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REIMBURSEMENT POLICY
CMS-1500
Proprietary information of UnitedHealthcare Community and State. Copyright 2017 United Healthcare Services, Inc. 2018R7100A
Clinical Diagnostic Labs Policy
Policy Number
2018R7100A Annual Approval Date
3/8/2018 Approved By
Reimbursement Policy Oversight Committee
IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY
You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT
®*), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines.
References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the
physician or other provider contracts, the enrollee’s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. (CPT Copyright American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association).
Proprietary information of UnitedHealthcare Community and State
Copyright 2017 United Healthcare Services, Inc.
Application
This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid products. This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Payment Policies for Medicare & Retirement, UnitedHealthcare Community Plan Medicare and Employer & Individual please use this link. Medicare & Retirement and UnitedHealthcare Community Plan Medicare Policies are listed under Medicare Advantage Reimbursement Policies. Employer & Individual are listed under Reimbursement Policies-Commercial.
https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=ca174ccb4726b010VgnVCM100000c520720a____
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REIMBURSEMENT POLICY
CMS-1500
Proprietary information of UnitedHealthcare Community and State. Copyright 2017 United Healthcare Services, Inc. 2018R7100A
Policy
Overview
Based on the CMS National Coverage Determination (NCD) coding policy manual, services that are excluded from coverage include routine physical examinations and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury. CMS interprets these provisions to prohibit coverage of screening services, including laboratory tests furnished in the absence of signs, symptoms, or personal history of disease or injury. A national coverage policy for diagnostic laboratory test(s) is a document stating CMS’s policy with respect to the circumstances under which the test(s) will be considered reasonable and necessary, and not screening.
Reimbursement Guidelines
This edit will allow clinical diagnostic lab procedure(s) when submitted with a diagnosis code found on the allowed diagnosis code list. When the clinical diagnostic lab procedure is billed as a routine screening service, as evidenced by the diagnosis code not found on the allowed diagnosis code list, the procedure code will deny.
Carcinoembryonic Antigen (CEA)
Carcinoembryonic antigen (CEA) is a protein polysaccharide found in some carcinomas. It is effective as a biochemical marker for monitoring the response of certain malignancies to therapy. UnitedHealthcare Community Plan reimburses for Carcinoembryonic antigen (CEA) (CPT codes 82378) when one of the diagnosis codes listed on a claim indicates a malignancy found on the list of approved diagnosis codes for this test.. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Alpha-fetoprotein (AFP)
Alpha-fetoprotein (AFP) is a polysaccharide found in some carcinomas. It is effective as a biochemical marker for monitoring the response of certain malignancies to therapy. AFP is useful for the diagnosis of hepatocellular carcinoma in high-risk patients (such as alcoholic cirrhosis, cirrhosis of viral etiology, hemochromatosis, and alpha 1-antitrypsin deficiency) and in separating patients with benign hepatocellular neoplasms or metastases from those with hepatocellular carcinoma and, as a non-specific tumor associated antigen, serves in marking germ cell neoplasms of the testis, ovary, retro peritoneum, and mediastinum. UnitedHealthcare Community Plan reimburses for Alpha-fetoprotein; serum (82105) when one of the diagnosis codes listed on a claim is found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Partial Thromboplastin Time (PTT)
Basic plasma coagulation function is readily assessed with a few simple laboratory tests: The Partial Thromboplastin Time (PTT), Prothrombin Time (PT), Thrombin Time (TT), or a quantitative fibrinogen determination. The PTT test is an in vitro laboratory test used to assess the intrinsic coagulation pathway and monitor heparin therapy. UnitedHealthcare Community Plan reimburses for Partial Thromboplastin Time (PTT) (CPT code 85730), when one billed with one of the approved diagnosis codes for this test.. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the and ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Prostate Specific Antigen (PSA)
Prostate Specific Antigen (PSA), a tumor marker for adenocarcinoma of the prostate, can predict residual tumor in the post-operative phase of prostate cancer. Three to 6 months after radical prostatectomy, PSA is reported to provide a sensitive indicator of persistent disease. Six months following introduction of
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REIMBURSEMENT POLICY
CMS-1500
Proprietary information of UnitedHealthcare Community and State. Copyright 2017 United Healthcare Services, Inc. 2018R7100A
antiandrogen therapy, PSA is reported of distinguishing patients with favorable response from those in whom limited response is anticipated. PSA when used in conjunction with other prostate cancer tests, such as digital rectal examination, may assist in the decision-making process for diagnosing prostate cancer. PSA also, serves as a marker in following the progress of most prostate tumors once a diagnosis has been established. This test is also an aid in the management of prostate cancer patients and in detecting metastatic or persistent disease in patients following treatment. UnitedHealthcare Community Plan reimburses for Prostate Specific Antigen (PSA) (CPT code 84153), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Urine Culture, Bacterial
A bacterial urine culture is a laboratory procedure performed on a urine specimen to establish the probable etiology of a presumed urinary tract infection. It is common practice to do a urinalysis prior to a urine culture. A urine culture may also be used as part of the evaluation and management of another related condition. The procedure includes aerobic agar-based isolation of bacteria or other cultivable organisms present, and quantitation of types present based on morphologic criteria. Isolates deemed significant may be subjected to additional identification and susceptibility procedures as requested by the ordering physician. The physician’s request may be through clearly documented and communicated laboratory protocols. UnitedHealthcare Community Plan reimburses for Urine Culture, Bacterial (CPT codes 87086 and 87088), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Serum Iron Studies
Serum iron studies are useful in the evaluation of disorders of iron metabolism, particularly iron deficiency and iron excess. Iron studies are best performed when the patient is fasting in the morning and has abstained from medications that may influence iron balance. Iron deficiency is the most common cause of anemia. In young children on a milk diet, iron deficiency is often secondary to dietary deficiency. In adults, iron deficiency is usually the result of blood loss and is only occasionally secondary to dietary deficiency or malabsorption. Following major surgery the patient may have iron deficient erythropoietin for months or years if adequate iron replacement has not been given. High doses of supplemental iron may cause the serum iron to be elevated. Serum iron may also be altered in acute and chronic inflammatory and neoplastic conditions. Total Iron Binding Capacity (TIBC) is an indirect measure of transferring, a protein that binds and transports iron. TIBC quantifies transferring by the amount of iron that it can bind. TIBC and transferring are elevated in iron deficiency, and with oral contraceptive use, and during pregnancy. TIBC and transferring may be decreased in malabsorption syndromes or in those affected with chronic diseases. The percent saturation represents the ratio of iron to the TIBC. Assays for ferreting are also useful in assessing iron balance. Low concentrations are associated with iron deficiency and are highly specific. High concentrations are found in hemosiderosis (iron overload without associated tissue injury) and hemochromatosis (iron overload with associated tissue injury). In these conditions the iron is elevated, the TIBC and transferrin are within the reference range or low, and the percent saturation is elevated. Serum ferritin can be useful for both initiating and monitoring treatment for iron overload. Transferrin and ferritin belong to a group of serum proteins known as acute phase reactants, and are increased in response to stressful or inflammatory conditions and also can occur with infection and tissue injury due to surgery, trauma or necrosis. