thyroiditis unspecified
disorders of thyrocalcitonin secretion
dyshormonogenic goiter
cyst of thyroid
hemorrhage and infarction of thyroid
other specified disorders of thyroid
unspecified disorder of thyroid
persistent hyperplasia of thymus
abscess of thymus
other specified diseases of thymus gland
unspecified disease of thymus gland
alpha-1-antitrypsin deficiency
cystic fibrosis with pulmonary manifestations
brachial plexus lesions
thoracic root lesions not elsewhere classified
other nerve root and plexus disorders
myasthenia gravis without (acute) exacerbation
myasthenia gravis with (acute) exacerbation
acute rheumatic pericarditis
acute rheumatic endocarditis
acute rheumatic myocarditis
other acute rheumatic heart disease
acute rheumatic heart disease unspecified
rheumatic myocarditis
aneurysm of heart (wall)
aneurysm of coronary vessels
other aneurysm of heart
iatrogenic pulmonary embolism and infarction
septic pulmonary embolism
other pulmonary embolism and infarction
arteriovenous fistula of pulmonary vessels
aneurysm of pulmonary artery
other specified diseases of pulmonary circulation
unspecified disease of pulmonary circulation
acute pericarditis in diseases classified elsewhere
acute pericarditis unspecified
acute idiopathic pericarditis
other acute pericarditis
acute myocarditis in diseases classified elsewhere
acute myocarditis unspecified
idiopathic myocarditis
septic myocarditis
toxic myocarditis
other acute myocarditis
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
423.0
423.1
423.2
423.3
423.8
423.9
425.0
425.1
425.2
425.3
425.4
425.5
425.7
425.8
425.9
440.0
441.00
441.01
441.02
441.03
441.1
441.2
441.3
441.4
441.5
441.6
441.7
441.9
442.82
444.1
446.7
447.0
447.2
453.2
456.0
456.1
456.20
456.21
459.0
459.2
492.0
492.8
494.1
508.0
508.1
508.8
508.9
510.0
510.9
512.0
hemopericardium
adhesive pericarditis
constrictive pericarditis
cardiac tamponade
other specified diseases of pericardium
unspecified disease of pericardium
endomyocardial fibrosis
hypertrophic obstructive cardiomyopathy
obscure cardiomyopathy of africa
endocardial fibroelastosis
other primary cardiomyopathies
alcoholic cardiomyopathy
nutritional and metabolic cardiomyopathy
cardiomyopathy in other diseases classified elsewhere
secondary cardiomyopathy unspecified
atherosclerosis of aorta
dissection of aorta aneurysm unspecified site
dissection of aorta thoracic
dissection of aorta abdominal
dissection of aorta thoracoabdominal
thoracic aneurysm ruptured
thoracic aneurysm without rupture
abdominal aneurysm ruptured
abdominal aneurysm without rupture
aortic aneurysm of unspecified site ruptured
thoracoabdominal aneurysm ruptured
thoracoabdominal aneurysm without rupture
aortic aneurysm of unspecified site without rupture
aneurysm of subclavian artery
embolism and thrombosis of thoracic aorta
takayasu’s disease
arteriovenous fistula acquired
rupture of artery
embolism and thrombosis of vena cava
esophageal varices with bleeding
esophageal varices without bleeding
esophageal varices in diseases classified elsewhere with bleeding
esophageal varices in diseases classified elsewhere without bleeding
hemorrhage unspecified
compression of vein
emphysematous bleb
other emphysema
bronchiectasis with acute exacerbation
acute pulmonary manifestations due to radiation
chronic and other pulmonary manifestations due to radiation
respiratory conditions due to other specified external agents
respiratory conditions due to unspecified external agent
empyema with fistula
empyema without fistula
spontaneous tension pneumothorax
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
512.1
512.8
513.0
513.1
514
515
516.3
518.0
518.1
518.2
518.3
518.4
518.5
518.6
518.81
518.82
518.84
518.89
519.19
519.2
519.3
519.4
519.8
519.9
530.0
530.10
530.11
530.12
530.13
530.19
530.20
530.21
530.3
530.4
530.5
530.6
530.7
530.81
530.82
530.84
530.85
530.86
530.87
551.20
551.21
551.29
551.3
551.8
552.3
553.3
iatrogenic pneumothorax
other spontaneous pneumothorax
abscess of lung
abscess of mediastinum
pulmonary congestion and hypostasis
postinflammatory pulmonary fibrosis
idiopathic fibrosing alveolitis
pulmonary collapse
interstitial emphysema
compensatory emphysema
pulmonary eosinophilia
acute edema of lung unspecified
pulmonary insufficiency following trauma and surgery
allergic bronchopulmonary aspergilliosis
acute respiratory failure
other pulmonary insufficiency not elsewhere classified
acute and chronic respiratory failure
other diseases of lung not elsewhere classified
other diseases of trachea and bronchus
mediastinitis
other diseases of mediastinum not elsewhere classified
disorders of diaphragm
other diseases of respiratory system not elsewhere classified
unspecified disease of respiratory system
achalasia and cardiospasm
esophagitis unspecified
reflux esophagitis
acute esophagitis
eosinophilic esophagitis
other esophagitis
ulcer of esophagus without bleeding
ulcer of esophagus with bleeding
stricture and stenosis of esophagus
perforation of esophagus
dyskinesia of esophagus
diverticulum of esophagus acquired
gastroesophageal laceration-hemorrhage syndrome
esophageal reflux
esophageal hemorrhage
tracheoesophageal fistula
barrett’s esophagus
infection of esophagostomy
mechanical complication of esophagostomy
unspecified ventral hernia with gangrene
incisional ventral hernia with gangrene
other ventral hernia with gangrene
diaphragmatic hernia with gangrene
hernia of other specified sites with gangrene
diaphragmatic hernia with obstruction
diaphragmatic hernia without obstruction or gangrene
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
683
718.78
718.79
745.0
745.10
745.11
745.12
745.19
745.2
745.3
745.4
745.5
745.60
745.61
745.69
745.7
745.8
745.9
746.00
746.01
746.02
746.09
746.1
746.2
746.3
746.4
746.5
746.6
746.7
746.81
746.82
746.83
746.84
746.85
746.86
746.87
746.89
746.9
747.0
747.10
747.11
747.20
747.21
747.22
747.29
747.3
747.40
747.41
747.42
747.49
acute lymphadenitis
developmental dislocation of joint other specified site
developmental dislocation of joint multiple sites
common truncus
complete transposition of great vessels
double outlet right ventricle
corrected transposition of great vessels
other transposition of great vessels
tetralogy of fallot
common ventricle
ventricular septal defect
ostium secundum type atrial septal defect
endocardial cushion defect unspecified type
ostium primum defect
other endocardial cushion defects
cor biloculare
other bulbus cordis anomalies and anomalies of cardiac septal closure
unspecified defect of septal closure
congenital pulmonary valve anomaly unspecified
atresia of pulmonary valve congenital
stenosis of pulmonary valve congenital
other congenital anomalies of pulmonary valve
tricuspid atresia and stenosis congenital
ebstein’s anomaly
congenital stenosis of aortic valve
congenital insufficiency of aortic valve
congenital mitral stenosis
congenital mitral insufficiency
hypoplastic left heart syndrome
subaortic stenosis congenital
cor triatriatum
infundibular pulmonic stenosis congenital
congenital obstructive anomalies of heart not elsewhere classified
coronary artery anomaly congenital
congenital heart block
malposition of heart and cardiac apex
other specified congenital anomalies of heart
unspecified congenital anomaly of heart
patent ductus arteriosus
coarctation of aorta (preductal) (postductal)
interruption of aortic arch
congenital anomaly of aorta unspecified
congenital anomalies of aortic arch
congenital atresia and stenosis of aorta
other congenital anomalies of aorta
congenital anomalies of pulmonary artery
congenital anomaly of great veins unspecified
total anomalous pulmonary venous connection
partial anomalous pulmonary venous connection
other anomalies of great veins
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
748.3
748.4
748.5
748.60
748.61
748.69
748.8
748.9
750.3
750.4
750.6
750.8
756.2
756.3
756.6
780.2
780.61
780.62
780.64
785.50
785.51
785.52
785.59
785.6
786.00
786.1
786.2
786.3
786.6
793.1
793.2
793.80
793.81
793.89
794.2
794.30
794.31
794.39
794.5
795.31
860.0
860.1
860.2
860.3
860.4
860.5
861.00
861.01
861.02
861.03
other congenital anomalies of larynx trachea and bronchus
congenital cystic lung
congenital agenesis hypoplasia and dysplasia of lung
congenital anomaly of lung unspecified
congenital bronchiectasis
other congenital anomalies of lung
other specified congenital anomalies of respiratory system
unspecified congenital anomaly of respiratory system
congenital tracheoesophageal fistula esophageal atresia and stenosis
other specified congenital anomalies of esophagus
congenital hiatus hernia
other specified congenital anomalies of upper alimentary tract
cervical rib
other congenital anomalies of ribs and sternum
congenital anomalies of diaphragm
syncope and collapse
fever presenting with conditions classified elsewhere
postprocedural fever
chills (without fever)
shock unspecified
cardiogenic shock
septic shock
other shock without trauma
enlargement of lymph nodes
respiratory abnormality unspecified
stridor
cough
hemoptysis
swelling mass or lump in chest
nonspecific abnormal findings on radiological and other examination of lung field
nonspecific abnormal findings on radiological and other examination of other intrathoracic organs
unspecified abnormal mammogram
mammographic microcalcification
other abnormal findings on radiological examination of breast
nonspecific abnormal results of function study of pulmonary system
unspecified abnormal function study of cardiovascular system
nonspecific abnormal electrocardiogram (ecg) (ekg)
other nonspecific abnormal function study of cardiovascular system
nonspecific abnormal results of function study of thyroid
nonspecific positive findings for anthrax
traumatic pneumothorax without open wound into thorax
traumatic pneumothorax with open wound into thorax
traumatic hemothorax without open wound into thorax
traumatic hemothorax with open wound into thorax
traumatic pneumohemothorax without open wound into thorax
traumatic pneumohemothorax with open wound into thorax
unspecified injury of heart without open wound into thorax
contusion of heart without open wound into thorax
laceration of heart without penetration of heart chambers or open wound into thorax
laceration of heart with penetration of heart chambers without open wound into thorax
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
861.10
861.11
861.12
861.13
861.20
861.21
861.22
861.30
861.31
861.32
862.0
862.1
862.21
862.22
862.29
862.31
862.32
862.39
862.8
862.9
875.0
875.1
901.0
901.1
901.2
901.3
901.40
901.41
901.42
901.81
901.82
901.83
901.89
906.0
908.0
908.4
922.0
922.1
926.8
934.0
934.1
934.8
934.9
935.0
935.1
935.2
958.0
958.1
958.2
958.3
unspecified injury of heart with open wound into thorax
contusion of heart with open wound into thorax
laceration of heart without penetration of heart chambers with open wound into thorax
laceration of heart with penetration of heart chambers and open wound into thorax
unspecified injury of lung without open wound into thorax
contusion of lung without open wound into thorax
laceration of lung without open wound into thorax
unspecified injury of lung with open wound into thorax
contusion of lung with open wound into thorax
laceration of lung with open wound into thorax
injury to diaphragm without open wound into cavity
injury to diaphragm with open wound into cavity
injury to bronchus without open wound into cavity
injury to esophagus without open wound into cavity
injury to other specified intrathoracic organs without open wound into cavity
injury to bronchus with open wound into cavity
injury to esophagus with open wound into cavity
injury to other specified intrathoracic organs with open wound into cavity
injury to multiple and unspecified intrathoracic organs without open wound into cavity
injury to multiple and unspecified intrathoracic organs with open wound into cavity
open wound of chest (wall) without complication
open wound of chest (wall) complicated
injury to thoracic aorta
injury to innominate and subclavian arteries
injury to superior vena cava
injury to innominate and subclavian veins
injury to pulmonary vessel(s) unspecified
injury to pulmonary artery
injury to pulmonary vein
injury to intercostal artery or vein
injury to internal mammary artery or vein
injury to multiple blood vessels of thorax
injury to other specified blood vessels of thorax
late effect of open wound of head neck and trunk
late effect of internal injury to chest
late effect of injury to blood vessel of thorax abdomen and pelvis
contusion of breast
contusion of chest wall
crushing injury of multiple sites of trunk
foreign body in trachea
foreign body in main bronchus
foreign body in other specified parts bronchus and lung
foreign body in respiratory tree unspecified
foreign body in mouth
foreign body in esophagus
foreign body in stomach
air embolism as an early complication of trauma
fat embolism as an early complication of trauma
secondary and recurrent hemorrhage as an early complication of trauma
posttraumatic wound infection not elsewhere classified
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
958.4
959.11
959.19
996.00
996.01
996.02
996.03
996.04
996.09
996.1
996.60
996.61
996.62
996.70
996.71
996.72
996.83
996.84
997.1
997.31
997.39
997.79
998.0
998.11
998.12
998.13
998.2
998.31
998.33
998.4
998.51
998.59
998.6
v10.00
v10.03
v10.04
v10.11
v10.12
v10.20
v10.29
v10.3
v10.40
v10.71
v10.72
v10.79
v10.81
v10.82
v10.83
v10.87
v67.00
traumatic shock
other injury of chest wall
other and unspecified injury of other sites of trunk
mechanical complications of unspecified cardiac device implant and graft
mechanical complication due to cardiac pacemaker (electrode)
mechanical complication due to heart valve prosthesis
mechanical complication due to coronary bypass graft
mechanical complication of automatic implantable cardiac defibrillator
other mechanical complication of cardiac device implant and graft
mechanical complication of other vascular device implant and graft
infection and inflammatory reaction due to unspecified device implant and graft
infection and inflammatory reaction due to cardiac device implant and graft
infection and inflammatory reaction due to other vascular device implant and graft
other complications due to unspecified device implant and graft
other complications due to heart valve prosthesis
other complications due to other cardiac device implant and graft
complications of transplanted heart
complications of transplanted lung
cardiac complications not elsewhere classified
ventilator associated pneumonia
other respiratory complications
vascular complications of other vessels
postoperative shock not elsewhere classified
hemorrhage complicating a procedure
hematoma complicating a procedure
seroma complicating a procedure
accidental puncture or laceration during a procedure not elsewhere classified
disruption of internal operation (surgical) wound
disruption of traumatic injury wound repair
foreign body accidentally left during a procedure not elsewhere classified
infected postoperative seroma
other postoperative infection
persistent postoperative fistula not elsewhere classified
personal history of malignant neoplasm of unspecified site in gastrointestinal tract
personal history of malignant neoplasm of esophagus
personal history of malignant neoplasm of stomach
personal history of malignant neoplasm of bronchus and lung
personal history of malignant neoplasm of trachea
personal history of malignant neoplasm of unspecified respiratory organ
personal history of malignant neoplasm of other respiratory and intrathoracic organs
personal history of malignant neoplasm of breast
personal history of malignant neoplasm of unspecified female genital organ
personal history of lymphosarcoma and reticulosarcoma
personal history of hodgkin’s disease
personal history of other lymphatic and hematopoietic neoplasms
personal history of malignant neoplasm of bone
personal history of malignant melanoma of skin
personal history of other malignant neoplasm of skin
personal history of malignant neoplasm of thyroid
follow-up examination following unspecified surgery
CMS Limitations
MRI Head, Neck, Face, Orbit, Jaw (con’t)
v67.09
v67.1
v67.2
v71.1
v71.82
v71.83
follow-up examination following other surgery
follow-up examination following radiotherapy
follow-up examination following chemotherapy
observation for suspected malignant neoplasm
observation and evaluation for suspected exposure to anthrax
observation and evaluation for suspected exposure to other biological agent
CMS Limitations
MRI Lower Extremity
LCD # L28723, Effective Date: 3/25/09
CPT codes: CPT 73718, CPT 73719, CPT 73720, CPT 73721, CPT 73722, CPT 73723, CPT 76376, CPT 76377
ICD-9 codes that support medical necemagnetic resonance (eg, proton) imaging, lower extremity other than joint;
without contrast material(s) (CPT 73718); magnetic resonance (eg, proton) imaging, lower extremity other than joint;
with contrast material(s) (CPT 73719); magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences (CPT 73720); magnetic resonance (eg,
proton) imaging, any joint of lower extremity; without contrast material (CPT 73721); magnetic resonance (eg, proton)
imaging, any joint of lower extremity; with contrast material(s) (CPT 73722); magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences
(CPT 73723); 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging,
ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation (CPT
76376); and 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation (CPT 76377):
170.7
170.8
170.9
171.3
172.7
173.7
195.5
198.5
198.89
209.29
209.30
213.7
213.8
215.3
216.7
228.1
232.7
238.0
239.2
249.70
249.71
250.70
250.71
250.72
250.73
353.6
354.5
355.0
355.1
355.2
355.3
355.4
355.5
malignant neoplasm of long bones of lower limb
malignant neoplasm of short bones of lower limb
malignant neoplasm of bone and articular cartilage site unspecified
malignant neoplasm of connective and other soft tissue of lower limb including hip
malignant melanoma of skin of lower limb including hip
other malignant neoplasm of skin of lower limb including hip
malignant neoplasm of lower limb
secondary malignant neoplasm of bone and bone marrow
secondary malignant neoplasm of other specified sites
malignant carcinoid tumor of other sites
malignant poorly differentiated neuroendocrine carcinoma, any site
benign neoplasm of long bones of lower limb
benign neoplasm of short bones of lower limb
other benign neoplasm of connective and other soft tissue of lower limb including hip
benign neoplasm of skin of lower limb including hip
lymphangioma any site
carcinoma in situ of skin of lower limb including hip
neoplasm of uncertain behavior of bone and articular cartilage
neoplasm of unspecified nature of bone soft tissue and skin
secondary diabetes mellitus with peripheral circulatory disorders, not stated as uncontrolled, or unspecified
secondary diabetes mellitus with peripheral circulatory disorders, uncontrolled
diabetes with peripheral circulatory disorders, type ii or unspecified type, not stated as uncontrolled
diabetes with peripheral circulatory disorders, type i [juvenile type], not stated as uncontrolled
diabetes with peripheral circulatory disorders, type ii or unspecified type, uncontrolled
diabetes with peripheral circulatory disorders, type i [juvenile type], uncontrolled
phantom limb (syndrome)
mononeuritis multiplex
lesion of sciatic nerve
meralgia paresthetica
other lesion of femoral nerve
lesion of lateral popliteal nerve
lesion of medial popliteal nerve
tarsal tunnel syndrome
CMS Limitations
MRI Lower Extremity (con’t)
355.6
355.71
355.79
359.21
359.22
359.23
359.29
359.3
442.3
444.22
457.1
682.6
682.7
711.05
711.06
711.07
713.5
714.0
715.00
715.09
715.10
715.15
715.16
715.17
715.20
715.25
715.26
715.27
715.30
715.35
715.36
715.37
715.80
715.90
715.95
715.96
715.97
716.15
716.16
716.17
717.0
717.1
717.2
717.3
717.40
717.41
717.42
717.43
717.49
lesion of plantar nerve
causalgia of lower limb
other mononeuritis of lower limb
myotonic muscular dystrophy
myotonia congenital
myotonic chondrodystrophy
other specified myotonic disorder
periodic paralysis
aneurysm of artery of lower extremity
arterial embolism and thrombosis of lower extremity
other lymphedema
cellulitis and abscess of leg except foot
cellulitis and abscess of foot except toes
pyogenic arthritis involving pelvic region and thigh
pyogenic arthritis involving lower leg
pyogenic arthritis involving ankle and foot
arthropathy associated with neurological disorders
rheumatoid arthritis
osteoarthrosis generalized involving unspecified site
osteoarthrosis generalized involving multiple sites
osteoarthrosis localized primary involving unspecified site
osteoarthrosis localized primary involving pelvic region and thigh
osteoarthrosis localized primary involving lower leg
osteoarthrosis localized primary involving ankle and foot
osteoarthrosis localized secondary involving unspecified site
osteoarthrosis localized secondary involving pelvic region and thigh
osteoarthrosis localized secondary involving lower leg
osteoarthrosis localized secondary involving ankle and foot
osteoarthrosis localized not specified whether primary or secondary involving unspecified site
osteoarthrosis localized not specified whether primary or secondary involving pelvic region and thigh
osteoarthrosis localized not specified whether primary or secondary involving lower leg
osteoarthrosis localized not specified whether primary or secondary involving ankle and foot
osteoarthrosis involving or with more than one site but not specified as generalized and involving unspecified site
osteoarthrosis unspecified whether generalized or localized involving unspecified site
osteoarthrosis unspecified whether generalized or localized involving pelvic region and thigh
osteoarthrosis unspecified whether generalized or localized involving lower leg
osteoarthrosis unspecified whether generalized or localized involving ankle and foot
traumatic arthropathy involving pelvic region and thigh
traumatic arthropathy involving lower leg
traumatic arthropathy involving ankle and foot
old bucket handle tear of medial meniscus
derangement of anterior horn of medial meniscus
derangement of posterior horn of medial meniscus
other and unspecified derangement of medial meniscus
derangement of lateral meniscus unspecified
bucket handle tear of lateral meniscus
derangement of anterior horn of lateral meniscus
derangement of posterior horn of lateral meniscus
other derangement of lateral meniscus
CMS Limitations
MRI Lower Extremity (con’t)
717.5
717.6
717.7
717.81
717.82
717.83
717.84
717.85
717.89
717.9
718.00
718.05
718.07
718.09
718.10
718.15
718.17
718.19
718.20
718.25
718.26
718.27
718.29
718.30
718.35
718.36
718.37
718.39
718.40
718.45
718.46
718.47
718.49
718.50
718.55
718.56
718.57
718.59
718.60
718.65
718.75
718.76
718.77
718.78
718.79
718.80
718.85
718.86
718.87
718.89
derangement of meniscus not elsewhere classified
loose body in knee
chondromalacia of patella
old disruption of lateral collateral ligament
old disruption of medial collateral ligament
old disruption of anterior cruciate ligament
old disruption of posterior cruciate ligament
old disruption of other ligaments of knee
other internal derangement of knee
unspecified internal derangement of knee
articular cartilage disorder site unspecified
articular cartilage disorder involving pelvic region and thigh
articular cartilage disorder involving ankle and foot
articular cartilage disorder involving multiple sites
loose body in joint site unspecified
loose body in joint of pelvic region and thigh
loose body in ankle and foot joint
loose body in joint of multiple sites
pathological dislocation of joint site unspecified
pathological dislocation of joint of pelvic region and thigh
pathological dislocation of joint of lower leg
pathological dislocation of ankle and foot joint
pathological dislocation of joint of multiple sites
recurrent dislocation of joint site unspecified
recurrent dislocation of joint of pelvic region and thigh
recurrent dislocation of lower leg joint
recurrent dislocation of ankle and foot joint
recurrent dislocation of joint of multiple sites
contracture of joint site unspecified
contracture of joint of pelvic region and thigh
contracture of lower leg joint
contracture of ankle and foot joint
contracture of joint of multiple sites
ankylosis of joint site unspecified
ankylosis of joint of pelvic region and thigh
ankylosis of lower leg joint
ankylosis of ankle and foot joint
ankylosis of joint of multiple sites
unspecified intrapelvic protrusion of acetabulum site unspecified
unspecified intrapelvic protrusion of acetabulum pelvic region and thigh
developmental dislocation of joint pelvic region and thigh
developmental dislocation of joint lower leg
developmental dislocation of joint ankle and foot
developmental dislocation of joint other specified site
developmental dislocation of joint multiple sites
other joint derangement not elsewhere classified involving unspecified site
other joint derangement not elsewhere classified involving pelvic region and thigh
other joint derangement not elsewhere classified involving lower leg
other joint derangement not elsewhere classified involving ankle and foot
other joint derangement not elsewhere classified involving multiple sites
CMS Limitations
MRI Lower Extremity (con’t)
718.90
718.95
718.97
718.98
718.99
719.05
719.06
719.07
719.15
719.16
719.17
719.25
719.26
719.27
719.40
719.45
719.46
719.47
719.7
726.5
726.60
726.61
726.62
726.63
726.64
726.65
726.71
727.02
727.06
727.40
727.41
727.42
727.50
727.51
727.65
727.66
727.67
727.68
728.3
729.6
730.05
730.06
730.07
730.09
730.15
730.16
730.17
730.19
730.25
730.26
unspecified derangement of joint site unspecified
unspecified derangement of joint of pelvic region and thigh
unspecified derangement of ankle and foot joint
unspecified derangement of joint of other specified sites
unspecified derangement of joint of multiple sites
effusion of joint of pelvic region and thigh
effusion of lower leg joint
effusion of ankle and foot joint
hemarthrosis involving pelvic region and thigh
hemarthrosis involving lower leg
hemarthrosis involving ankle and foot
villonodular synovitis involving pelvic region and thigh
villonodular synovitis involving lower leg
villonodular synovitis involving ankle and foot
pain in joint site unspecified
pain in joint involving pelvic region and thigh
pain in joint involving lower leg
pain in joint involving ankle and foot
difficulty in walking
enthesopathy of hip region
enthesopathy of knee unspecified
pes anserinus tendinitis or bursitis
tibial collateral ligament bursitis
fibular collateral ligament bursitis
patellar tendinitis
prepatellar bursitis
achilles bursitis or tendinitis
giant cell tumor of tendon sheath
tenosynovitis of foot and ankle
synovial cyst unspecified
ganglion of joint
ganglion of tendon sheath
rupture of synovium unspecified
synovial cyst of popliteal space
nontraumatic rupture of quadriceps tendon
nontraumatic rupture of patellar tendon
nontraumatic rupture of achilles tendon
nontraumatic rupture of other tendons of foot and ankle
other specific muscle disorders
residual foreign body in soft tissue
acute osteomyelitis involving pelvic region and thigh
acute osteomyelitis involving lower leg
acute osteomyelitis involving ankle and foot
acute osteomyelitis involving multiple sites
chronic osteomyelitis involving pelvic region and thigh
chronic osteomyelitis involving lower leg
chronic osteomyelitis involving ankle and foot
chronic osteomyelitis involving multiple sites
unspecified osteomyelitis involving pelvic region and thigh
unspecified osteomyelitis involving lower leg
CMS Limitations
MRI Lower Extremity (con’t)
730.27
733.00
733.01
733.02
733.03
733.09
733.14
733.15
733.16
733.20
733.21
733.22
733.42
733.43
733.44
733.81
733.82
733.90
733.93
733.94
733.95
733.97
747.60
747.64
793.7
836.0
836.1
836.2
843.0
843.1
843.8
843.9
844.0
844.1
844.2
844.3
844.8
844.9
845.00
845.01
845.02
845.03
845.09
845.10
845.11
845.12
845.13
845.19
928.00
928.01
unspecified osteomyelitis involving ankle and foot
osteoporosis unspecified
senile osteoporosis
idiopathic osteoporosis
disuse osteoporosis
other osteoporosis
pathological fracture of neck of femur
pathological fracture of other specified part of femur
pathological fracture of tibia or fibula
cyst of bone (localized) unspecified
solitary bone cyst
aneurysmal bone cyst
aseptic necrosis of head and neck of femur
aseptic necrosis of medial femoral condyle
aseptic necrosis of talus
malunion of fracture
nonunion of fracture
disorder of bone and cartilage unspecified
stress fracture of tibia or fibula
stress fracture of the metatarsals
stress fracture of other bone
stress fracture of shaft of femur
anomaly of the peripheral vascular system unspecified site
lower limb vessel anomaly
nonspecific abnormal findings on radiological and other examination of musculoskeletal system
tear of medial cartilage or meniscus of knee current
tear of lateral cartilage or meniscus of knee current
other tear of cartilage or meniscus of knee current
iliofemoral (ligament) sprain
ischiocapsular (ligament) sprain
sprain of other specified sites of hip and thigh
sprain of unspecified site of hip and thigh
sprain of lateral collateral ligament of knee
sprain of medial collateral ligament of knee
sprain of cruciate ligament of knee
sprain of tibiofibular (joint) (ligament) superior of knee
sprain of other specified sites of knee and leg
sprain of unspecified site of knee and leg
unspecified site of ankle sprain
deltoid (ligament) ankle sprain
calcaneofibular (ligament) ankle sprain
tibiofibular (ligament) sprain distal
other ankle sprain
unspecified site of foot sprain
tarsometatarsal (joint) (ligament) sprain
metatarsaophalangeal (joint) sprain
interphalangeal (joint) toe sprain
other foot sprain
crushing injury of thigh
crushing injury of hip
CMS Limitations
MRI Lower Extremity (con’t)
928.10
928.11
928.20
928.21
928.3
928.8
996.1
996.40
996.62
997.79
v10.81
v67.00
v67.09
v67.1
v67.2
v71.1
crushing injury of lower leg
crushing injury of knee
crushing injury of foot
crushing injury of ankle
crushing injury of toe(s)
crushing injury of multiple sites of lower limb
mechanical complication of other vascular device implant and graft
unspecified mechanical complication of internal orthopedic device, implant, and graft
infection and inflammatory reaction due to other vascular device implant and graft
vascular complications of other vessels
personal history of malignant neoplasm of bone
follow-up examination following unspecified surgery
follow-up examination following other surgery
follow-up examination following radiotherapy
follow-up examination following chemotherapy
observation for suspected malignant neoplasm
CMS Limitations
MRI Lumbar Spine
LCD # L1326, Effective Date: 8/26/08
CPT/HCPCS Codes: CPT 72148, CPT 72149, CPT 72158
ICD-9 codes that support medical necessity for magnetic resonance (eg, proton) imaging, spinal canal and contents,
lumbar; without contrast material (CPT 72148); magnetic resonance (eg, proton) imaging, spinal canal and contents,
lumbar; with contrast material(s) (CPT 72149); and magnetic resonance (eg, proton) imaging, spinal canal and contents,
without contrast material, followed by contrast material(s) and further sequences; lumbar (CPT 72158):
015.00 - 015.06 tuberculosis of vertebral column unspecified examination - tuberculosis of vertebral column tubercle
bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other
methods (inoculation of animals)
170.2
malignant neoplasm of vertebral column excluding sacrum and coccyx
170.6
malignant neoplasm of pelvic bones sacrum and coccyx
195.8
malignant neoplasm of other specified sites
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
198.89
secondary malignant neoplasm of other specified sites
200.00 - 208.91 reticulosarcoma unspecified site - unspecified leukemia in remission
213.2
benign neoplasm of vertebral column excluding sacrum and coccyx
213.6
benign neoplasm of pelvic bones sacrum and coccyx
215.7
other benign neoplasm of connective and other soft tissue of trunk unspecified
225.3 - 225.4 benign neoplasm of spinal cord - benign neoplasm of spinal meninges
228.00 - 228.1 hemangioma of unspecified site - lymphangioma any site
229.0 - 229.9 benign neoplasm of lymph nodes - benign neoplasm of unspecified site
238.0 - 238.2 neoplasm of uncertain behavior of bone and articular cartilage - neoplasm of uncertain behavior of
skin
239.8
neoplasm of unspecified nature of other specified sites
320.0 - 320.9 hemophilus meningitis - meningitis due to unspecified bacterium
321.0 - 321.8 cryptococcal meningitis - meningitis due to other nonbacterial organisms classified elsewhere
322.0 - 322.9 nonpyogenic meningitis - meningitis unspecified
324.1
intraspinal abscess
324.9
intracranial and intraspinal abscess of unspecified site
335.0 - 335.9 werdnig-hoffmann disease - anterior horn cell disease unspecified
336.0 - 336.9 syringomyelia and syringobulbia - unspecified disease of spinal cord
337.00 - 337.9 idiopathic peripheral autonomic neuropathy, unspecified - unspecified disorder of autonomic nervous
system
340
multiple sclerosis
341.0 - 341.9 neuromyelitis optica - demyelinating disease of central nervous system unspecified
344.00 - 344.9 quadriplegia unspecified - paralysis unspecified
353.0 - 353.4 brachial plexus lesions - lumbosacral root lesions not elsewhere classified
353.8
other nerve root and plexus disorders
353.9
unspecified nerve root and plexus disorder
357.0
acute infective polyneuritis
715.18
osteoarthrosis localized primary involving other specified sites
715.28
osteoarthrosis localized secondary involving other specified sites
715.38
osteoarthrosis localized not specified whether primary or secondary involving other specified sites
720.0 - 720.9 ankylosing spondylitis - unspecified inflammatory spondylopathy
721.1 - 721.91 cervical spondylosis with myelopathy - spondylosis of unspecified site with myelopathy
CMS Limitations
MRI Lumbar Spine (con’t)
722.10 - 722.93 displacement of lumbar intervertebral disc without myelopathy - other and unspecified disc disorder
of lumbar region
723.0 - 723.4 spinal stenosis in cervical region - brachial neuritis or radiculitis nos
723.9
unspecified musculoskeletal disorders and symptoms referable to neck
724.00 - 724.9 spinal stenosis of unspecified region - other unspecified back disorders
730.08
acute osteomyelitis involving other specified sites
730.18
chronic osteomyelitis involving other specified sites
730.28
unspecified osteomyelitis involving other specified sites
730.98
unspecified infection of bone of other specified sites
732.0
juvenile osteochondrosis of spine
732.7
osteochondritis dissecans
732.8
other specified forms of osteochondropathy
732.9
unspecified osteochondropathy
733.00 - 733.09 osteoporosis unspecified - other osteoporosis
733.10 - 733.19 pathological fracture unspecified site - pathological fracture of other specified site
733.20 - 733.29 cyst of bone (localized) unspecified - other bone cyst
733.40
aseptic necrosis of bone site unspecified
737.0 - 737.9 adolescent postural kyphosis - unspecified curvature of spine associated with other conditions
738.4
acquired spondylolisthesis
738.5
other acquired deformity of back or spine
738.8 - 738.9 acquired musculoskeletal deformity of other specified site - acquired musculoskeletal deformity of
unspecified site
739.1 - 739.4 nonallopathic lesions of cervical region not elsewhere classified - nonallopathic lesions of sacral region
not elsewhere classified
741.00 - 741.93 spina bifida unspecified region with hydrocephalus - spina bifida lumbar region without hydrocephalus
742.51 - 742.59 diastematomyelia - other specified congenital anomalies of spinal cord
742.8
other specified congenital anomalies of nervous system
742.9
unspecified congenital anomaly of brain spinal cord and nervous system
756.10 - 756.19 congenital anomaly of spine unspecified - other congenital anomalies of spine
781.0 - 781.8 abnormal involuntary movements - neurological neglect syndrome
792.0
nonspecific abnormal findings in cerebrospinal fluid
793.91
image test inconclusive due to excess body fat
793.99
other nonspecific abnormal findings on radiological and other examinations of body structure
794.10
nonspecific abnormal response to unspecified nerve stimulation
794.17
nonspecific abnormal electromyogram (emg)
796.1
abnormal reflex
805.00 - 805.9 closed fracture of cervical vertebra unspecified level - open fracture of unspecified part of vertebral
column without spinal cord injury
806.00 - 806.9 closed fracture of c1-c4 level with unspecified spinal cord injury - open fracture of unspecified vertebra
with spinal cord injury
839.00 - 839.59 closed dislocation cervical vertebra unspecified - open dislocation other vertebra
952.00 - 952.9 c1-c4 level spinal cord injury unspecified - unspecified site of spinal cord injury without spinal bone
injury
953.0 - 953.9 injury to cervical nerve root - injury to unspecified site of nerve roots and spinal plexus
v10.81
personal history of malignant neoplasm of bone
v10.86
personal history of malignant neoplasm of other parts of nervous system
CMS Limitations
MRI Thoracic Spine
LCD # L28723, Effective Date: 3/25/09
CPT codes: CPT 72146, CPT 72147, CPT 72157, CPT 76376*, CPT 76377*
ICD-9 codes that SUPPORT medical necessity for magnetic resonance (eg, proton) imaging, spinal canal and contents,
thoracic; without contrast material (CPT 72146); magnetic resonance (eg, proton) imaging, spinal canal and contents,
thoracic; with contrast material(s) (CPT 72147); magnetic resonance (eg, proton) imaging, spinal canal and contents,
without contrast material, followed by contrast material(s) and further sequences; thoracic (CPT 72157); 3D rendering
with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation (CPT 76376*); and 3D rendering
with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation (CPT 76377*):
*Note: For the purposes of this LCD, CPT code 76376 or 76377 is allowed only when billed in conjunction with another
MRI procedure code.
170.2
185
192.2
192.3
192.8
192.9
193
195.1
196.1
197.0
197.1
197.2
197.3
198.3
198.4
198.5
199.0
199.2
203.00
203.01
203.02
209.30
213.2
225.3
225.4
228.1
237.5
322.0
322.1
322.2
322.9
324.1
334.8
334.9
malignant neoplasm of vertebral column excluding sacrum and coccyx
malignant neoplasm of prostate
malignant neoplasm of spinal cord
malignant neoplasm of spinal meninges
malignant neoplasm of other specified sites of nervous system
malignant neoplasm of nervous system part unspecified
malignant neoplasm of thyroid gland
malignant neoplasm of thorax
secondary and unspecified malignant neoplasm of intrathoracic lymph nodes
secondary malignant neoplasm of lung
secondary malignant neoplasm of mediastinum
secondary malignant neoplasm of pleura
secondary malignant neoplasm of other respiratory organs
secondary malignant neoplasm of brain and spinal cord
secondary malignant neoplasm of other parts of nervous system
secondary malignant neoplasm of bone and bone marrow
disseminated malignant neoplasm
malignant neoplasm associated with transplant organ
multiple myeloma, without mention of having achieved remission
multiple myeloma in remission
multiple myeloma, in relapse
malignant poorly differentiated neuroendocrine carcinoma, any site
benign neoplasm of vertebral column excluding sacrum and coccyx
benign neoplasm of spinal cord
benign neoplasm of spinal meninges
lymphangioma any site
neoplasm of uncertain behavior of brain and spinal cord
nonpyogenic meningitis
eosinophilic meningitis
chronic meningitis
meningitis unspecified
intraspinal abscess
other spinocerebellar diseases
spinocerebellar disease unspecified
CMS Limitations
MRI Thoracic Spine (con’t)
336.0
336.1
340
341.8
341.9
342.00
342.01
342.02
342.10
342.11
342.12
342.80
342.81
342.82
342.90
342.91
342.92
344.00
344.1
344.30
344.31
344.32
344.40
344.41
344.42
344.5
349.31
349.39
353.3
353.8
357.1
357.2
357.3
718.78
718.79
720.0
720.1
720.81
721.2
721.41
721.91
722.11
722.2
722.31
722.51
722.6
722.70
722.72
722.82
722.92
syringomyelia and syringobulbia
vascular myelopathies
multiple sclerosis
other demyelinating diseases of central nervous system
demyelinating disease of central nervous system unspecified
flaccid hemiplegia and hemiparesis affecting unspecified side
flaccid hemiplegia and hemiparesis affecting dominant side
flaccid hemiplegia and hemiparesis affecting nondominant side
spastic hemiplegia and hemiparesis affecting unspecified side
spastic hemiplegia and hemiparesis affecting dominant side
spastic hemiplegia and hemiparesis affecting nondominant side
other specified hemiplegia and hemiparesis affecting unspecified side
other specified hemiplegia and hemiparesis affecting dominant side
other specified hemiplegia and hemiparesis affecting nondominant side
unspecified hemiplegia and hemiparesis affecting unspecified side
unspecified hemiplegia and hemiparesis affecting dominant side
unspecified hemiplegia and hemiparesis affecting nondominant side
quadriplegia unspecified
paraplegia
monoplegia of lower limb affecting unspecified side
monoplegia of lower limb affecting dominant side
monoplegia of lower limb affecting nondominant side
monoplegia of upper limb affecting unspecified side
monoplegia of upper limb affecting dominant side
monoplegia of upper limb affecting nondominant sde
unspecified monoplegia
accidental puncture or laceration of dura during a procedure
other dural tear
thoracic root lesions not elsewhere classified
other nerve root and plexus disorders
polyneuropathy in collagen vascular disease
polyneuropathy in diabetes
polyneuropathy in malignant disease
developmental dislocation of joint other specified site
developmental dislocation of joint multiple sites
ankylosing spondylitis
spinal enthesopathy
inflammatory spondylopathies in diseases classified elsewhere
thoracic spondylosis without myelopathy
spondylosis with myelopathy thoracic region
spondylosis of unspecified site with myelopathy
displacement of thoracic intervertebral disc without myelopathy
displacement of intervertebral disc site unspecified without myelopathy
schmorl’s nodes of thoracic region
degeneration of thoracic or thoracolumbar intervertebral disc
degeneration of intervertebral disc site unspecified
intervertebral disc disorder with myelopathy unspecified region
intervertebral disc disorder with myelopathy thoracic region
postlaminectomy syndrome of thoracic region
other and unspecified disc disorder of thoracic region
CMS Limitations
MRI Thoracic Spine (con’t)
724.01
724.1
724.4
730.08
730.18
730.28
730.38
733.00
733.01
733.02
733.03
733.09
733.10
733.13
733.19
733.20
733.21
733.22
733.29
733.40
737.10
737.30
738.4
738.5
741.02
741.92
742.51
742.53
742.59
754.2
756.10
756.12
756.13
756.14
756.15
793.7
805.2
805.3
806.20
806.21
806.22
806.23
806.24
806.25
806.26
806.27
806.28
806.29
806.30
806.31
spinal stenosis of thoracic region
pain in thoracic spine
thoracic or lumbosacral neuritis or radiculitis unspecified
acute osteomyelitis involving other specified sites
chronic osteomyelitis involving other specified sites
unspecified osteomyelitis involving other specified sites
periostitis without osteomyelitis involving other specified sites
osteoporosis unspecified
senile osteoporosis
idiopathic osteoporosis
disuse osteoporosis
other osteoporosis
pathological fracture unspecified site
pathological fracture of vertebrae
pathological fracture of other specified site
cyst of bone (localized) unspecified
solitary bone cyst
aneurysmal bone cyst
other bone cyst
aseptic necrosis of bone site unspecified
kyphosis (acquired) (postural)
scoliosis (and kyphoscoliosis) idiopathic
acquired spondylolisthesis
other acquired deformity of back or spine
spina bifida dorsal (thoracic) region with hydrocephalus
spina bifida dorsal (thoracic) region without hydrocephalus
diastematomyelia
hydromyelia
other specified congenital anomalies of spinal cord
congenital musculoskeletal deformities of spine
congenital anomaly of spine unspecified
spondylolisthesis congenital
absence of vertebra congenital
hemivertebra
fusion of spine (vertebra) congenital
nonspecific abnormal findings on radiological and other examination of musculoskeletal system
closed fracture of dorsal (thoracic) vertebra without spinal cord injury
open fracture of dorsal (thoracic) vertebra without spinal cord injury
closed fracture of t1-t6 level with unspecified spinal cord injury
closed fracture of t1-t6 level with complete lesion of cord
closed fracture of t1-t6 level with anterior cord syndrome
closed fracture of t1-t6 level with central cord syndrome
closed fracture of t1-t6 level with other specified spinal cord injury
closed fracture of t7-t12 level with unspecified spinal cord injury
closed fracture of t7-t12 level with complete lesion of cord
closed fracture of t7-t12 level with anterior cord syndrome
closed fracture of t7-t12 level with central cord syndrome
closed fracture of t7-t12 level with other specified spinal cord injury
open fracture of t1-t6 level with unspecified spinal cord injury
open fracture of t1-t6 level with complete lesion of cord
CMS Limitations
MRI Thoracic Spine (con’t)
806.32
806.33
806.34
806.35
806.36
806.37
806.38
806.39
839.21
839.31
952.10
952.11
952.12
952.13
952.14
952.15
952.16
952.17
952.18
952.19
952.8
953.1
v10.81
v10.86
v67.00
v67.09
v67.1
v67.2
v71.1
open fracture of t1-t6 level with anterior cord syndrome
open fracture of t1-t6 level with central cord syndrome
open fracture of t1-t6 level with other specified spinal cord injury
open fracture of t7-t12 level with unspecified spinal cord injury
open fracture of t7-t12 level with complete lesion of cord
open fracture of t7-t12 level with anterior cord syndrome
open fracture of t7-t12 level with central cord syndrome
open fracture of t7-t12 level with other specified spinal cord injury
closed dislocation thoracic vertebra
open dislocation thoracic vertebra
t1-t6 level spinal cord injury unspecified
t1-t6 level with complete lesion of spinal cord
t1-t6 level with anterior cord syndrome
t1-t6 level with central cord syndrome
t1-t6 level with other specified spinal cord injury
t7-t12 level spinal cord injury unspecified
t7-t12 level with complete lesion of spinal cord
t7-t12 level with anterior cord syndrome
t7-t12 level with central cord syndrome
t7-t12 level with other specified spinal cord injury
multiple sites of spinal cord injury without spinal bone injury
injury to dorsal nerve root
personal history of malignant neoplasm of bone
personal history of malignant neoplasm of other parts of nervous system
follow-up examination following unspecified surgery
follow-up examination following other surgery
follow-up examination following radiotherapy
follow-up examination following chemotherapy
observation for suspected malignant neoplasm
CMS Limitations
MRI Upper Extremity
LCD # L28723, Effective Date: 3/25/09
CPT/HCPCS codes: CPT 73218, CPT 73219, CPT 73220, CPT 73221, CPT 73222, CPT 73223, CPT 76376*, CPT 76377*
ICD-9 codes that support medical necessity for magnetic resonance (eg, proton) imaging, upper extremity, other than
joint; without contrast material(s) (CPT 73218); magnetic resonance (eg, proton) imaging, upper extremity, other than
joint; with contrast material(s) (CPT 73219); magnetic resonance (eg, proton) imaging, upper extremity, other than joint;
without contrast material(s), followed by contrast material(s) and further sequences (CPT 73220); magnetic resonance
(eg, proton) imaging, any joint of upper extremity; without contrast material(s) (CPT 73221); magnetic resonance (eg,
proton) imaging, any joint of upper extremity; with contrast material(s) (CPT 73222); magnetic resonance (eg, proton)
imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences (CPT 73223); 3D rendering with interpretation and reporting of computed tomography, magnetic resonance
imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation (CPT 76376*); and 3D rendering with interpretation and reporting of computed tomography, magnetic resonance
imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation
(CPT 76377*):
*Note: For the purposes of this LCD, CPT code 76376 or 76377 is allowed only when billed in conjunction with another
MRI procedure code.
170.4
170.5
170.9
171.2
172.6
173.6
195.4
198.5
198.89
209.29
209.30
213.4
213.5
215.2
216.6
228.1
232.6
238.0
239.2
333.84
354.0
354.1
354.2
354.3
354.4
354.5
359.21
359.22
359.23
359.29
malignant neoplasm of scapula and long bones of upper limb
malignant neoplasm of short bones of upper limb
malignant neoplasm of bone and articular cartilage site unspecified
malignant neoplasm of connective and other soft tissue of upper limb including shoulder
malignant melanoma of skin of upper limb including shoulder
other malignant neoplasm of skin of upper limb including shoulder
malignant neoplasm of upper limb
secondary malignant neoplasm of bone and bone marrow
secondary malignant neoplasm of other specified sites
malignant carcinoid tumor of other sites
malignant poorly differentiated neuroendocrine carcinoma, any site
benign neoplasm of scapula and long bones of upper limb
benign neoplasm of short bones of upper limb
other benign neoplasm of connective and other soft tissue of upper limb including shoulder
benign neoplasm of skin of upper limb including shoulder
lymphangioma any site
carcinoma in situ of skin of upper limb including shoulder
neoplasm of uncertain behavior of bone and articular cartilage
neoplasm of unspecified nature of bone soft tissue and skin
organic writers’ cramp
carpal tunnel syndrome
other lesion of median nerve
lesion of ulnar nerve
lesion of radial nerve
causalgia of upper limb
mononeuritis multiplex
myotonic muscular dystrophy
myotonia congenital
myotonic chondrodystrophy
other specified myotonic disorder
CMS Limitations
MRI Upper Extremity (con’t)
359.3
442.0
444.21
457.0
457.1
682.3
711.01
711.02
711.03
711.04
714.0
715.00
715.04
715.09
715.11
715.12
715.13
715.14
715.20
715.21
715.22
715.23
715.24
715.30
715.31
715.32
715.33
715.34
715.80
715.89
715.90
715.91
715.92
715.93
715.94
716.11
716.12
716.13
716.14
718.00
718.01
718.02
718.03
718.04
718.10
718.11
718.12
718.13
718.14
periodic paralysis
aneurysm of artery of upper extremity
arterial embolism and thrombosis of upper extremity
postmastectomy lymphedema syndrome
other lymphedema
cellulitis and abscess of upper arm and forearm
pyogenic arthritis involving shoulder region
pyogenic arthritis involving upper arm
pyogenic arthritis involving forearm
pyogenic arthritis involving hand
rheumatoid arthritis
osteoarthrosis generalized involving unspecified site
osteoarthrosis generalized involving hand
osteoarthrosis generalized involving multiple sites
osteoarthrosis localized primary involving shoulder region
osteoarthrosis localized primary involving upper arm
osteoarthrosis localized primary involving forearm
osteoarthrosis localized primary involving hand
osteoarthrosis localized secondary involving unspecified site
osteoarthrosis localized secondary involving shoulder region
osteoarthrosis localized secondary involving upper arm
osteoarthrosis localized secondary involving forearm
osteoarthrosis localized secondary involving hand
osteoarthrosis localized not specified whether primary or secondary involving unspecified site
osteoarthrosis localized not specified whether primary or secondary involving shoulder region
osteoarthrosis localized not specified whether primary or secondary involving upper arm
osteoarthrosis localized not specified whether primary or secondary involving forearm
osteoarthrosis localized not specified whether primary or secondary involving hand
osteoarthrosis involving or with more than one site but not specified as generalized and involving unspecified site
osteoarthrosis involving or with multiple sites but not specified as generalized
osteoarthrosis unspecified whether generalized or localized involving unspecified site
osteoarthrosis unspecified whether generalized or localized involving shoulder region
osteoarthrosis unspecified whether generalized or localized involving upper arm
osteoarthrosis unspecified whether generalized or localized involving forearm
osteoarthrosis unspecified whether generalized or localized involving hand
traumatic arthropathy involving shoulder region
traumatic arthropathy involving upper arm
traumatic arthropathy involving forearm
traumatic arthropathy involving hand
articular cartilage disorder site unspecified
articular cartilage disorder involving shoulder region
articular cartilage disorder involving upper arm
articular cartilage disorder involving forearm
articular cartilage disorder involving hand
loose body in joint site unspecified
loose body in joint of shoulder region
loose body in upper arm joint
loose body in forearm joint
loose body in hand joint
CMS Limitations
MRI Upper Extremity (con’t)
718.20
718.21
718.22
718.23
718.24
718.30
718.31
718.32
718.33
718.34
718.40
718.41
718.42
718.43
718.44
718.50
718.51
718.52
718.53
718.54
718.71
718.72
718.73
718.74
718.78
718.79
718.80
718.81
718.82
718.83
718.84
718.90
718.91
718.92
718.93
718.94
719.01
719.02
719.03
719.04
719.11
719.12
719.13
719.14
719.21
719.22
719.23
719.24
719.41
719.42
pathological dislocation of joint site unspecified
pathological dislocation of joint of shoulder region
pathological dislocation of upper arm joint
pathological dislocation of forearm joint
pathological dislocation of hand joint
recurrent dislocation of joint site unspecified
recurrent dislocation of joint of shoulder region
recurrent dislocation of upper arm joint
recurrent dislocation of forearm joint
recurrent dislocation of hand joint
contracture of joint site unspecified
contracture of joint of shoulder region
contracture of upper arm joint
contracture of forearm joint
contracture of hand joint
ankylosis of joint site unspecified
ankylosis of joint of shoulder region
ankylosis of upper arm joint
ankylosis of forearm joint
ankylosis of hand joint
developmental dislocation of joint shoulder region
developmental dislocation of joint upper arm
developmental dislocation of joint forearm
developmental dislocation of joint hand
developmental dislocation of joint other specified site
developmental dislocation of joint multiple sites
other joint derangement not elsewhere classified involving unspecified site
other joint derangement not elsewhere classified involving shoulder region
other joint derangement not elsewhere classified involving upper arm
other joint derangement not elsewhere classified involving forearm
other joint derangement not elsewhere classified involving hand
unspecified derangement of joint site unspecified
unspecified derangement of joint of shoulder region
unspecified derangement of upper arm joint
unspecified derangement of forearm joint
unspecified derangement of hand joint
effusion of joint of shoulder region
effusion of upper arm joint
effusion of forearm joint
effusion of hand joint
herarthrosis involving shoulder region
hemarthorsis involving upper arm
hemarthrosis involving forearm
hemarthrosis involving hand
villonodular synovitis involving shoulder region
villonodular synovitis involving upper arm
villonodular synovitis involving forearm
villonodular synovitis involving hand
pain in joint involving shoulder region
pain in joint involving upper arm
CMS Limitations
MRI Upper Extremity (con’t)
719.43
719.44
726.0
726.10
726.11
726.12
726.30
726.31
726.32
726.33
727.02
727.03
727.04
727.05
727.40
727.41
727.42
727.61
727.62
727.63
727.64
730.01
730.02
730.03
730.04
730.11
730.12
730.13
730.14
730.20
730.21
730.22
730.23
730.24
733.00
733.01
733.02
733.03
733.09
733.11
733.12
733.20
733.21
733.22
733.41
733.81
733.82
733.90
747.63
793.7
pain in joint involving forearm
pain in joint involving hand
adhesive capsulitis of shoulder
disorders of bursae and tendons in shoulder region unspecified
calcifying tendinitis of shoulder
bicipital tenosynovitis
enthesopathy of elbow unspecified
medial epicondylitis
lateral epicondylitis
olecranon bursitis
giant cell tumor of tendon sheath
trigger finger (acquired)
radial styloid tenosynovitis
other tenosynovitis of hand and wrist
synovial cyst unspecified
ganglion of joint
ganglion of tendon sheath
complete rupture of rotator cuff
nontraumatic rupture of tendons of biceps (long head)
nontraumatic rupture of extensor tendons of hand and wrist
nontraumatic rupture of flexor tendons of hand and wrist
acute osteomyelitis involving shoulder region
acute osteomyelitis involving upper arm
acute osteomyelitis involving forearm
acute osteomyelitis involving hand
chronic osteomyelitis involving shoulder region
chronic osteomyelitis involving upper arm
chronic osteomyelitis involving forearm
chronic osteomyelitis involving hand
unspecified osteomyelitis site unspecified
unspecified osteomyelitis involving shoulder region
unspecified osteomyelitis involving upper arm
unspecified osteomyelitis involving forearm
unspecified osteomyelitis involving hand
osteoporosis unspecified
senile osteoporosis
idiopathic osteoporosis
disuse osteoporosis
other osteoporosis
pathological fracture of humerus
pathological fracture of distal radius and ulna
cyst of bone (localized) unspecified
solitary bone cyst
aneurysmal bone cyst
aseptic necrosis of head of humerus
malunion of fracture
nonunion of fracture
disorder of bone and cartilage unspecified
upper limb vessel anomaly
nonspecific abnormal findings on radiological and other examination of musculoskeletal system
CMS Limitations
MRI Upper Extremity (con’t)
840.0
840.1
840.2
840.3
840.4
840.5
840.6
840.7
840.8
840.9
841.0
841.1
841.2
841.3
841.8
841.9
842.00
842.01
842.02
842.09
842.10
842.11
842.12
842.13
842.19
927.00
927.01
927.02
927.03
927.09
927.10
927.11
927.20
927.21
927.3
927.8
996.1
996.40
996.62
v10.81
v67.00
v67.09
v67.1
v67.2
v71.1
acromioclavicular (joint) (ligament) sprain
coracoclavicular (ligament) sprain
coracohumeral (ligament) sprain
infraspinatus (muscle) (tendon) sprain
rotator cuff (capsule) sprain
subscapularis (muscle) sprain
supraspinatus (muscle) (tendon) sprain
superior glenoid labrum lesion
sprain of other specified sites of shoulder and upper arm
sprain of unspecified site of shoulder and upper arm
radial collateral ligament sprain
ulnar collateral ligament sprain
radiohumeral (joint) sprain
ulnohumeral (joint) sprain
sprain of other specified sites of elbow and forearm
sprain of unspecified site of elbow and forearm
sprain of unspecified site of wrist
sprain of carpal (joint) of wrist
sprain of radiocarpal (joint) (ligament) of wrist
other wrist sprain
sprain of unspecified site of hand
sprain of carpometacarpal (joint) of hand
sprain of metacarpophalangeal (joint) of hand
sprain of interphalangeal (joint) of hand
other hand sprain
crushing injury of shoulder region
crushing injury of scapular region
crushing injury of axillary region
crushing injury of upper arm
crushing injury of multiple sites of upper arm
crushing injury of forearm
crushing injury of elbow
crushing injury of hand(s)
crushing injury of wrist
crushing injury of finger(s)
crushing injury of multiple sites of upper limb
mechanical complication of other vascular device implant and graft
unspecified mechanical complication of internal orthopedic device, implant, and graft
infection and inflammatory reaction due to other vascular device implant and graft
personal history of malignant neoplasm of bone
follow-up examination following unspecified surgery
follow-up examination following other surgery
follow-up examination following radiotherapy
follow-up examination following chemotherapy
observation for suspected malignant neoplasm
CMS Limitations
Radiologic Examination of the Chest
LCD # L26901, Effective date: 03/01/2009
CPT/HCPCS Codes: CPT 71010, CPT 71015, CPT 71020, CPT 71021, CPT 71022, CPT 71023, CPT 71030, CPT 71034, CPT
71035
ICD-9 codes that SUPPORT medical necessity for Radiologic Examination, Chest; Single View, Frontal (CPT 71010);
Radiologic Examination, Chest; Stereo, Frontal (CPT 71015); Radiologic Examination, Chest, 2 Views, Frontal and Lateral
(CPT 71020); Radiologic Examination, Chest, 2 Views, Frontal and Lateral; with Apical Lordotic Procedure (CPT 71021);
Radiologic Examination, Chest, 2 Views, Frontal and Lateral; with Oblique Projections (CPT 71022); Radiologic Examination, Chest, 2 Views, Frontal and Lateral; with Fluoroscopy (CPT 71023); Radiologic Examination, Chest, Complete, Minimum of 4 Views (CPT 71030); Radiologic Examination, Chest, Complete, Minimum of 4 Views; with Fluoroscopy (CPT
71034); Radiologic Examination, Chest, Special Views (eg. Lateral Decubitus, Bucky Studies) (CPT 71035):
006.4
010.00
010.01
010.02
010.03
010.04
010.05
010.06
010.10
010.11
010.12
010.13
010.14
010.15
010.16
010.80
010.81
010.82
010.83
010.84
010.85
010.86
010.90
010.91
amebic lung abscess
primary tuberculous complex unspecified examination
primary tuberculous complex bacteriological or histological examination not done
primary tuberculous complex bacteriological or histological examination results unknown (at present)
primary tuberculous complex tubercle bacilli found (in sputum) by microscopy
primary tuberculous complex tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
primary tuberculous complex tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
primary tuberculous complex tubercle bacilli not found by bacteriological or histological examination
but tuberculosis confirmed by other methods (inoculation of animals)
tuberculous pleurisy in primary progressive tuberculosis confirmation unspecified
tuberculous pleurisy in primary progressive tuberculosis bacteriological or histological examination not
done
tuberculous pleurisy in primary progressive tuberculosis bacteriological or histological examination
results unknown (at present)
tuberculous pleurisy in primary progressive tuberculosis tubercle bacilli found (in sputum) by microscopy
tuberculous pleurisy in primary progressive tuberculosis tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
tuberculous pleurisy in primary progressive tuberculosis tubercle bacilli not found by bacteriological
examination but tuberculosis confirmed histologically
tuberculous pleurisy in primary progressive tuberculosis tubercle bacilli not found by bacteriological or
histological examination but tuberculosis confirmed by other methods (inoculation of animals)
other primary progressive tuberculosis confirmation unspecified
other primary progressive tuberculosis bacteriological or histological examination not done
other primary progressive tuberculosis bacteriological or histological examination results unknown (at
present)
other primary progressive tuberculosis tubercle bacilli found (in sputum) by microscopy
other primary progressive tuberculosis tubercle bacilli not found (in sputum) by microscopy but found
by bacterial culture
other primary progressive tuberculosis tubercle bacilli not found by bacteriological examination but
tuberculosis confirmed histologically
other primary progressive tuberculosis tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
primary tuberculous infection unspecified type confirmation unspecified
primary tuberculous infection unspecified type bacteriological or histological examination not done
CMS Limitations
Radiologic Examination of the Chest (con’t)
010.92
010.93
010.94
010.95
010.96
011.00
011.01
011.02
011.03
011.04
011.05
011.06
011.10
011.11
011.12
011.13
011.14
011.15
011.16
011.20
011.21
011.22
011.23
011.24
011.25
011.26
011.30
011.31
011.32
011.33
011.34
011.35
011.36
primary tuberculous infection unspecified type bacteriological or histological examination results unknown (at present)
primary tuberculous infection unspecified type tubercle bacilli found (in sputum) by microscopy
primary tuberculous infection unspecified type tubercle bacilli not found (in sputum) by microscopy
but found by bacterial culture
primary tuberculous infection unspecified type tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
primary tuberculous infection unspecified type tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculosis of lung infiltrative confirmation unspecified
tuberculosis of lung infiltrative bacteriological or histological examination not done
tuberculosis of lung infiltrative bacteriological or histological examination results unknown (at present)
tuberculosis of lung infiltrative tubercle bacilli found (in sputum) by microscopy
tuberculosis of lung infiltrative tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
tuberculosis of lung infiltrative tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculosis of lung infiltrative tubercle bacilli not found bacteriological or histological examination but
tuberculosis confirmed by other methods (inoculation of animals)
tuberculosis of lung nodular unspecified examination
tuberculosis of lung nodular bacteriological or histological examination not done
tuberculosis of lung nodular bacteriological or histological examination results unknown (at present)
tuberculosis of lung nodular tubercle bacilli found (in sputum) by microscopy
tuberculosis of lung nodular tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
tuberculosis of lung nodular tubercle bacilli not found by bacteriological examination but tuberculosis
confirmed histologically
tuberculosis of lung nodular tubercle bacilli not found by bacteriological or histological examination
but tuberculosis confirmed by other methods (inoculation of animals)
tuberculosis of lung with cavitation unspecified examination
tuberculosis of lung with cavitation bacteriological or histological examination not done
tuberculosis of lung with cavitation bacteriological or histological examination results unknown (at
present)
tuberculosis of lung with cavitation tubercle bacilli found (in sputum) by microscopy
tuberculosis of lung with cavitation tubercle bacilli not found (in sputum) by microscopy but found by
bacterial culture
tuberculosis of lung with cavitation tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculosis of lung with cavitation tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculosis of bronchus unspecified examination
tuberculosis of bronchus bacteriological or histological examination not done
tuberculosis of bronchus bacteriological or histological examination results unknown (at present)
tuberculosis of bronchus tubercle bacilli found (in sputum) by microscopy
tuberculosis of bronchus tubercle bacilli not found (in sputum) by microscopy but found in bacterial
culture
tuberculosis of bronchus tubercle bacilli not found by bacteriological examination but tuberculosis
confirmed histologically
tuberculosis of bronchus tubercle bacilli not found by bacteriological or histological examination but
tuberculosis confirmed by other methods (inoculation of animals)
CMS Limitations
Radiologic Examination of the Chest (con’t)
011.40
011.41
011.42
011.43
011.44
011.45
011.46
011.50
011.51
011.52
011.53
011.54
011.55
011.56
011.60
011.61
011.62
011.63
011.64
011.65
011.66
011.70
011.71
011.72
011.73
011.74
011.75
011.76
011.80
011.81
011.82
011.83
011.84
011.85
tuberculous fibrosis of lung unspecified examination
tuberculous fibrosis of lung bacteriological or histological examination not done
tuberculous fibrosis of lung bacteriological or histological examination unknown (at present)
tuberculous fibrosis of lung tubercle bacilli found (in sputum) by microscopy
tuberculous fibrosis of lung tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
tuberculous fibrosis of lung tubercle bacilli not found by bacteriological examination but tuberculosis
confirmed histologically
tuberculous fibrosis of lung tubercle bacilli not found by bacteriological or histological examination but
tuberculosis confirmed by other methods (inoculation of animals)
tuberculous bronchiectasis unspecified examination
tuberculous bronchiectasis bacteriological or histological examination not done
tuberculous bronchiectasis bacteriological or histological examination results unknown (at present)
tuberculous bronchiectasis tubercle bacilli found (in sputum) by microscopy
tuberculous bronchiectasis tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
tuberculous bronchiectasis tubercle bacilli not found by bacteriological examination but tuberculosis
confirmed histologically
tuberculous bronchiectasis tubercle bacilli not found by bacteriological or histological examination but
tuberculosis confirmed by other methods (inoculation of animals)
tuberculous pneumonia (any form) unspecified examination
tuberculous pneumonia (any form) bacteriological or histological examination not done
tuberculous pneumonia (any form) bacteriological or histological examination results unknown (at
present)
tuberculous pneumonia (any form) tubercle bacilli found (in sputum) by microscopy
tuberculous pneumonia (any form) tubercle bacilli not found (in sputum) by microscopy but found by
bacterial culture
tuberculous pneumonia (any form) tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculous pneumonia (any form) tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculous pneumothorax unspecified examination
tuberculous pneumothorax bacteriological or histological examination not done
tuberculous pneumothorax bacteriological or histological examination results unknown (at present)
tuberculous pneumothorax tubercle bacilli found (in sputum) by microscopy
tuberculous pneumothorax tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
tuberculous pneumothorax tubercle bacilli not found by bacteriological examination but tuberculosis
confirmed histologically
tuberculous pneumothorax tubercle bacilli not found by bacteriological or histological examination but
tuberculosis confirmed by other methods (inoculation of animals)
other specified pulmonary tuberculosis unspecified confirmation
other specified pulmonary tuberculosis bacteriological or histological examination not done
other specified pulmonary tuberculosis bacteriological or histological examination results unknown (at
present)
other specified pulmonary tuberculosis tubercle bacilli found (in sputum) by microscopy
other specified pulmonary tuberculosis tubercle bacilli not found (in sputum) by microscopy but found
by bacterial culture
other specified pulmonary tuberculosis tubercle bacilli not found by bacteriological examination but
tuberculosis confirmed histologically
CMS Limitations
Radiologic Examination of the Chest (con’t)
011.86
011.90
011.91
011.92
011.93
011.94
011.95
011.96
012.00
012.01
012.02
012.03
012.04
012.05
012.06
012.10
012.11
012.12
012.13
012.14
012.15
012.16
012.20
012.21
012.22
012.23
012.24
012.25
012.26
012.30
012.31
012.32
012.33
other specified pulmonary tuberculosis tubercle bacilli not found by bacteriological or histological
examination but tuberculosis confirmed by other methods (inoculation of animals)
unspecified pulmonary tuberculosis confirmation unspecified
unspecified pulmonary tuberculosis bacteriological or histological examination not done
unspecified pulmonary tuberculosis bacteriological or histological examination results unknown (at
present)
unspecified pulmonary tuberculosis tubercle bacilli found (in sputum) by microscopy
unspecified pulmonary tuberculosis tubercle bacilli not found (in sputum) by microscopy but found by
bacterial culture
unspecified pulmonary tuberculosis tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
unspecified pulmonary tuberculosis tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculous pleurisy confirmation unspecified
tuberculous pleurisy bacteriological or histological examination not done
tuberculous pleurisy bacteriological or histological examination results unknown (at present)
tuberculous pleurisy tubercle bacilli found (in sputum) by microscopy
tuberculous pleurisy tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
tuberculous pleurisy tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculous pleurisy tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculosis of intrathoracic lymph nodes confirmation unspecified
tuberculosis of intrathoracic lymph nodes bacteriological or histological examination not done
tuberculosis of intrathoracic lymph nodes bacteriological or histological examination results unknown
(at present)
tuberculosis of intrathoracic lymph nodes tubercle bacilli found (in sputum) by microscopy
tuberculosis of intrathoracic lymph nodes tubercle bacilli not found (in sputum) by microscopy but
found by bacterial culture
tuberculosis of intrathoracic lymph nodes tubercle bacilli not found by bacteriological examination but
tuberculosis confirmed histologically
tuberculosis of intrathoracic lymph nodes tubercle bacilli not found by bacteriological or histological
examination but tuberculosis confirmed by other methods (inoculation of animals)
isolated tracheal or bronchial tuberculosis unspecified examination
isolated tracheal or bronchial tuberculosis bacteriological or histological examination not done
isolated tracheal or bronchial tuberculosis bacteriological or histological examination results unknown
(at present)
isolated tracheal or bronchial tuberculosis tubercle bacilli found (in sputum) by microscopy
isolated tracheal or bronchial tuberculosis tubercle bacilli not found (in sputum) by microscopy but
found by bacterial culture
isolated tracheal or bronchial tuberculosis tubercle bacilli not found by bacteriological examination but
tuberculosis confirmed histologically
isolated tracheal or bronchial tuberculosis tubercle bacilli not found by bacteriological or histological
examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculous laryngitis unspecified examination
tuberculous laryngitis bacteriological or histological examination not done
tuberculous laryngitis bacteriological or histological examination results unknown (at present)
tuberculous laryngitis tubercle bacilli found (in sputum) by microscopy
CMS Limitations
Radiologic Examination of the Chest (con’t)
012.34
012.35
012.36
012.80
012.81
012.82
012.83
012.84
012.85
012.86
013.00
013.01
013.02
013.03
013.04
013.05
013.06
013.10
013.11
013.12
013.13
013.14
013.15
013.16
013.20
013.21
013.22
013.23
013.24
013.25
013.26
013.30
013.31
013.32
tuberculous laryngitis tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
tuberculous laryngitis tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculous laryngitis tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
other specified respiratory tuberculosis unspecified examination
other specified respiratory tuberculosis bacteriological or histological examination not done
other specified respiratory tuberculosis bacteriological or histological examination results unknown (at
present)
other specified respiratory tuberculosis tubercle bacilli found (in sputum) by microscopy
other specified respiratory tuberculosis tubercle bacilli not found (in sputum) by microscopy but found
by bacterial culture
other specified respiratory tuberculosis tubercle bacilli not found by bacteriological examination but
tuberculosis confirmed histologically
other specified respiratory tuberculosis tubercle bacilli not found by bacteriological or histological
examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculous meningitis unspecified examination
tuberculous meningitis bacteriological or histological examination not done
tuberculous meningitis bacteriological or histological examination results unknown (at present)
tuberculous meningitis tubercle bacilli found (in sputum) by microscopy
tuberculous meningitis tubercle bacilli not found (in sputum) by microscopy but found by bacterial
culture
tuberculous meningitis tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculous meningitis tubercle bacilli not found by bacteriological or histological examination but
tuberculosis confirmed by other methods (inoculation of animals)
tuberculoma of meninges unspecified examination
tuberculoma of meninges bacteriological or histological examination not done
tuberculoma of meninges bacteriological or histological examination results unknown (at present)
tuberculoma of meninges tubercle bacilli found (in sputum) by microscopy
tuberculoma of meninges tubercle bacilli not found (in sputum) by microscopy but found by bacterial
culture
tuberculoma of meninges tubercle bacilli not found by bacteriological examination but tuberculosis
confirmed histologically
tuberculoma of meninges tubercle bacilli not found by bacteriological or histological examination but
tuberculosis confirmed by other methods (inoculation of animals)
tuberculoma of brain unspecified examination
tuberculoma of brain bacteriological or histological examination not done
tuberculoma of brain bacteriological or histological examination results unknown (at present)
tuberculoma of brain tubercle bacilli found (in sputum) by microscopy
tuberculoma of brain tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
tuberculoma of brain tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculoma of brain tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculous abscess of brain unspecified examination
tuberculous abscess of brain bacteriological or histological examination not done
tuberculous abscess of brain bacteriological or histological examination results unknown (at present)
CMS Limitations
Radiologic Examination of the Chest (con’t)
013.33
013.34
013.35
013.36
013.40
013.41
013.42
013.43
013.44
013.45
013.46
013.50
013.51
013.52
013.53
013.54
013.55
013.56
013.60
013.61
013.62
013.63
013.64
013.65
013.66
013.80
013.81
013.82
013.83
013.84
013.85
tuberculous abscess of brain tubercle bacilli found (in sputum) by microscopy
tuberculous abscess of brain tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
tuberculous abscess of brain tubercle bacilli not found by bacteriological examination but tuberculosis
confirmed histologically
tuberculous abscess of brain tubercle bacilli not found by bacteriological or histological examination
but tuberculosis confirmed by other methods (inoculation of animals)
tuberculoma of spinal cord unspecified examination
tuberculoma of spinal cord bacteriological or histological examination not done
tuberculoma of spinal cord bacteriological or histological examination results unknown (at present)
tuberculoma of spinal cord tubercle bacilli found (in sputum) by microscopy
tuberculoma of spinal cord tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
tuberculoma of spinal cord tubercle bacilli not found by bacteriological examination but tuberculosis
confirmed histologically
tuberculoma of spinal cord tubercle bacilli not found by bacteriological or histological examination but
tuberculosis confirmed by other methods (inoculation of animals)
tuberculous abscess of spinal cord unspecified examination
tuberculous abscess of spinal cord bacteriological or histological examination not done
tuberculous abscess of spinal cord bacteriological or histological examination results unknown (at
present)
tuberculous abscess of spinal cord tubercle bacilli found (in sputum) by microscopy
tuberculous abscess of spinal cord tubercle bacilli not found (in sputum) by microscopy but found by
bacterial culture
tuberculous abscess of spinal cord tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculous abscess of spinal cord tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculous encephalitis or myelitis unspecified examination
tuberculous encephalitis or myelitis bacteriological or histological examination not done
tuberculous encephalitis or myelitis bacteriological or histological examination results unknown (at
present)
tuberculous encephalitis or myelitis tubercle bacilli found (in sputum) by microscopy
tuberculous encephalitis or myelitis tubercle bacilli not found (in sputum) by microscopy but found by
bacterial culture
tuberculous encephalitis or myelitis tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculous encephalitis or myelitis tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
other specified tuberculosis of central nervous system unspecified examination
other specified tuberculosis of central nervous system bacteriological or histological examination not
done
other specified tuberculosis of central nervous system bacteriological or histological examination results unknown (at present)
other specified tuberculosis of central nervous system tubercle bacilli found (in sputum) by microscopy
other specified tuberculosis of central nervous system tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
other specified tuberculosis of central nervous system tubercle bacilli not found by bacteriological
examination but tuberculosis confirmed histologically
CMS Limitations
Radiologic Examination of the Chest (con’t)
013.86
013.90
013.91
013.92
013.93
013.94
013.95
013.96
014.00
014.01
014.02
014.03
014.04
014.05
014.06
014.80
014.81
014.82
014.83
014.84
014.85
014.86
015.00
015.01
015.02
015.03
015.04
015.05
015.06
015.10
015.11
other specified tuberculosis of central nervous system tubercle bacilli not found by bacteriological or
histological examination but tuberculosis confirmed by other methods (inoculation of animals)
unspecified tuberculosis of central nervous system unspecified examination
unspecified tuberculosis of central nervous system bacteriological or histological examination not
done
unspecified tuberculosis of central nervous system bacteriological or histological examination results
unknown (at present)
unspecified tuberculosis of central nervous system tubercle bacilli found (in sputum) by microscopy
unspecified tuberculosis of central nervous system tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
unspecified tuberculosis of central nervous system tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
unspecified tuberculosis of central nervous system tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculous peritonitis unspecified examination
tuberculous peritonitis bacteriological or histological examination not done
tuberculous peritonitis bacteriological or histological examination results unknown (at present)
tuberculous peritonitis tubercle bacilli found (in sputum) by microscopy
tuberculous peritonitis tubercle bacilli not found (in sputum) by microscopy but found by bacterial
culture
tuberculous peritonitis tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculous peritonitis tubercle bacilli not found by bacteriological or histological examination but
tuberculosis confirmed by other methods (inoculation of animals)
other tuberculosis of intestines and mesenteric glands unspecified examination
other tuberculosis of intestines and mesenteric glands bacteriological or histological examination not
done
other tuberculosis of intestines and mesenteric glands bacteriological or histological examination results unknown (at present)
other tuberculosis of intestines and mesenteric glands tubercle bacilli found (in sputum) by microscopy
other tuberculosis of intestines and mesenteric glands tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
other tuberculosis of intestines and mesenteric glands tubercle bacilli not found by bacteriological
examination but tuberculosis confirmed histologically
other tuberculosis of intestines and mesenteric glands tubercle bacilli not found by bacteriological or
histological examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculosis of vertebral column unspecified examination
tuberculosis of vertebral column bacteriological or histological examination not done
tuberculosis of vertebral column bacteriological or histological examination results unknown (at present)
tuberculosis of vertebral column tubercle bacilli found (in sputum) by microscopy
tuberculosis of vertebral column tubercle bacilli not found (in sputum) by microscopy but found by
bacterial culture
tuberculosis of vertebral column tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculosis of vertebral column tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculosis of hip unspecified examination
tuberculosis of hip bacteriological or histological examination not done
CMS Limitations
Radiologic Examination of the Chest (con’t)
015.12
015.13
015.14
015.15
015.16
015.20
015.21
015.22
015.23
015.24
015.25
015.26
015.50
015.51
015.52
015.53
015.54
015.55
015.56
015.60
015.61
015.62
015.63
015.64
015.65
015.66
015.70
015.71
015.72
015.73
015.74
015.75
015.76
015.80
015.81
tuberculosis of hip bacteriological or histological examination results unknown (at present)
tuberculosis of hip tubercle bacilli found (in sputum) by microscopy
tuberculosis of hip tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
tuberculosis of hip tubercle bacilli not found by bacteriological examination but tuberculosis confirmed
histologically
tuberculosis of hip tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculosis of knee unspecified examination
tuberculosis of knee bacteriological or histological examination not done
tuberculosis of knee bacteriological or histological examination results unknown (at present)
tuberculosis of knee tubercle bacilli found (in sputum) by microscopy
tuberculosis of knee tubercle bacilli not found (in sputum) by microscopy but found by bacterial culture
tuberculosis of knee tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculosis of knee tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculosis of limb bones unspecified examination
tuberculosis of limb bones bacteriological or histological examination not done
tuberculosis of limb bones bacteriological or histological examination results unknown (at present)
tuberculosis of limb bones tubercle bacilli found (in sputum) by microscopy
tuberculosis of limb bones tubercle bacilli not found (in sputum) by microscopy but found by bacterial
culture
tuberculosis of limb bones tubercle bacilli not found by bacteriological examination but tuberculosis
confirmed histologically
tuberculosis of limb bones tubercle bacilli not found by bacteriological or histological examination but
tuberculosis confirmed by other methods (inoculation of animals)
tuberculosis of mastoid unspecified examination
tuberculosis of mastoid bacteriological or histological examination not done
tuberculosis of mastoid bacteriological or histological examination results unknown (at present)
tuberculosis of mastoid tubercle bacilli found (in sputum) by microscopy
tuberculosis of mastoid tubercle bacilli not found (in sputum) by microscopy but found by bacterial
culture
tuberculosis of mastoid tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculosis of mastoid tubercle bacilli not found by bacteriological or histological examination but
tuberculosis confirmed by other methods (inoculation of animals)
tuberculosis of other specified bone unspecified examination
tuberculosis of other specified bone bacteriological or histological examination not done
tuberculosis of other specified bone bacteriological or histological examination results unknown (at
present)
tuberculosis of other specified bone tubercle bacilli found (in sputum) by microscopy
tuberculosis of other specified bone tubercle bacilli not found (in sputum) by microscopy but found by
bacterial culture
tuberculosis of other specified bone tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculosis of other specified bone tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
tuberculosis of other specified joint unspecified examination
tuberculosis of other specified joint bacteriological or histological examination not done
CMS Limitations
Radiologic Examination of the Chest (con’t)
015.82
015.83
015.84
015.85
015.86
018.01
018.02
018.03
018.04
018.05
018.06
018.80
018.81
018.82
018.83
018.84
018.85
018.86
018.90
018.91
018.92
018.93
018.94
018.95
018.96
020.2
020.3
020.4
020.5
021.2
022.1
025
027.0
027.2
031.0
tuberculosis of other specified joint bacteriological or histological examination results unknown (at
present)
tuberculosis of other specified joint tubercle bacilli found (in sputum) by microscopy
tuberculosis of other specified joint tubercle bacilli not found (in sputum) by microscopy but found by
bacterial culture
tuberculosis of other specified joint tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
tuberculosis of other specified joint tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
acute miliary tuberculosis bacteriological or histological examination not done
acute miliary tuberculosis bacteriological or histological examination results unknown (at present)
acute miliary tuberculosis tubercle bacilli found (in sputum) by microscopy
acute miliary tuberculosis tubercle bacilli not found (in sputum) by microscopy but found by bacterial
culture
acute miliary tuberculosis tubercle bacilli not found by bacteriological examination but tuberculosis
confirmed histologically
acute miliary tuberculosis tubercle bacilli not found by bacteriological or histological examination but
tuberculosis confirmed by other methods (inoculation of animals)
other specified miliary tuberculosis unspecified examination
other specified miliary tuberculosis bacteriological or histological examination not done
other specified miliary tuberculosis bacteriological or histological examination results unknown (at
present)
other specified miliary tuberculosis tubercle bacilli found (in sputum) by microscopy
other specified miliary tuberculosis tubercle bacilli not found (in sputum) by microscopy but found by
bacterial culture
other specified miliary tuberculosis tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
other specified miliary tuberculosis tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
unspecified miliary tuberculosis unspecified examination
unspecified miliary tuberculosis bacteriological or histological examination not done
unspecified miliary tuberculosis bacteriological or histological examination results unknown (at present)
unspecified miliary tuberculosis tubercle bacilli found (in sputum) by microscopy
unspecified miliary tuberculosis tubercle bacilli not found (in sputum) by microscopy but found by
bacterial culture
unspecified miliary tuberculosis tubercle bacilli not found by bacteriological examination but tuberculosis confirmed histologically
unspecified miliary tuberculosis tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (inoculation of animals)
septicemic plague
primary pneumonic plague
secondary pneumonic plague
pneumonic plague unspecified
pulmonary tularemia
pulmonary anthrax
melioidosis
listeriosis
pasteurellosis
pulmonary diseases due to other mycobacteria
CMS Limitations
Radiologic Examination of the Chest (con’t)
033.0
033.1
033.8
033.9
039.1
039.8
040.82
042
052.1
055.1
066.40
066.41
066.42
066.49
073.0
074.1
074.20
074.21
074.22
074.23
075
079.6
079.81
079.82
080
081.0
084.0
084.1
084.2
084.3
084.4
084.5
084.6
084.7
084.8
086.0
093.0
093.1
093.20
093.21
093.22
093.23
093.24
093.81
093.82
093.89
093.9
095.1
098.83
098.84
whooping cough due to bordetella pertussis (b. pertussis)
whooping cough due to bordetella parapertussis (b. parapertussis)
whooping cough due to other specified organism
whooping cough unspecified organism
pulmonary actinomycotic infection
actinomycotic infection of other specified sites
toxic shock syndrome
human immunodeficiency virus (hiv) disease
varicella (hemorrhagic) pneumonitis
postmeasles pneumonia
west nile fever, unspecified
west nile fever with encephalitis
west nile fever with other neurologic manifestation
west nile fever with other complications
ornithosis with pneumonia
epidemic pleurodynia
coxsackie carditis unspecified
coxsackie pericarditis
coxsackie endocarditis
coxsackie myocarditis
infectious mononucleosis
respiratory syncytial virus (rsv)
hantaviris infection
sars-associated coronavirus infection
louse-borne (epidemic) typhus
murine (endemic) typhus
falciparum malaria (malignant tertian)
vivax malaria (benign tertian)
quartan malaria
ovale malaria
other malaria
mixed malaria
malaria unspecified
induced malaria
blackwater fever
chagas’ disease with heart involvement
aneurysm of aorta specified as syphilitic
syphilitic aortitis
syphilitic endocarditis of valve unspecified
syphilitic endocarditis of mitral valve
syphilitic endocarditis of aortic valve
syphilitic endocarditis of tricuspid valve
syphilitic endocarditis of pulmonary valve
syphilitic pericarditis
syphilitic myocarditis
other specified cardiovascular syphilis
cardiovascular syphilis unspecified
syphilis of lung
gonococcal pericarditis
gonococcal endocarditis
CMS Limitations
Radiologic Examination of the Chest (con’t)
098.85
100.0
112.4
112.5
112.81
114.0
114.1
114.3
114.4
114.5
115.03
115.04
115.05
115.13
115.14
115.15
115.93
115.94
115.95
116.0
116.1
116.2
117.1
117.3
117.5
120.0
120.1
120.2
121.0
121.1
121.2
121.3
121.4
121.5
121.6
121.8
122.0
122.1
130.3
130.4
135
136.1
136.3
136.5
137.0
137.1
137.2
137.3
137.4
141.0
other gonococcal heart disease
leptospirosis icterohemorrhagica
candidiasis of lung
disseminated candidiasis
candidal endocarditis
primary coccidioidomycosis (pulmonary)
primary extrapulmonary coccidioidomycosis
other forms of progressive coccidioidomycosis
chronic pulmonary coccidioidomycosis
pulmonary coccidioidomycosis unspecified
histoplasma capsulatum pericarditis
histoplasma capsulatum endocarditis
histoplasma capsulatum pneumonia
histoplasma duboisii pericarditis
histoplasma duboisii endocarditis
histoplasma duboisii pneumonia
histoplasmosis pericarditis unspecified
histoplasmosis endocarditis
histoplasmosis pneumonia unspecified
blastomycosis
paracoccidioidomycosis
lobomycosis
sporotrichosis
aspergillosis
cryptococcosis
schistosomiasis due to schistosoma haematobium
schistosomiasis due to schistosoma mansoni
schistosomiasis due to schistosoma japonicum
opisthorchiasis
clonorchiasis
paragonimiasis
fascioliasis
fasciolopsiasis
metagonimiasis
heterophyiasis
other specified trematode infections
echinococcus granulosus infection of liver
echinococcus granulosus infection of lung
myocarditis due to toxoplasmosis
pneumonitis due to toxoplasmosis
sarcoidosis
behcet’s syndrome
pneumocystosis
sarcosporidiosis
late effects of respiratory or unspecified tuberculosis
late effects of central nervous system tuberculosis
late effects of genitourinary tuberculosis
late effects of tuberculosis of bones and joints
late effects of tuberculosis of other specified organs
malignant neoplasm of base of tongue
CMS Limitations
Radiologic Examination of the Chest (con’t)
141.1
141.2
141.3
141.4
141.5
141.6
141.8
141.9
142.0
142.1
142.2
142.8
142.9
143.0
143.1
143.8
143.9
144.0
144.1
144.8
144.9
145.0
145.1
145.2
145.3
145.4
145.5
145.6
145.8
145.9
146.0
146.1
146.2
146.3
146.4
146.5
146.6
146.7
146.8
146.9
147.0
147.1
147.2
147.3
148.0
148.1
148.2
148.3
148.8
148.9
malignant neoplasm of dorsal surface of tongue
malignant neoplasm of tip and lateral border of tongue
malignant neoplasm of ventral surface of tongue
malignant neoplasm of anterior two-thirds of tongue part unspecified
malignant neoplasm of junctional zone of tongue
malignant neoplasm of lingual tonsil
malignant neoplasm of other sites of tongue
malignant neoplasm of tongue unspecified
malignant neoplasm of parotid gland
malignant neoplasm of submandibular gland
malignant neoplasm of sublingual gland
malignant neoplasm of other major salivary glands
malignant neoplasm of salivary gland unspecified
malignant neoplasm of upper gum
malignant neoplasm of lower gum
malignant neoplasm of other sites of gum
malignant neoplasm of gum unspecified
malignant neoplasm of anterior portion of floor of mouth
malignant neoplasm of lateral portion of floor of mouth
malignant neoplasm of other sites of floor of mouth
malignant neoplasm of floor of mouth part unspecified
malignant neoplasm of cheek mucosa
malignant neoplasm of vestibule of mouth
malignant neoplasm of hard palate
malignant neoplasm of soft palate
malignant neoplasm of uvula
malignant neoplasm of palate unspecified
malignant neoplasm of retromolar area
malignant neoplasm of other specified parts of mouth
malignant neoplasm of mouth unspecified
malignant neoplasm of tonsil
malignant neoplasm of tonsillar fossa
malignant neoplasm of tonsillar pillars (anterior) (posterior)
malignant neoplasm of vallecula epiglottica
malignant neoplasm of anterior aspect of epiglottis
malignant neoplasm of junctional region of oropharynx
malignant neoplasm of lateral wall of oropharynx
malignant neoplasm of posterior wall of oropharynx
malignant neoplasm of other specified sites of oropharynx
malignant neoplasm of oropharynx unspecified site
malignant neoplasm of superior wall of nasopharynx
malignant neoplasm of posterior wall of nasopharynx
malignant neoplasm of lateral wall of nasopharynx
malignant neoplasm of anterior wall of nasopharynx
malignant neoplasm of postcricoid region of hypopharynx
malignant neoplasm of pyriform sinus
malignant neoplasm of aryepiglottic fold hypopharyngeal aspect
malignant neoplasm of posterior hypopharyngeal wall
malignant neoplasm of other specified sites of hypopharynx
malignant neoplasm of hypopharynx unspecified site
CMS Limitations
Radiologic Examination of the Chest (con’t)
149.0
149.1
149.8
149.9
150.0
150.1
150.2
150.3
150.4
150.5
150.8
150.9
151.0
151.1
151.2
151.3
151.4
151.5
151.6
151.8
151.9
153.0
153.1
153.2
153.3
153.4
153.5
153.6
153.7
153.8
153.9
154.0
154.1
154.2
154.3
154.8
155.0
155.1
155.2
157.0
157.1
157.2
157.3
157.4
157.8
157.9
162.0
162.2
162.3
162.4
malignant neoplasm of pharynx unspecified
malignant neoplasm of waldeyer’s ring
malignant neoplasm of other sites within the lip and oral cavity
malignant neoplasm of ill-defined sites within the lip and oral cavity
malignant neoplasm of cervical esophagus
malignant neoplasm of thoracic esophagus
malignant neoplasm of abdominal esophagus
malignant neoplasm of upper third of esophagus
malignant neoplasm of middle third of esophagus
malignant neoplasm of lower third of esophagus
malignant neoplasm of other specified part of esophagus
malignant neoplasm of esophagus unspecified site
malignant neoplasm of cardia
malignant neoplasm of pylorus
malignant neoplasm of pyloric antrum
malignant neoplasm of fundus of stomach
malignant neoplasm of body of stomach
malignant neoplasm of lesser curvature of stomach unspecified
malignant neoplasm of greater curvature of stomach unspecified
malignant neoplasm of other specified sites of stomach
malignant neoplasm of stomach unspecified site
malignant neoplasm of hepatic flexure
malignant neoplasm of transverse colon
malignant neoplasm of descending colon
malignant neoplasm of sigmoid colon
malignant neoplasm of cecum
malignant neoplasm of appendix vermiformis
malignant neoplasm of ascending colon
malignant neoplasm of splenic flexure
malignant neoplasm of other specified sites of large intestine
malignant neoplasm of colon unspecified site
malignant neoplasm of rectosigmoid junction
malignant neoplasm of rectum
malignant neoplasm of anal canal
malignant neoplasm of anus unspecified site
malignant neoplasm of other sites of rectum rectosigmoid junction and anus
malignant neoplasm of liver primary
malignant neoplasm of intrahepatic bile ducts
malignant neoplasm of liver not specified as primary or secondary
malignant neoplasm of head of pancreas
malignant neoplasm of body of pancreas
malignant neoplasm of tail of pancreas
malignant neoplasm of pancreatic duct
malignant neoplasm of islets of langerhans
malignant neoplasm of other specified sites of pancreas
malignant neoplasm of pancreas part unspecified
malignant neoplasm of trachea
malignant neoplasm of main bronchus
malignant neoplasm of upper lobe bronchus or lung
malignant neoplasm of middle lobe bronchus or lung
CMS Limitations
Radiologic Examination of the Chest (con’t)
162.5
162.8
162.9
163.0
163.1
163.8
163.9
164.1
164.2
164.3
164.8
164.9
165.0
165.8
165.9
170.3
171.2
171.3
171.4
171.5
171.6
171.7
171.8
171.9
172.0
172.1
172.2
172.3
172.4
172.5
172.6
172.7
172.8
172.9
174.0
174.1
174.2
174.3
174.4
174.5
174.6
174.8
174.9
175.0
175.9
176.4
176.5
180.1
180.8
180.9
malignant neoplasm of lower lobe bronchus or lung
malignant neoplasm of other parts of bronchus or lung
malignant neoplasm of bronchus and lung unspecified
malignant neoplasm of parietal pleura
malignant neoplasm of visceral pleura
malignant neoplasm of other specified sites of pleura
malignant neoplasm of pleura unspecified
malignant neoplasm of heart
malignant neoplasm of anterior mediastinum
malignant neoplasm of posterior mediastinum
malignant neoplasm of other parts of mediastinum
malignant neoplasm of mediastinum part unspecified
malignant neoplasm of upper respiratory tract part unspecified
malignant neoplasm of other sites within the respiratory system and intrathoracic organs
malignant neoplasm of ill-defined sites within the respiratory system
malignant neoplasm of ribs sternum and clavicle
malignant neoplasm of connective and other soft tissue of upper limb including shoulder
malignant neoplasm of connective and other soft tissue of lower limb including hip
malignant neoplasm of connective and other soft tissue of thorax
malignant neoplasm of connective and other soft tissue of abdomen
malignant neoplasm of connective and other soft tissue of pelvis
malignant neoplasm of connective and other soft tissue of trunk unspecified
malignant neoplasm of other specified sites of connective and other soft tissue
malignant neoplasm of connective and other soft tissue site unspecified
malignant melanoma of skin of lip
malignant melanoma of skin of eyelid including canthus
malignant melanoma of skin of ear and external auditory canal
malignant melanoma of skin of other and unspecified parts of face
malignant melanoma of skin of scalp and neck
malignant melanoma of skin of trunk except scrotum
malignant melanoma of skin of upper limb including shoulder
malignant melanoma of skin of lower limb including hip
malignant melanoma of other specified sites of skin
melanoma of skin site unspecified
malignant neoplasm of nipple and areola of female breast
malignant neoplasm of central portion of female breast
malignant neoplasm of upper-inner quadrant of female breast
malignant neoplasm of lower-inner quadrant of female breast
malignant neoplasm of upper-outer quadrant of female breast
malignant neoplasm of lower-outer quadrant of female breast
malignant neoplasm of axillary tail of female breast
malignant neoplasm of other specified sites of female breast
malignant neoplasm of breast (female) unspecified site
malignant neoplasm of nipple and areola of male breast
malignant neoplasm of other and unspecified sites of male breast
kaposi’s sarcoma lung
kaposi’s sarcoma lymph nodes
malignant neoplasm of exocervix
malignant neoplasm of other specified sites of cervix
malignant neoplasm of cervix uteri unspecified site
CMS Limitations
Radiologic Examination of the Chest (con’t)
182.0
182.1
182.8
183.0
183.2
183.3
183.4
183.5
183.8
183.9
184.4
185
186.0
186.9
188.0
188.1
188.2
188.3
188.4
188.5
188.6
188.7
188.8
188.9
189.0
189.1
189.2
189.3
189.4
189.8
189.9
193
194.3
195.0
195.1
195.2
195.4
195.8
196.0
196.1
196.2
196.3
196.5
196.6
196.8
196.9
197.0
197.1
197.2
197.3
malignant neoplasm of corpus uteri except isthmus
malignant neoplasm of isthmus
malignant neoplasm of other specified sites of body of uterus
malignant neoplasm of ovary
malignant neoplasm of fallopian tube
malignant neoplasm of broad ligament of uterus
malignant neoplasm of parametrium
malignant neoplasm of round ligament of uterus
malignant neoplasm of other specified sites of uterine adnexa
malignant neoplasm of uterine adnexa unspecified site
malignant neoplasm of vulva unspecified site
malignant neoplasm of prostate
malignant neoplasm of undescended testis
malignant neoplasm of other and unspecified testis
malignant neoplasm of trigone of urinary bladder
malignant neoplasm of dome of urinary bladder
malignant neoplasm of lateral wall of urinary bladder
malignant neoplasm of anterior wall of urinary bladder
malignant neoplasm of posterior wall of urinary bladder
malignant neoplasm of bladder neck
malignant neoplasm of ureteric orifice
malignant neoplasm of urachus
malignant neoplasm of other specified sites of bladder
malignant neoplasm of bladder part unspecified
malignant neoplasm of kidney except pelvis
malignant neoplasm of renal pelvis
malignant neoplasm of ureter
malignant neoplasm of urethra
malignant neoplasm of paraurethral glands
malignant neoplasm of other specified sites of urinary organs
malignant neoplasm of urinary organ site unspecified
malignant neoplasm of thyroid gland
malignant neoplasm of pituitary gland and craniopharyngeal duct
malignant neoplasm of head face and neck
malignant neoplasm of thorax
malignant neoplasm of abdomen
malignant neoplasm of upper limb
malignant neoplasm of other specified sites
secondary and unspecified malignant neoplasm of lymph nodes of head face and neck
secondary and unspecified malignant neoplasm of intrathoracic lymph nodes
secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb
secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and lower limb
secondary and unspecified malignant neoplasm of intrapelvic lymph nodes
secondary and unspecified malignant neoplasm of lymph nodes of multiple sites
secondary and unspecified malignant neoplasm of lymph nodes site unspecified
secondary malignant neoplasm of lung
secondary malignant neoplasm of mediastinum
secondary malignant neoplasm of pleura
secondary malignant neoplasm of other respiratory organs
CMS Limitations
Radiologic Examination of the Chest (con’t)
198.0
198.1
198.3
198.4
198.5
198.6
198.81
199.0
200.00
200.01
200.02
200.03
200.04
200.05
200.06
200.07
200.08
200.10
200.11
200.12
200.13
200.14
200.15
200.16
200.17
200.18
200.20
200.21
200.22
200.23
200.24
200.25
200.26
200.27
200.28
200.30
200.31
200.32
200.34
200.40
200.41
200.42
200.44
200.50
200.51
200.52
200.54
200.60
200.61
200.62
secondary malignant neoplasm of kidney
secondary malignant neoplasm of other urinary organs
secondary malignant neoplasm of brain and spinal cord
secondary malignant neoplasm of other parts of nervous system
secondary malignant neoplasm of bone and bone marrow
secondary malignant neoplasm of ovary
secondary malignant neoplasm of breast
disseminated malignant neoplasm
reticulosarcoma unspecified site
reticulosarcoma involving lymph nodes of head face and neck
reticulosarcoma involving intrathoracic lymph nodes
reticulosarcoma involving intra-abdominal lymph nodes
reticulosarcoma involving lymph nodes of axilla and upper limb
reticulosarcoma involving lymph nodes of inguinal region and lower limb
reticulosarcoma involving intrapelvic lymph nodes
reticulosarcoma involving spleen
reticulosarcoma involving lymph nodes of multiple sites
lymphosarcoma unspecified site
lymphosarcoma involving lymph nodes of head face and neck
lymphosarcoma involving intrathoracic lymph nodes
lymphosarcoma involving intra-abdominal lymph nodes
lymphosarcoma involving lymph nodes of axilla and upper limb
lymphosarcoma involving lymph nodes of inguinal region and lower limb
lymphosarcoma involving intrapelvic lymph nodes
lymphosarcoma involving spleen
lymphosarcoma involving lymph nodes of multiple sites
burkitt’s tumor or lymphoma unspecified site
burkitt’s tumor or lymphoma involving lymph nodes of head face and neck
burkitt’s tumor or lymphoma involving intrathoracic lymph nodes
burkitt’s tumor or lymphoma involving intra-abdominal lymph nodes
burkitt’s tumor or lymphoma involving lymph nodes of axilla and upper limb
burkitt’s tumor or lymphoma involving lymph nodes of inguinal region and lower limb
burkitt’s tumor or lymphoma involving intrapelvic lymph nodes
burkitt’s tumor or lymphoma involving spleen
burkitt’s tumor or lymphoma involving lymph nodes of multiple sites
marginal zone lymphoma, unspecified site, extranodal and solid organ sites
marginal zone lymphoma,lymph nodes of head, face, and neck
marginal zone lymphoma,intrathoracic lymph nodes
marginal zone lymphoma, lymph nodes of axilla and upper limb
mantle cell lymphoma, unspecified site, extranodal and solid organ sites
mantle cell lymphoma, lymph nodes of head, face, and neck
mantle cell lymphoma, intrathoracic lymph nodes
mantle cell lymphoma, lymph nodes of axilla and upper limb
primary central nervous system lymphoma, unspecified site, extranodal and solid organ sites
primary central nervous system lymphoma, lymph nodes of head, face, and neck
primary central nervous system lymphoma, intrathoracic lymph nodes
primary central nervous system lymphoma, lymph nodes of axilla and upper limb
anaplastic large cell lymphoma, unspecified site, extranodal and solid organ sites
anaplastic large cell lymphoma, lymph nodes of head, face, and neck
anaplastic large cell lymphoma, intrathoracic lymph nodes
CMS Limitations
Radiologic Examination of the Chest (con’t)
200.64
200.70
200.71
200.72
200.74
200.80
200.81
200.82
200.83
200.84
200.85
200.86
200.87
200.88
201.00
201.01
201.02
201.03
201.04
201.05
201.06
201.07
201.08
201.10
201.11
201.12
201.13
201.14
201.15
201.16
201.17
201.18
201.20
201.21
201.22
201.23
201.24
201.25
201.26
201.27
201.28
201.40
201.41
201.42
201.43
201.44
anaplastic large cell lymphoma, lymph nodes of axilla and upper limb
large cell lymphoma, unspecified site, extranodal and solid organ sites
large cell lymphoma, lymph nodes of head, face, and neck
large cell lymphoma, intrathoracic lymph nodes
large cell lymphoma, lymph nodes of axilla and upper limb
other named variants of lymphosarcoma and reticulosarcoma unspecified site
other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of head face and
neck
other named variants of lymphosarcoma and reticulosarcoma involving intrathoracic lymph nodes
other named variants of lymphosarcoma and reticulosarcoma involving intra-abdominal lymph nodes
other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of axilla and upper limb
other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of inguinal region
and lower limb
other named variants of lymphosarcoma and reticulosarcoma involving intrapelvic lymph nodes
other named variants of lymphosarcoma and reticulosarcoma involving spleen
other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of multiple sites
hodgkin’s paragranuloma unspecified site
hodgkin’s paragranuloma involving lymph nodes of head face and neck
hodgkin’s paragranuloma involving intrathoracic lymph nodes
hodgkin’s paragranuloma involving intra-abdominal lymph nodes
hodgkin’s paragranuloma involving lymph nodes of axilla and upper limb
hodgkin’s paragranuloma involving lymph nodes of inguinal region and lower limb
hodgkin’s paragranuloma involving intrapelvic lymph nodes
hodgkin’s paragranuloma involving spleen
hodgkin’s paragranuloma involving lymph nodes of multiple sites
hodgkin’s granuloma unspecified site
hodgkin’s granuloma involving lymph nodes of head face and neck
hodgkin’s granuloma involving intrathoracic lymph nodes
hodgkin’s granuloma involving intra-abdominal lymph nodes
hodgkin’s granuloma involving lymph nodes of axilla and upper limb
hodgkin’s granuloma involving lymph nodes of inguinal region and lower limb
hodgkin’s granuloma involving intrapelvic lymph nodes
hodgkin’s granuloma involving spleen
hodgkin’s granuloma involving lymph nodes of multiple sites
hodgkin’s sarcoma unspecified site
hodgkin’s sarcoma involving lymph nodes of head face and neck
hodgkin’s sarcoma involving intrathoracic lymph nodes
hodgkin’s sarcoma involving intra-abdominal lymph nodes
hodgkin’s sarcoma involving lymph nodes of axilla and upper limb
hodgkin’s sarcoma involving lymph nodes of inguinal region and lower limb
hodgkin’s sarcoma involving intrapelvic lymph nodes
hodgkin’s sarcoma involving spleen
hodgkin’s sarcoma involving lymph nodes of multiple sites
hodgkin’s disease lymphocytic-histiocytic predominance unspecified site
hodgkin’s disease lymphocytic-histiocytic predominance involving lymph nodes of head face and neck
hodgkin’s disease lymphocytic-histiocytic predominance involving intrathoracic lymph nodes
hodgkin’s disease lymphocytic-histiocytic predominance involving intra-abdominal lymph nodes
hodgkin’s disease lymphocytic-histiocytic predominance involving lymph nodes of axilla and upper
limb
CMS Limitations
Radiologic Examination of the Chest (con’t)
201.45
201.46
201.47
201.48
201.50
201.51
201.52
201.53
201.54
201.55
201.56
201.57
201.58
201.60
201.61
201.62
201.63
201.64
201.65
201.66
201.67
201.68
201.70
201.71
201.72
201.73
201.74
201.75
201.76
201.77
201.78
201.90
201.91
201.92
201.93
201.94
201.95
201.96
201.97
201.98
202.00
202.01
202.02
202.03
202.04
202.05
202.06
202.07
202.08
hodgkin’s disease lymphocytic-histiocytic predominance involving lymph nodes of inguinal region and
lower limb
hodgkin’s disease lymphocytic-histiocytic predominance involving intrapelvic lymph nodes
hodgkin’s disease lymphocytic-histiocytic predominance involving spleen
hodgkin’s disease lymphocytic-histiocytic predominance involving lymph nodes of multiple sites
hodgkin’s disease nodular sclerosis unspecified site
hodgkin’s disease nodular sclerosis involving lymph nodes of head face and neck
hodgkin’s disease nodular sclerosis involving intrathoracic lymph nodes
hodgkin’s disease nodular sclerosis involving intra-abdominal lymph nodes
hodgkin’s disease nodular sclerosis involving lymph nodes of axilla and upper limb
hodgkin’s disease nodular sclerosis involving lymph nodes of inguinal region and lower limb
hodgkin’s disease nodular sclerosis involving intrapelvic lymph nodes
hodgkin’s disease nodular sclerosis involving spleen
hodgkin’s disease nodular sclerosis involving lymph nodes of multiple sites
hodgkin’s disease mixed cellularity unspecified site
hodgkin’s disease mixed cellularity involving lymph nodes of head face and neck
hodgkin’s disease mixed cellularity involving intrathoracic lymph nodes
hodgkin’s disease mixed cellularity involving intra-abdominal lymph nodes
hodgkin’s disease mixed cellularity involving lymph nodes of axilla and upper limb
hodgkin’s disease mixed cellularity involving lymph nodes of inguinal region and lower limb
hodgkin’s disease mixed cellularity involving intrapelvic lymph nodes
hodgkin’s disease mixed cellularity involving spleen
hodgkin’s disease mixed cellularity involving lymph nodes of multiple sites
hodgkin’s disease lymphocytic depletion unspecified site
hodgkin’s disease lymphocytic depletion involving lymph nodes of head face and neck
hodgkin’s disease lymphocytic depletion involving intrathoracic lymph nodes
hodgkin’s disease lymphocytic depletion involving intra-abdominal lymph nodes
hodgkin’s disease lymphocytic depletion involving lymph nodes of axilla and upper limb
hodgkin’s disease lymphocytic depletion involving lymph nodes of inguinal region and lower limb
hodgkin’s disease lymphocytic depletion involving intrapelvic lymph nodes
hodgkin’s disease lymphocytic depletion involving spleen
hodgkin’s disease lymphocytic depletion involving lymph nodes of multiple sites
hodgkin’s disease unspecified type unspecified site
hodgkin’s disease unspecified type involving lymph nodes of head face and neck
hodgkin’s disease unspecified type involving intrathoracic lymph nodes
hodgkin’s disease unspecified type involving intra-abdominal lymph nodes
hodgkin’s disease unspecified type involving lymph nodes of axilla and upper limb
hodgkin’s disease unspecified type involving lymph nodes of inguinal region and lower limb
hodgkin’s disease unspecified type involving intrapelvic lymph nodes
hodgkin’s disease unspecified type involving spleen
hodgkin’s disease unspecified type involving lymph nodes of multiple sites
nodular lymphoma unspecified site
nodular lymphoma involving lymph nodes of head face and neck
nodular lymphoma involving intrathoracic lymph nodes
nodular lymphoma involving intra-abdominal lymph nodes
nodular lymphoma involving lymph nodes of axilla and upper limb
nodular lymphoma involving lymph nodes of inguinal region and lower limb
nodular lymphoma involving intrapelvic lymph nodes
nodular lymphoma involving spleen
nodular lymphoma involving lymph nodes of multiple sites
CMS Limitations
Radiologic Examination of the Chest (con’t)
202.10
202.11
202.12
202.13
202.14
202.15
202.16
202.17
202.18
202.20
202.21
202.22
202.23
202.24
202.25
202.26
202.27
202.28
202.30
202.31
202.32
202.33
202.34
202.35
202.36
202.37
202.38
202.40
202.41
202.42
202.43
202.44
202.45
202.46
202.47
202.48
202.50
202.51
202.52
202.53
202.54
202.55
202.56
202.57
202.58
202.60
202.61
202.62
202.63
202.64
mycosis fungoides unspecified site
mycosis fungoides involving lymph nodes of head face and neck
mycosis fungoides involving intrathoracic lymph nodes
mycosis fungoides involving intra-abdominal lymph nodes
mycosis fungoides involving lymph nodes of axilla and upper limb
mycosis fungoides involving lymph nodes of inguinal region and lower limb
mycosis fungoides involving intrapelvic lymph nodes
mycosis fungoides involving spleen
mycosis fungoides involving lymph nodes of multiple sites
sezary’s disease unspecified site
sezary’s disease involving lymph nodes of head face and neck
sezary’s disease involving intrathoracic lymph nodes
sezary’s disease involving intra-abdominal lymph nodes
sezary’s disease involving lymph nodes of axilla and upper limb
sezary’s disease involving lymph nodes of inguinal region and lower limb
sezary’s disease involving intrapelvic lymph nodes
sezary’s disease involving spleen
sezary’s disease involving lymph nodes of multiple sites
malignant histiocytosis unspecified site
malignant histiocytosis involving lymph nodes of head face and neck
malignant histiocytosis involving intrathoracic lymph nodes
malignant histiocytosis involving intra-abdominal lymph nodes
malignant histiocytosis involving lymph nodes of axilla and upper limb
malignant histiocytosis involving lymph nodes of inguinal region and lower limb
malignant histiocytosis involving intrapelvic lymph nodes
malignant histiocytosis involving spleen
malignant histiocytosis involving lymph nodes of multiple sites
leukemic reticuloendotheliosis unspecified site
leukemic reticuloendotheliosis involving lymph nodes of head face and neck
leukemic reticuloendotheliosis involving intrathoracic lymph nodes
leukemic reticuloendotheliosis involving intra-abdominal lymph nodes
leukemic reticuloendotheliosis involving lymph nodes of axilla and upper arm
leukemic reticuloendotheliosis involving lymph nodes of inguinal region and lower limb
leukemic reticuloendotheliosis involving intrapelvic lymph nodes
leukemic reticuloendotheliosis involving spleen
leukemic reticuloendotheliosis involving lymph nodes of multiple sites
letterer-siwe disease unspecified site
letterer-siwe disease involving lymph nodes of head face and neck
letterer-siwe disease involving intrathoracic lymph nodes
letterer-siwe disease involving intra-abdominal lymph nodes
letterer-siwe disease involving lymph nodes of axilla and upper limb
letterer-siwe disease involving lymph nodes of inguinal region and lower limb
letterer-siwe disease involving intrapelvic lymph nodes
letterer-siwe disease involving spleen
letterer-siwe disease involving lymph nodes of multiple sites
malignant mast cell tumors unspecified site
malignant mast cell tumors involving lymph nodes of head face and neck
malignant mast cell tumors involving intrathoracic lymph nodes
malignant mast cell tumors involving intra-abdominal lymph nodes
malignant mast cell tumors involving lymph nodes of axilla and upper limb
CMS Limitations
Radiologic Examination of the Chest (con’t)
202.65
202.66
202.67
202.68
202.70
202.71
202.72
202.74
202.80
202.81
202.82
202.83
202.84
202.85
202.86
202.87
202.88
202.90
202.91
202.92
202.94
203.00
203.01
203.10
203.11
203.80
203.81
211.0
212.2
212.3
212.4
212.5
212.6
212.7
212.8
212.9
213.3
213.4
214.2
215.2
215.4
227.6
228.00
228.1
230.1
231.1
231.2
malignant mast cell tumors involving lymph nodes of inguinal region and lower limb
malignant mast cell tumors involving intrapelvic lymph nodes
malignant mast cell tumors involving spleen
malignant mast cell tumors involving lymph nodes of multiple sites
peripheral t cell lymphoma, unspecified site, extranodal and solid organ sites
peripheral t cell lymphoma, lymph nodes of head, face, and neck
peripheral t cell lymphoma, intrathoracic lymph nodes
peripheral t cell lymphoma, lymph nodes of axilla and upper limb
other malignant lymphomas unspecified site
other malignant lymphomas involving lymph nodes of head face and neck
other malignant lymphomas involving intrathoracic lymph nodes
other malignant lymphomas involving intra-abdominal lymph nodes
other malignant lymphomas involving lymph nodes of axilla and upper limb
other malignant lymphomas involving lymph nodes of inguinal region and lower limb
other malignant lymphomas involving intrapelvic lymph nodes
other malignant lymphomas involving spleen
other malignant lymphomas involving lymph nodes of multiple sites
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue unspecified site
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes
of head face and neck
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving intrathoracic
lymph nodes
other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes
of axilla and upper limb
multiple myeloma, without mention of having achieved remission
multiple myeloma in remission
plasma cell leukemia, without mention of having achieved remission
plasma cell leukemia in remission
other immunoproliferative neoplasms, without mention of having achieved remission
other immunoproliferative neoplasms in remission
benign neoplasm of esophagus
benign neoplasm of trachea
benign neoplasm of bronchus and lung
benign neoplasm of pleura
benign neoplasm of mediastinum
benign neoplasm of thymus
benign neoplasm of heart
benign neoplasm of other specified sites of respiratory and intrathoracic organs
benign neoplasm of respiratory and intrathoracic organs site unspecified
benign neoplasm of ribs sternum and clavicle
benign neoplasm of scapula and long bones of upper limb
lipoma of intrathoracic organs
other benign neoplasm of connective and other soft tissue of upper limb including shoulder
other benign neoplasm of connective and other soft tissue of thorax
benign neoplasm of aortic body and other paraganglia
hemangioma of unspecified site
lymphangioma any site
carcinoma in situ of esophagus
carcinoma in situ of trachea
carcinoma in situ of bronchus and lung
CMS Limitations
Radiologic Examination of the Chest (con’t)
231.8
231.9
233.0
235.7
235.8
235.9
236.0
236.2
236.3
236.90
236.91
237.2
237.3
237.4
238.0
238.1
238.3
239.1
239.3
254.0
254.1
254.8
254.9
259.2
273.4
276.2
276.3
276.4
276.6
277.00
277.01
277.02
277.30
277.31
277.39
277.5
306.0
306.1
306.2
353.0
354.8
391.0
391.1
391.2
391.8
391.9
392.0
393
394.0
394.1
carcinoma in situ of other specified parts of respiratory system
carcinoma in situ of respiratory system part unspecified
carcinoma in situ of breast
neoplasm of uncertain behavior of trachea bronchus and lung
neoplasm of uncertain behavior of pleura thymus and mediastinum
neoplasm of uncertain behavior of other and unspecified respiratory organs
neoplasm of uncertain behavior of uterus
neoplasm of uncertain behavior of ovary
neoplasm of uncertain behavior of other and unspecified female genital organs
neoplasm of uncertain behavior of urinary organ unspecified
neoplasm of uncertain behavior of kidney and ureter
neoplasm of uncertain behavior of adrenal gland
neoplasm of uncertain behavior of paraganglia
neoplasm of uncertain behavior of other and unspecified endocrine glands
neoplasm of uncertain behavior of bone and articular cartilage
neoplasm of uncertain behavior of connective and other soft tissue
neoplasm of uncertain behavior of breast
neoplasm of unspecified nature of respiratory system
neoplasm of unspecified nature of breast
persistent hyperplasia of thymus
abscess of thymus
other specified diseases of thymus gland
unspecified disease of thymus gland
carcinoid syndrome
alpha-1-antitrypsin deficiency
acidosis
alkalosis
mixed acid-base balance disorder
fluid overload disorder
cystic fibrosis without meconium ileus
cystic fibrosis with meconium ileus
cystic fibrosis with pulmonary manifestations
amyloidosis, unspecified
familial mediterranean fever
other amyloidosis
mucopolysaccharidosis
musculoskeletal malfunction arising from mental factors
respiratory malfunction arising from mental factors
cardiovascular malfunction arising from mental factors
brachial plexus lesions
other mononeuritis of upper limb
acute rheumatic pericarditis
acute rheumatic endocarditis
acute rheumatic myocarditis
other acute rheumatic heart disease
acute rheumatic heart disease unspecified
rheumatic chorea with heart involvement
chronic rheumatic pericarditis
mitral stenosis
rheumatic mitral insufficiency
CMS Limitations
Radiologic Examination of the Chest (con’t)
394.2
394.9
395.0
395.1
395.2
395.9
396.8
396.9
397.0
397.1
397.9
398.0
398.90
398.91
398.99
401.0
401.1
401.9
402.00
402.01
402.10
402.11
402.90
402.91
403.00
403.01
403.90
403.91
404.00
404.01
404.02
404.03
404.10
404.11
404.12
404.13
404.90
mitral stenosis with insufficiency
other and unspecified mitral valve diseases
rheumatic aortic stenosis
rheumatic aortic insufficiency
rheumatic aortic stenosis with insufficiency
other and unspecified rheumatic aortic diseases
multiple involvement of mitral and aortic valves
mitral and aortic valve diseases unspecified
diseases of tricuspid valve
rheumatic diseases of pulmonary valve
rheumatic diseases of endocardium valve unspecified
rheumatic myocarditis
rheumatic heart disease unspecified
rheumatic heart failure (congestive)
other rheumatic heart diseases
malignant essential hypertension
benign essential hypertension
unspecified essential hypertension
malignant hypertensive heart disease without heart failure
malignant hypertensive heart disease with heart failure
benign hypertensive heart disease without heart failure
benign hypertensive heart disease with heart failure
unspecified hypertensive heart disease without heart failure
unspecified hypertensive heart disease with heart failure
hypertensive chronic kidney disease, malignant, with chronic kidney disease stage i through stage iv,
or unspecified
hypertensive chronic kidney disease, malignant, with chronic kidney disease stage v or end stage renal
disease
hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv,
or unspecified
hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage
renal disease
hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney
disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney
disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, benign, without heart failure and with chronic kidney
disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, benign, without heart failure and with chronic kidney
disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease
stage v or end stage renal disease
hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage i through stage iv, or unspecified
CMS Limitations
Radiologic Examination of the Chest (con’t)
404.91
404.92
404.93
405.01
405.09
405.11
405.19
410.00
410.01
410.02
410.10
410.11
410.12
410.20
410.21
410.22
410.30
410.31
410.32
410.40
410.41
410.42
410.50
410.51
410.52
410.60
410.61
410.62
410.70
410.71
410.72
410.80
410.81
410.82
410.90
410.91
410.92
411.0
411.1
411.81
411.89
412
413.0
413.1
413.9
414.00
414.01
hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney
disease stage i through stage iv, or unspecified
hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage v or end stage renal disease
hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage v or end stage renal disease
malignant renovascular hypertension
other malignant secondary hypertension
benign renovascular hypertension
other benign secondary hypertension
acute myocardial infarction of anterolateral wall episode of care unspecified
acute myocardial infarction of anterolateral wall initial episode of care
acute myocardial infarction of anterolateral wall subsequent episode of care
acute myocardial infarction of other anterior wall episode of care unspecified
acute myocardial infarction of other anterior wall initial episode of care
acute myocardial infarction of other anterior wall subsequent episode of care
acute myocardial infarction of inferolateral wall episode of care unspecified
acute myocardial infarction of inferolateral wall initial episode of care
acute myocardial infarction of inferolateral wall subsequent episode of care
acute myocardial infarction of inferoposterior wall episode of care unspecified
acute myocardial infarction of inferoposterior wall initial episode of care
acute myocardial infarction of inferoposterior wall subsequent episode of care
acute myocardial infarction of other inferior wall episode of care unspecified
acute myocardial infarction of other inferior wall initial episode of care
acute myocardial infarction of other inferior wall subsequent episode of care
acute myocardial infarction of other lateral wall episode of care unspecified
acute myocardial infarction of other lateral wall initial episode of care
acute myocardial infarction of other lateral wall subsequent episode of care
true posterior wall infarction episode of care unspecified
true posterior wall infarction initial episode of care
true posterior wall infarction subsequent episode of care
subendocardial infarction episode of care unspecified
subendocardial infarction initial episode of care
subendocardial infarction subsequent episode of care
acute myocardial infarction of other specified sites episode of care unspecified
acute myocardial infarction of other specified sites initial episode of care
acute myocardial infarction of other specified sites subsequent episode of care
acute myocardial infarction of unspecified site episode of care unspecified
acute myocardial infarction of unspecified site initial episode of care
acute myocardial infarction of unspecified site subsequent episode of care
postmyocardial infarction syndrome
intermediate coronary syndrome
acute coronary occlusion without myocardial infarction
other acute and subacute forms of ischemic heart disease other
old myocardial infarction
angina decubitus
prinzmetal angina
other and unspecified angina pectoris
coronary atherosclerosis of unspecified type of vessel native or graft
coronary atherosclerosis of native coronary artery
CMS Limitations
Radiologic Examination of the Chest (con’t)
414.02
414.03
414.06
414.07
414.10
414.11
414.12
414.19
414.8
414.9
415.0
415.11
415.12
415.19
416.0
416.1
416.8
416.9
417.0
417.1
417.8
417.9
420.0
420.90
420.91
420.99
421.0
421.1
421.9
422.0
422.90
422.91
422.92
422.93
422.99
423.0
423.1
423.2
423.3
423.8
423.9
424.0
424.1
424.2
424.3
424.90
424.91
424.99
425.0
425.1
coronary atherosclerosis of autologous vein bypass graft
coronary atherosclerosis of nonautologous biological bypass graft
coronary atherosclerosis of native coronary artery of transplanted heart
coronary atherosclerosis of bypass graft (artery) (vein) of transplanted heart
aneurysm of heart (wall)
aneurysm of coronary vessels
dissection of coronary artery
other aneurysm of heart
other specified forms of chronic ischemic heart disease
chronic ischemic heart disease unspecified
acute cor pulmonale
iatrogenic pulmonary embolism and infarction
septic pulmonary embolism
other pulmonary embolism and infarction
primary pulmonary hypertension
kyphoscoliotic heart disease
other chronic pulmonary heart diseases
chronic pulmonary heart disease unspecified
arteriovenous fistula of pulmonary vessels
aneurysm of pulmonary artery
other specified diseases of pulmonary circulation
unspecified disease of pulmonary circulation
acute pericarditis in diseases classified elsewhere
acute pericarditis unspecified
acute idiopathic pericarditis
other acute pericarditis
acute and subacute bacterial endocarditis
acute and subacute infective endocarditis in diseases classified elsewhere
acute endocarditis unspecified
acute myocarditis in diseases classified elsewhere
acute myocarditis unspecified
idiopathic myocarditis
septic myocarditis
toxic myocarditis
other acute myocarditis
hemopericardium
adhesive pericarditis
constrictive pericarditis
cardiac tamponade
other specified diseases of pericardium
unspecified disease of pericardium
mitral valve disorders
aortic valve disorders
tricuspid valve disorders specified as nonrheumatic
pulmonary valve disorders
endocarditis valve unspecified unspecified cause
endocarditis in diseases classified elsewhere
other endocarditis valve unspecified
endomyocardial fibrosis
hypertrophic obstructive cardiomyopathy
CMS Limitations
Radiologic Examination of the Chest (con’t)
425.2
425.3
425.4
425.5
425.7
425.8
425.9
427.0
427.1
427.2
427.31
427.32
427.41
427.42
427.5
427.60
427.61
427.69
427.81
427.89
427.9
428.0
428.1
428.20
428.21
428.22
428.23
428.30
428.31
428.32
428.33
428.40
428.41
428.42
428.43
428.9
429.0
429.1
429.3
429.4
429.5
429.6
429.71
429.79
429.81
429.82
441.00
441.01
441.02
441.03
obscure cardiomyopathy of africa
endocardial fibroelastosis
other primary cardiomyopathies
alcoholic cardiomyopathy
nutritional and metabolic cardiomyopathy
cardiomyopathy in other diseases classified elsewhere
secondary cardiomyopathy unspecified
paroxysmal supraventricular tachycardia
paroxysmal ventricular tachycardia
paroxysmal tachycardia unspecified
atrial fibrillation
atrial flutter
ventricular fibrillation
ventricular flutter
cardiac arrest
premature beats unspecified
supraventricular premature beats
other premature beats
sinoatrial node dysfunction
other specified cardiac dysrhythmias
cardiac dysrhythmia unspecified
congestive heart failure unspecified
left heart failure
unspecified systolic heart failure
acute systolic heart failure
chronic systolic heart failure
acute on chronic systolic heart failure
unspecified diastolic heart failure
acute diastolic heart failure
chronic diastolic heart failure
acute on chronic diastolic heart failure
unspecified combined systolic and diastolic heart failure
acute combined systolic and diastolic heart failure
chronic combined systolic and diastolic heart failure
acute on chronic combined systolic and diastolic heart failure
heart failure unspecified
myocarditis unspecified
myocardial degeneration
cardiomegaly
functional disturbances following cardiac surgery
rupture of chordae tendineae
rupture of papillary muscle
certain sequelae of myocardial infarction not elsewhere classified acquired cardiac septal defect
certain sequelae of myocardial infarction not elsewhere classified other
other disorders of papillary muscle
hyperkinetic heart disease
dissection of aorta aneurysm unspecified site
dissection of aorta thoracic
dissection of aorta abdominal
dissection of aorta thoracoabdominal
CMS Limitations
Radiologic Examination of the Chest (con’t)
441.1
441.2
441.6
441.7
442.81
442.82
442.89
444.0
444.1
445.89
446.1
446.4
446.7
447.2
459.2
464.10
464.11
464.20
464.21
464.4
465.8
466.0
466.11
466.19
476.1
480.0
480.1
480.2
480.3
480.8
480.9
481
482.0
482.1
482.2
482.30
482.31
482.32
482.39
482.40
482.41
482.42
482.49
482.81
482.82
482.83
482.84
482.89
482.9
483.0
thoracic aneurysm ruptured
thoracic aneurysm without rupture
thoracoabdominal aneurysm ruptured
thoracoabdominal aneurysm without rupture
aneurysm of artery of neck
aneurysm of subclavian artery
aneurysm of other specified site
embolism and thrombosis of abdominal aorta
embolism and thrombosis of thoracic aorta
atheroembolism of other site
acute febrile mucocutaneous lymph node syndrome (mcls)
wegener’s granulomatosis
takayasu’s disease
rupture of artery
compression of vein
acute tracheitis without obstruction
acute tracheitis with obstruction
acute laryngotracheitis without obstruction
acute laryngotracheitis with obstruction
croup
acute upper respiratory infections of other multiple sites
acute bronchitis
acute bronchiolitis due to respiratory syncytial virus (rsv)
acute bronciolitis due to other infectious organisms
chronic laryngotracheitis
pneumonia due to adenovirus
pneumonia due to respiratory syncytial virus
pneumonia due to parainfluenza virus
pneumonia due to sars-associated coronavirus
pneumonia due to other virus not elsewhere classified
viral pneumonia unspecified
pneumococcal pneumonia [streptococcus pneumoniae pneumonia]
pneumonia due to klebsiella pneumoniae
pneumonia due to pseudomonas
pneumonia due to hemophilus influenzae (h. influenzae)
pneumonia due to streptococcus unspecified
pneumonia due to streptococcus group a
pneumonia due to streptococcus group b
pneumonia due to other streptococcus
pneumonia due to staphylococcus unspecified
methicillin susceptible pneumonia due to staphylococcus aureus
methicillin resistant pneumonia due to staphylococcus aureus
other staphylococcus pneumonia
pneumonia due to anaerobes
pneumonia due to escherichia coli [e.coli]
pneumonia due to other gram-negative bacteria
pneumonia due to legionnaires’ disease
pneumonia due to other specified bacteria
bacterial pneumonia unspecified
pneumonia due to mycoplasma pneumoniae
CMS Limitations
Radiologic Examination of the Chest (con’t)
483.1
483.8
484.1
484.3
484.5
484.6
484.7
484.8
485
486
487.0
487.1
488
490
491.0
491.1
491.20
491.21
491.22
491.8
491.9
492.0
492.8
493.00
493.01
493.02
493.10
493.11
493.12
493.20
493.21
493.22
493.81
493.82
493.90
493.91
493.92
494.0
494.1
495.0
495.1
495.2
495.3
495.4
495.5
495.6
495.7
495.8
495.9
496
pneumonia due to chlamydia
pneumonia due to other specified organism
pneumonia in cytomegalic inclusion disease
pneumonia in whooping cough
pneumonia in anthrax
pneumonia in aspergillosis
pneumonia in other systemic mycoses
pneumonia in other infectious diseases classified elsewhere
bronchopneumonia organism unspecified
pneumonia organism unspecified
influenza with pneumonia
influenza with other respiratory manifestations
influenza due to identified avian influenza virus
bronchitis not specified as acute or chronic
simple chronic bronchitis
mucopurulent chronic bronchitis
obstructive chronic bronchitis without exacerbation
obstructive chronic bronchitis with (acute) exacerbation
obstructive chronic bronchitis with acute bronchitis
other chronic bronchitis
unspecified chronic bronchitis
emphysematous bleb
other emphysema
extrinsic asthma unspecified
extrinsic asthma with status asthmaticus
extrinsic asthma with (acute) exacerbation
intrinsic asthma unspecified
intrinsic asthma with status asthmaticus
intrinsic asthma with (acute) exacerbation
chronic obstructive asthma unspecified
chronic obstructive asthma with status asthmaticus
chronic obstructive asthma with (acute) exacerbation
exercise-induced bronchospasm
cough variant asthma
asthma unspecified
asthma unspecified type with status asthmaticus
asthma unspecified with (acute) exacerbation
bronchiectasis without acute exacerbation
bronchiectasis with acute exacerbation
farmers’ lung
bagassosis
bird-fanciers’ lung
suberosis
malt workers’ lung
mushroom workers’ lung
maple bark-strippers’ lung
‘ventilation’ pneumonitis
other specified allergic alveolitis and pneumonitis
unspecified allergic alveolitis and pneumonitis
chronic airway obstruction not elsewhere classified
CMS Limitations
Radiologic Examination of the Chest (con’t)
500
501
502
503
504
505
506.0
506.1
506.2
506.3
506.4
506.9
507.0
507.1
507.8
508.0
508.1
508.8
508.9
510.0
510.9
511.0
511.1
511.81
511.89
511.9
512.0
512.1
512.8
513.0
513.1
514
515
516.0
516.1
516.2
516.3
516.8
516.9
517.1
517.2
517.3
517.8
518.0
518.1
518.2
518.3
518.4
518.5
518.6
coal workers’ pneumoconiosis
asbestosis
pneumoconiosis due to other silica or silicates
pneumoconiosis due to other inorganic dust
pneumonopathy due to inhalation of other dust
pneumoconiosis unspecified
bronchitis and pneumonitis due to fumes and vapors
acute pulmonary edema due to fumes and vapors
upper respiratory inflammation due to fumes and vapors
other acute and subacute respiratory conditions due to fumes and vapors
chronic respiratory conditions due to fumes and vapors
unspecified respiratory conditions due to fumes and vapors
pneumonitis due to inhalation of food or vomitus
pneumonitis due to inhalation of oils and essences
pneumonitis due to other solids and liquids
acute pulmonary manifestations due to radiation
chronic and other pulmonary manifestations due to radiation
respiratory conditions due to other specified external agents
respiratory conditions due to unspecified external agent
empyema with fistula
empyema without fistula
pleurisy without effusion or current tuberculosis
pleurisy with effusion with a bacterial cause other than tuberculosis
malignant pleural effusion
other specified forms of effusion, except tuberculous
unspecified pleural effusion
spontaneous tension pneumothorax
iatrogenic pneumothorax
other spontaneous pneumothorax
abscess of lung
abscess of mediastinum
pulmonary congestion and hypostasis
postinflammatory pulmonary fibrosis
pulmonary alveolar proteinosis
idiopathic pulmonary hemosiderosis
pulmonary alveolar microlithiasis
idiopathic fibrosing alveolitis
other specified alveolar and parietoalveolar pneumonopathies
unspecified alveolar and parietoalveolar pneumonopathy
rheumatic pneumonia
lung involvement in systemic sclerosis
acute chest syndrome
lung involvement in other diseases classified elsewhere
pulmonary collapse
interstitial emphysema
compensatory emphysema
pulmonary eosinophilia
acute edema of lung unspecified
pulmonary insufficiency following trauma and surgery
allergic bronchopulmonary aspergilliosis
CMS Limitations
Radiologic Examination of the Chest (con’t)
518.7
518.81
518.82
518.83
518.84
518.89
519.11
519.19
519.2
519.3
519.4
519.8
519.9
530.0
530.10
530.11
530.12
530.19
530.20
530.21
530.3
530.4
530.5
530.6
530.7
530.81
530.82
530.83
530.84
530.85
530.86
530.87
530.89
551.3
552.3
553.3
611.71
611.72
639.5
639.6
642.50
642.51
642.52
642.53
642.54
642.60
642.61
642.62
642.63
642.64
transfusion related acute lung injury (trali)
acute respiratory failure
other pulmonary insufficiency not elsewhere classified
chronic respiratory failure
acute and chronic respiratory failure
other diseases of lung not elsewhere classified
acute bronchospasm
other diseases of trachea and bronchus
mediastinitis
other diseases of mediastinum not elsewhere classified
disorders of diaphragm
other diseases of respiratory system not elsewhere classified
unspecified disease of respiratory system
achalasia and cardiospasm
esophagitis unspecified
reflux esophagitis
acute esophagitis
other esophagitis
ulcer of esophagus without bleeding
ulcer of esophagus with bleeding
stricture and stenosis of esophagus
perforation of esophagus
dyskinesia of esophagus
diverticulum of esophagus acquired
gastroesophageal laceration-hemorrhage syndrome
esophageal reflux
esophageal hemorrhage
esophageal leukoplakia
tracheoesophageal fistula
barrett’s esophagus
infection of esophagostomy
mechanical complication of esophagostomy
other diseases of esophagus
diaphragmatic hernia with gangrene
diaphragmatic hernia with obstruction
diaphragmatic hernia without obstruction or gangrene
mastodynia
lump or mass in breast
shock following abortion or ectopic and molar pregnancies
embolism following abortion or ectopic and molar pregnancies
severe pre-eclampsia unspecified as to episode of care
severe pre-eclampsia with delivery
severe pre-eclampsia with delivery with postpartum complication
severe pre-eclampsia antepartum
severe pre-eclampsia postpartum
eclampsia complicating pregnancy childbirth or the puerperium unspecified as to episode of care
eclampsia with delivery
eclampsia with delivery with postpartum complication
eclampsia antepartum
eclampsia postpartum
CMS Limitations
Radiologic Examination of the Chest (con’t)
642.70
642.71
642.72
642.73
642.74
648.50
648.51
648.52
648.53
648.54
668.00
668.01
668.02
668.03
668.04
668.10
668.11
668.12
668.13
668.14
669.00
669.01
669.02
669.03
669.04
669.10
669.11
669.12
669.13
669.14
669.20
669.21
669.22
669.23
669.24
672.00
672.02
672.04
673.00
673.01
673.02
673.03
673.04
pre-eclampsia or eclampsia superimposed on pre-existing hypertension complicating pregnancy childbirth or the puerperium unspecified as to episode of care
pre-eclampsia or eclampsia superimposed on pre-existing hypertension with delivery
pre-eclampsia or eclampsia superimposed on pre-existing hypertension with delivery with postpartum
complication
pre-eclampsia or eclampsia superimposed on pre-existing hypertension antepartum
pre-eclampsia or eclampsia superimposed on pre-existing hypertension postpartum
congenital cardiovascular disorders of mother complicating pregnancy childbirth or the puerperium
unspecified as to episode of care
congenital cardiovascular disorders of mother with delivery
congenital cardiovascular disorders of mother with delivery with postpartum complication
congenital cardiovascular disorders of mother antepartum
congenital cardiovascular disorders of mother postpartum
pulmonary complications of anesthesia or other sedation in labor and delivery unspecified as to episode of care
pulmonary complications of anesthesia or other sedation in labor and delivery delivered
pulmonary complications of anesthesia or other sedation in labor and delivery delivered with postpartum complication
pulmonary complications of anesthesia or other sedation in labor and delivery antepartum
pulmonary complications of anesthesia or other sedation in labor and delivery postpartum
cardiac complications of anesthesia or other sedation in labor and delivery unspecified as to episode
of care
cardiac complications of anesthesia or other sedation in labor and delivery delivered
cardiac complications of anesthesia or other sedation in labor and delivery delivered with postpartum
complication
cardiac complications of anesthesia or other sedation in labor and delivery antepartum
cardiac complications of anesthesia or other sedation in labor and delivery postpartum
maternal distress complicating labor and delivery unspecified as to episode of care
maternal distress with delivery with or without antepartum condition
maternal distress with delivery with postpartum complication
maternal distress complicating labor and delivery antepartum condition or complication
maternal distress complicating labor and delivery postpartum condition or complication
obstetric shock unspecified as to episode of care
obstetric shock with delivery with or without antepartum condition
obstetric shock with delivery with postpartum complication
antepartum obstetric shock
postpartum obstetric shock
maternal hypotension syndrome complicating labor and delivery unspecified as to episode of care
maternal hypotension syndrome with delivery with or without antepartum condition
maternal hypotension syndrome with delivery with postpartum complication
maternal hypotension syndrome antepartum
maternal hypotension syndrome postpartum
puerperal pyrexia of unknown origin unspecified as to episode of care
puerperal pyrexia of unknown origin delivered with postpartum complication
puerperal pyrexia of unknown origin postpartum
obstetrical air embolism unspecified as to episode of care
obstetrical air embolism with delivery with or without antepartum condition
obstetrical air embolism with delivery with postpartum complication
obstetrical air embolism antepartum condition or complication
obstetrical air embolism postpartum condition or complication
CMS Limitations
Radiologic Examination of the Chest (con’t)
673.10
673.11
673.12
673.13
673.14
673.20
673.21
673.22
673.23
673.24
673.30
673.31
673.32
673.33
673.34
673.80
673.81
673.82
673.83
673.84
674.50
674.51
674.52
674.53
674.54
710.1
710.3
710.4
714.0
714.2
714.81
733.6
737.10
737.11
737.30
737.31
737.32
737.33
737.34
738.3
739.2
739.8
745.0
745.10
745.11
745.12
745.19
745.2
745.3
745.4
amniotic fluid embolism unspecified as to episode of care
amniotic fluid embolism with delivery with or without antepartum condition
amniotic fluid embolism with delivery with postpartum complication
amniotic fluid embolism antepartum condition or complication
amniotic fluid embolism postpartum condition or complication
obstetrical blood-clot embolism unspecified as to episode of care
obstetrical blood-clot embolism with delivery with or without antepartum condition
obstetrical blood-clot embolism with postpartum complication
obstetrical blood-clot embolism antepartum
obstetrical blood-clot embolism postpartum
obstetrical pyemic and septic embolism unspecified as to episode of care
obstetrical pyemic and septic embolism with delivery with or without antepartum condition
obstetrical pyemic and septic embolism with delivery with postpartum complicaton
obstetrical pyemic and septic embolism antepartum
obstetrical pyemic and septic embolism postpartum
other obstetrical pulmonary embolism unspecified as to episode of care
other obstetrical pulmonary embolism with delivery with or without antepartum condition
other obstetrical pulmonary embolism with delivery with postpartum complication
other obstetrical pulmonary embolism antepartum
other obstetrical pulmonary embolism postpartum
peripart cardiomyopathy unspecified
peripartum cardiomyopathy with delivery with or without antepartum condition
peripartum cardiomyopathy with delivery with postpartum complication
peripartum cardiomyopathy with antepartum condition or complication
peripartum cardiomyopathy with postpartum condition or complication
systemic sclerosis
dermatomyositis
polymyositis
rheumatoid arthritis
other rheumatoid arthritis with visceral or systemic involvement
rheumatoid lung
tietze’s disease
kyphosis (acquired) (postural)
kyphosis due to radiation
scoliosis (and kyphoscoliosis) idiopathic
resolving infantile idiopathic scoliosis
progressive infantile idiopathic scoliosis
scoliosis due to radiation
thoracogenic scoliosis
acquired deformity of chest and rib
nonallopathic lesions of thoracic region not elsewhere classified
nonallopathic lesions of rib cage not elsewhere classified
common truncus
complete transposition of great vessels
double outlet right ventricle
corrected transposition of great vessels
other transposition of great vessels
tetralogy of fallot
common ventricle
ventricular septal defect
CMS Limitations
Radiologic Examination of the Chest (con’t)
745.5
745.60
745.61
745.69
745.7
745.8
745.9
746.00
746.01
746.02
746.09
746.1
746.2
746.3
746.4
746.5
746.6
746.7
746.81
746.82
746.83
746.84
746.87
746.89
746.9
747.0
747.20
747.21
747.22
747.29
747.3
747.40
747.41
747.42
747.49
748.3
748.4
748.5
748.60
748.61
748.69
748.8
748.9
750.3
750.4
756.2
756.3
756.6
756.83
759.3
ostium secundum type atrial septal defect
endocardial cushion defect unspecified type
ostium primum defect
other endocardial cushion defects
cor biloculare
other bulbus cordis anomalies and anomalies of cardiac septal closure
unspecified defect of septal closure
congenital pulmonary valve anomaly unspecified
atresia of pulmonary valve congenital
stenosis of pulmonary valve congenital
other congenital anomalies of pulmonary valve
tricuspid atresia and stenosis congenital
ebstein’s anomaly
congenital stenosis of aortic valve
congenital insufficiency of aortic valve
congenital mitral stenosis
congenital mitral insufficiency
hypoplastic left heart syndrome
subaortic stenosis congenital
cor triatriatum
infundibular pulmonic stenosis congenital
congenital obstructive anomalies of heart not elsewhere classified
malposition of heart and cardiac apex
other specified congenital anomalies of heart
unspecified congenital anomaly of heart
patent ductus arteriosus
congenital anomaly of aorta unspecified
congenital anomalies of aortic arch
congenital atresia and stenosis of aorta
other congenital anomalies of aorta
congenital anomalies of pulmonary artery
congenital anomaly of great veins unspecified
total anomalous pulmonary venous connection
partial anomalous pulmonary venous connection
other anomalies of great veins
other congenital anomalies of larynx trachea and bronchus
congenital cystic lung
congenital agenesis hypoplasia and dysplasia of lung
congenital anomaly of lung unspecified
congenital bronchiectasis
other congenital anomalies of lung
other specified congenital anomalies of respiratory system
unspecified congenital anomaly of respiratory system
congenital tracheoesophageal fistula esophageal atresia and stenosis
other specified congenital anomalies of esophagus
cervical rib
other congenital anomalies of ribs and sternum
congenital anomalies of diaphragm
ehlers-danlos syndrome
situs inversus
CMS Limitations
Radiologic Examination of the Chest (con’t)
759.4
759.7
759.82
780.01
780.09
780.60
780.61
780.62
780.64
780.65
781.5
782.5
783.0
783.21
785.0
785.1
785.2
785.3
785.50
785.51
785.52
785.59
785.6
786.00
786.01
786.02
786.05
786.06
786.07
786.09
786.1
786.2
786.3
786.4
786.50
786.51
786.52
786.59
786.6
786.7
786.8
786.9
787.20
787.21
787.22
787.23
787.24
787.29
790.91
793.1
conjoined twins
multiple congenital anomalies so described
marfan syndrome
coma
alteration of consciousness other
fever, unspecified
fever presenting with conditions classified elsewhere
postprocedural fever
chills (without fever)
hypothermia not associated with low environmental temperature
clubbing of fingers
cyanosis
anorexia
loss of weight
tachycardia unspecified
palpitations
undiagnosed cardiac murmurs
other abnormal heart sounds
shock unspecified
cardiogenic shock
septic shock
other shock without trauma
enlargement of lymph nodes
respiratory abnormality unspecified
hyperventilation
orthopnea
shortness of breath
tachypnea
wheezing
respiratory abnormality other
stridor
cough
hemoptysis
abnormal sputum
unspecified chest pain
precordial pain
painful respiration
other chest pain
swelling mass or lump in chest
abnormal chest sounds
hiccough
other symptoms involving respiratory system and chest
dysphagia, unspecified
dysphagia, oral phase
dysphagia, oropharyngeal phase
dysphagia, pharyngeal phase
dysphagia, pharyngoesophageal phase
other dysphagia
abnormal arterial blood gases
nonspecific abnormal findings on radiological and other examination of lung field
CMS Limitations
Radiologic Examination of the Chest (con’t)
793.2
793.89
794.2
794.30
794.31
794.39
795.31
795.5
799.01
799.02
799.1
799.4
806.24
806.34
807.00
807.01
807.02
807.03
807.04
807.05
807.06
807.07
807.08
807.09
807.10
807.11
807.12
807.13
807.14
807.15
807.16
807.17
807.18
807.19
807.2
807.3
807.4
807.5
807.6
810.00
810.01
810.02
810.03
810.10
810.11
810.12
810.13
811.00
811.01
811.02
nonspecific abnormal findings on radiological and other examination of other intrathoracic organs
other abnormal findings on radiological examination of breast
nonspecific abnormal results of function study of pulmonary system
unspecified abnormal function study of cardiovascular system
nonspecific abnormal electrocardiogram (ecg) (ekg)
other nonspecific abnormal function study of cardiovascular system
nonspecific positive findings for anthrax
nonspecific reaction to tuberculin skin test without active tuberculosis
asphyxia
hypoxemia
respiratory arrest
cachexia
closed fracture of t1-t6 level with other specified spinal cord injury
open fracture of t1-t6 level with other specified spinal cord injury
closed fracture of rib(s) unspecified
closed fracture of one rib
closed fracture of two ribs
closed fracture of three ribs
closed fracture of four ribs
closed fracture of five ribs
closed fracture of six ribs
closed fracture of seven ribs
closed fracture of eight or more ribs
closed fracture of multiple ribs unspecified
open fracture of rib(s) unspecified
open fracture of one rib
open fracture of two ribs
open fracture of three ribs
open fracture of four ribs
open fracture of five ribs
open fracture of six ribs
open fracture of seven ribs
open fracture of eight or more ribs
open fracture of multiple ribs unspecified
closed fracture of sternum
open fracture of sternum
flail chest
closed fracture of larynx and trachea
open fracture of larynx and trachea
closed fracture of clavicle unspecified part
closed fracture of sternal end of clavicle
closed fracture of shaft of clavicle
closed fracture of acromial end of clavicle
open fracture of clavicle unspecified part
open fracture of sternal end of clavicle
open fracture of shaft of clavicle
open fracture of acromial end of clavicle
closed fracture of scapula unspecified part
closed fracture of acromial process of scapula
closed fracture of coracoid process of scapula
CMS Limitations
Radiologic Examination of the Chest (con’t)
811.03
811.09
811.10
811.11
811.12
811.13
811.19
819.0
819.1
828.0
828.1
839.61
839.71
847.1
848.3
848.40
848.41
848.42
848.49
860.0
860.1
860.2
860.3
860.4
860.5
861.00
861.01
861.02
861.03
861.10
861.11
861.12
861.13
861.20
861.21
861.22
861.30
861.31
861.32
862.0
862.1
862.21
862.22
862.29
862.31
862.32
862.39
862.8
closed fracture of glenoid cavity and neck of scapula
closed fracture of other part of scapula
open fracture of scapula unspecified part
open fracture of acromial process of scapula
open fracture of coracoid process
open fracture of glenoid cavity and neck of scapula
open fracture of other part of scapula
multiple closed fractures involving both upper limbs and upper limb with rib(s) and sternum
multiple open fractures involving both upper limbs and upper limb with rib(s) and sternum
multiple fractures involving both lower limbs lower with upper limb and lower limb(s) with rib(s) and
sternum closed
multiple fractures involving both lower limbs lower with upper limb and lower limb(s) with rib(s) and
sternum open
closed dislocation sternum
open dislocation sternum
thoracic sprain
sprain of ribs
sternum sprain unspecified part
sternoclavicular (joint) (ligament) sprain
chondrosternal (joint) sprain
other sprain of sternum
traumatic pneumothorax without open wound into thorax
traumatic pneumothorax with open wound into thorax
traumatic hemothorax without open wound into thorax
traumatic hemothorax with open wound into thorax
traumatic pneumohemothorax without open wound into thorax
traumatic pneumohemothorax with open wound into thorax
unspecified injury of heart without open wound into thorax
contusion of heart without open wound into thorax
laceration of heart without penetration of heart chambers or open wound into thorax
laceration of heart with penetration of heart chambers without open wound into thorax
unspecified injury of heart with open wound into thorax
contusion of heart with open wound into thorax
laceration of heart without penetration of heart chambers with open wound into thorax
laceration of heart with penetration of heart chambers and open wound into thorax
unspecified injury of lung without open wound into thorax
contusion of lung without open wound into thorax
laceration of lung without open wound into thorax
unspecified injury of lung with open wound into thorax
contusion of lung with open wound into thorax
laceration of lung with open wound into thorax
injury to diaphragm without open wound into cavity
injury to diaphragm with open wound into cavity
injury to bronchus without open wound into cavity
injury to esophagus without open wound into cavity
injury to other specified intrathoracic organs without open wound into cavity
injury to bronchus with open wound into cavity
injury to esophagus with open wound into cavity
injury to other specified intrathoracic organs with open wound into cavity
injury to multiple and unspecified intrathoracic organs without open wound into cavity
CMS Limitations
Radiologic Examination of the Chest (con’t)
862.9
874.10
874.11
874.12
875.0
875.1
879.1
879.7
901.0
901.1
901.2
901.3
901.40
901.41
901.42
901.81
901.82
901.83
901.89
901.9
903.00
903.01
903.02
905.1
906.0
908.0
908.2
908.4
909.0
909.1
909.2
909.3
909.4
909.5
922.0
922.1
926.11
926.8
927.01
927.02
933.0
933.1
934.0
934.1
934.8
934.9
935.1
935.2
942.00
942.01
injury to multiple and unspecified intrathoracic organs with open wound into cavity
open wound of larynx with trachea complicated
open wound of larynx complicated
open wound of trachea complicated
open wound of chest (wall) without complication
open wound of chest (wall) complicated
open wound of breast complicated
open wound of other and unspecified parts of trunk complicated
injury to thoracic aorta
injury to innominate and subclavian arteries
injury to superior vena cava
injury to innominate and subclavian veins
injury to pulmonary vessel(s) unspecified
injury to pulmonary artery
injury to pulmonary vein
injury to intercostal artery or vein
injury to internal mammary artery or vein
injury to multiple blood vessels of thorax
injury to other specified blood vessels of thorax
injury to unspecified blood vessel of thorax
injury to axillary vessel(s) unspecified
injury to axillary artery
injury to axillary vein
late effect of fracture of spine and trunk without spinal cord lesion
late effect of open wound of head neck and trunk
late effect of internal injury to chest
late effect of internal injury to other internal organs
late effect of injury to blood vessel of thorax abdomen and pelvis
late effect of poisoning due to drug medicinal or biological substance
late effect of toxic effects of nonmedical substances
late effect of radiation
late effect of complications of surgical and medical care
late effect of certain other external causes
late effect of adverse effect of drug medicinal or biological substance
contusion of breast
contusion of chest wall
crushing injury of back
crushing injury of multiple sites of trunk
crushing injury of scapular region
crushing injury of axillary region
foreign body in pharynx
foreign body in larynx
foreign body in trachea
foreign body in main bronchus
foreign body in other specified parts bronchus and lung
foreign body in respiratory tree unspecified
foreign body in esophagus
foreign body in stomach
burn of unspecified degree of unspecified site of trunk
burn of unspecified degree of breast
CMS Limitations
Radiologic Examination of the Chest (con’t)
942.02
942.04
942.20
942.21
942.22
942.24
942.30
942.31
942.32
942.34
942.40
942.41
942.42
942.44
942.50
942.51
942.52
942.54
947.1
947.2
948.10
948.11
948.20
948.21
948.22
948.30
948.31
948.32
948.33
948.40
948.41
948.42
948.43
948.44
948.50
948.51
948.52
948.53
948.54
burn of unspecified degree of chest wall excluding breast and nipple
burn of unspecified degree of back (any part)
blisters with epidermal loss due to burn (second degree) of unspecified site of trunk
blisters with epidermal loss due to burn (second degree) of breast
blisters with epidermal loss due to burn (second degree) of chest wall excluding breast and nipple
blisters with epidermal loss due to burn (second degree) of back (any part)
full-thickness skin loss due to burn (third degree nos) of unspecified site of trunk
full-thickness skin loss due to burn (third degree nos) of breast
full-thickness skin loss due to burn (third degree nos) of chest wall excluding breast and nipple
full-thickness skin loss due to burn (third degree nos) of back (any part)
deep necrosis of underlying tissues due to burn (deep third degree) of trunk unspecified site without
loss of body part
deep necrosis of underlying tissues due to burn (deep third degree) of breast without loss of breast
deep necrosis of underlying tissues due to burn (deep third degree) of chest wall excluding breast and
nipple without loss of chest wall
deep necrosis of underlying tissues due to burn (deep third degree) of back (any part) without loss of
back
deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of trunk with
loss of body part
deep necrosis of underlying tissues due to burn (deep third degree) of breast with loss of breast
deep necrosis of underlying tissues due to burn (deep third degree) of chest wall excluding breast and
nipple with loss of chest wall
deep necrosis of underlying tissues due to burn (deep third degree) of back (any part) with loss of
back
burn of larynx trachea and lung
burn of esophagus
burn (any degree) involving 10-19 percent of body surface with third degree burn of less than 10 percent or unspecified amount
burn (any degree) involving 10-19 percent of body surface with third degree burn of 10-19%
burn (any degree) involving 20-29 percent of body surface with third degree burn of less than 10 percent or unspecified amount
burn (any degree) involving 20-29 percent of body surface with third degree burn of 10-19%
burn (any degree) involving 20-29 percent of body surface with third degree burn of 20-29%
burn (any degree) involving 30-39 percent of body surface with third degree burn of less than 10 percent or unspecified amount
burn (any degree) involving 30-39 percent of body surface with third degree burn of 10-19%
burn (any degree) involving 30-39 percent of body surface with third degree burn of 20-29%
burn (any degree) involving 30-39 percent of body surface with third degree burn of 30-39%
burn (any degree) involving 40-49 percent of body surface with third degree burn of less than 10 percent or unspecified amount
burn (any degree) involving 40-49 percent of body surface with third degree burn of 10-19%
burn (any degree) involving 40-49 percent of body surface with third degree burn of 20-29%
burn (any degree) involving 40-49 percent of body surface with third degree burn of 30-39%
burn (any degree) involving 40-49 percent of body surface with third degree burn of 40-49%
burn (any degree) involving 50-59 percent of body surface with third degree burn of less than 10 percent or unspecified amount
burn (any degree) involving 50-59 percent of body surface with third degree burn of 10-19%
burn (any degree) involving 50-59 percent of body surface with third degree burn of 20-29%
burn (any degree) involving 50-59 percent of body surface with third degree burn of 30-39%
burn (any degree) involving 50-59 percent of body surface with third degree burn of 40-49%
CMS Limitations
Radiologic Examination of the Chest (con’t)
948.55
948.60
948.61
948.62
948.63
948.64
948.65
948.66
948.70
948.71
948.72
948.73
948.74
948.75
948.76
948.77
948.80
948.81
948.82
948.83
948.84
948.85
948.86
948.87
948.88
948.90
948.91
948.92
948.93
948.94
948.95
948.96
948.97
948.98
948.99
958.0
958.1
958.2
958.4
958.7
959.11
959.12
959.19
977.8
977.9
burn (any degree) involving 50-59 percent of body surface with third degree burn of 50-59%
burn (any degree) involving 60-69 percent of body surface with third degree burn of less than 10 percent or unspecified amount
burn (any degree) involving 60-69 percent of body surface with third degree burn of 10-19%
burn (any degree) involving 60-69 percent of body surface with third degree burn of 20-29%
burn (any degree) involving 60-69 percent of body surface with third degree burn of 30-39%
burn (any degree) involving 60-69 percent of body surface with third degree burn of 40-49%
burn (any degree) involving 60-69 percent of body surface with third degree burn of 50-59%
burn (any degree) involving 60-69 percent of body surface with third degree burn of 60-69%
burn (any degree) involving 70-79 percent of body surface with third degree burn of less than 10 percent or unspecified amount
burn (any degree) involving 70-79 percent of body surface with third degree burn of 10-19%
burn (any degree) involving 70-79 percent of body surface with third degree burn of 20-29%
burn (any degree) involving 70-79 percent of body surface with third degree burn of 30-39%
burn (any degree) involving 70-79 percent of body surface with third degree burn of 40-49%
burn (any degree) involving 70-79 percent of body surface with third degree burn of 50-59%
burn (any degree) involving 70-79 percent of body surface with third degree burn of 60-69%
burn (any degree) involving 70-79 percent of body surface with third degree burn of 70-79%
burn (any degree) involving 80-89 percent of body surface with third degree burn of less than 10 percent or unspecified amount
burn (any degree) involving 80-89 percent of body surface with third degree burn of 10-19%
burn (any degree) involving 80-89 percent of body surface with third degree burn of 20-29%
burn (any degree) involving 80-89 percent of body surface with third degree burn of 30-39%
burn (any degree) involving 80-89 percent of body surface with third degree burn of 40-49%
burn (any degree) involving 80-89 percent of body surface with third degree burn of 50-59%
burn (any degree) involving 80-89 percent of body surface with third degree burn of 60-69%
burn (any degree) involving 80-89 percent of body surface with third degree burn of 70-79%
burn (any degree) involving 80-89 percent of body surface with third degree burn of 80-89%
burn (any degree) involving 90 percent or more of body surface with third degree burn of less than 10
percent or unspecified amount
burn (any degree) involving 90 percent or more of body surface with third degree burn of 10-19%
burn (any degree) involving 90 percent or more of body surface with third degree burn of 20-29%
burn (any degree) involving 90 percent or more of body surface with third degree burn of 30-39%
burn (any degree) involving 90 percent or more of body surface with third degree burn of 40-49%
burn (any degree) involving 90 percent or more of body surface with third degree burn of 50-59%
burn (any degree) involving 90 percent or more of body surface with third degree burn of 60-69%
burn (any degree) involving 90 percent or more of body surface with third degree burn of 70-79%
burn (any degree) involving 90 percent or more of body surface with third degree burn of 80-89%
burn (any degree) involving 90 percent or more of body surface with third degree burn of 90% or
more of body surface
air embolism as an early complication of trauma
fat embolism as an early complication of trauma
secondary and recurrent hemorrhage as an early complication of trauma
traumatic shock
traumatic subcutaneous emphysema
other injury of chest wall
other injury of abdomen
other and unspecified injury of other sites of trunk
poisoning by other specified drugs and medicinal substances
poisoning by unspecified drug or medicinal substance
CMS Limitations
Radiologic Examination of the Chest (con’t)
980.3
981
982.0
982.1
982.2
982.3
982.4
982.8
983.0
983.1
983.2
983.9
986
987.0
987.1
987.2
987.3
987.4
987.5
987.6
987.7
987.8
987.9
993.2
993.3
994.0
994.1
994.7
995.0
995.22
996.00
996.01
996.02
996.03
996.04
996.09
996.1
996.2
996.61
996.63
996.71
996.72
996.75
996.79
996.83
996.84
997.02
997.1
997.31
997.39
toxic effect of fusel oil
toxic effect of petroleum products
toxic effect of benzene and homologues
toxic effect of carbon tetrachloride
toxic effect of carbon disulfide
toxic effect of other chlorinated hydrocarbon solvents
toxic effect of nitroglycol
toxic effect of other nonpetroleum-based solvents
toxic effect of corrosive aromatics
toxic effect of acids
toxic effect of caustic alkalis
toxic effect of caustic unspecified
toxic effect of carbon monoxide
toxic effect of liquefied petroleum gases
toxic effect of other hydrocarbon gas
toxic effect of nitrogen oxides
toxic effect of sulfur dioxide
toxic effect of freon
toxic effect of lacrimogenic gas
toxic effect of chlorine gas
toxic effect of hydrocyanic acid gas
toxic effect of other specified gases fumes or vapors
toxic effect of unspecified gas fume or vapor
other and unspecified effects of high altitude
caisson disease
effects of lightning
drowning and nonfatal submersion
asphyxiation and strangulation
other anaphylactic shock not elsewhere classified
unspecified adverse effect of anesthesia
mechanical complications of unspecified cardiac device implant and graft
mechanical complication due to cardiac pacemaker (electrode)
mechanical complication due to heart valve prosthesis
mechanical complication due to coronary bypass graft
mechanical complication of automatic implantable cardiac defibrillator
other mechanical complication of cardiac device implant and graft
mechanical complication of other vascular device implant and graft
mechanical complication of nervous system device implant and graft
infection and inflammatory reaction due to cardiac device implant and graft
infection and inflammatory reaction due to nervous system device implant and graft
other complications due to heart valve prosthesis
other complications due to other cardiac device implant and graft
other complications due to nervous system device implant and graft
other complications due to other internal prosthetic device implant and graft
complications of transplanted heart
complications of transplanted lung
iatrogenic cerebrovascular infarction or hemorrhage
cardiac complications not elsewhere classified
ventilator associated pneumonia
other respiratory complications
CMS Limitations
Radiologic Examination of the Chest (con’t)
998.0
998.11
998.12
998.13
998.2
998.4
998.51
998.59
998.81
999.1
999.31
999.39
999.4
v01.82
v10.00
v10.01
v10.02
v10.03
v10.04
v10.05
v10.06
v10.07
v10.09
v10.11
v10.12
v10.20
v10.21
v10.22
v10.29
v10.3
v10.40
v10.41
v10.42
v10.43
v10.44
v10.45
v10.46
v10.47
v10.48
v10.49
v10.50
v10.51
v10.52
v10.53
v10.59
v10.71
v10.72
v10.79
v10.81
v10.82
postoperative shock not elsewhere classified
hemorrhage complicating a procedure
hematoma complicating a procedure
seroma complicating a procedure
accidental puncture or laceration during a procedure not elsewhere classified
foreign body accidentally left during a procedure not elsewhere classified
infected postoperative seroma
other postoperative infection
emphysema (subcutaneous) (surgical) resulting from procedure
air embolism as a complication of medical care not elsewhere classified
infection duet central venous catheter
infection following other infusion, injection, transfusion, or vaccination
anaphylactic shock due to serum not elsewhere classified
exposure to sars-associated coronavirus
personal history of malignant neoplasm of unspecified site in gastrointestinal tract
personal history of malignant neoplasm of tongue
personal history of malignant neoplasm of other and unspecified parts of oral cavity and pharynx
personal history of malignant neoplasm of esophagus
personal history of malignant neoplasm of stomach
personal history of malignant neoplasm of large intestine
personal history of malignant neoplasm of rectum rectosigmoid junction and anus
personal history of malignant neoplasm of liver
personal history of malignant neoplasm of other sites in gastrointestinal tract
personal history of malignant neoplasm of bronchus and lung
personal history of malignant neoplasm of trachea
personal history of malignant neoplasm of unspecified respiratory organ
personal history of malignant neoplasm of larynx
personal history of malignant neoplasm of nasal cavities middle ear and accessory sinuses
personal history of malignant neoplasm of other respiratory and intrathoracic organs
personal history of malignant neoplasm of breast
personal history of malignant neoplasm of unspecified female genital organ
personal history of malignant neoplasm of cervix uteri
personal history of malignant neoplasm of other parts of uterus
personal history of malignant neoplasm of ovary
personal history of malignant neoplasm of other female genital organs
personal history of malignant neoplasm of unspecified male genital organ
personal history of malignant neoplasm of prostate
personal history of malignant neoplasm of testis
personal history of malignant neoplasm of epididymis
personal history of malignant neoplasm of other male genital organs
personal history of malignant neoplasm of unspecified urinary organ
personal history of malignant neoplasm of bladder
personal history of malignant neoplasm of kidney
personal history of malignant neoplasm of renal pelvis
personal history of malignant neoplasm of other urinary organs
personal history of lymphosarcoma and reticulosarcoma
personal history of hodgkin’s disease
personal history of other lymphatic and hematopoietic neoplasms
personal history of malignant neoplasm of bone
personal history of malignant melanoma of skin
CMS Limitations
Radiologic Examination of the Chest (con’t)
v10.83
v10.87
v12.01
v15.84
v41.6
v42.1
v42.2
v42.6
v43.21
v43.22
v43.3
v45.00
v45.01
v45.02
v45.09
v45.2
v45.76
v45.81
v53.31
v53.32
v55.0
v56.1
v58.74
v58.81
v58.82
v67.1
v67.2
v71.1
v71.2
v71.82
v71.83
personal history of other malignant neoplasm of skin
personal history of malignant neoplasm of thyroid
personal history of tuberculosis
personal history of exposure to asbestos
problems with swallowing and mastication
heart replaced by transplant
heart valve replaced by transplant
lung replaced by transplant
heart replaced by heart assist device
heart replaced by fully implantable artificial heart
heart valve replaced by other means
unspecified cardiac device in situ
cardiac pacemaker in situ
automatic implantable cardiac defibrillator in situ
other specified cardiac device in situ
postsurgical presence of cerebrospinal fluid drainage device
acquired absence of organ lung
postsurgical aortocoronary bypass status
fitting and adjustment of cardiac pacemaker
fitting and adjustment of automatic implantable cardiac defibrillator
attention to tracheostomy
fitting and adjustment of extracorporeal dialysis catheter
aftercare following surgery of the respiratory system not elsewhere classified
fitting and adjustment of vascular catheter
fitting and adjustment of nonvascular catheter not elsewhere classified
follow-up examination following radiotherapy
follow-up examination following chemotherapy
observation for suspected malignant neoplasm
observation for suspected tuberculosis
observation and evaluation for suspected exposure to anthrax
observation and evaluation for suspected exposure to other biological agent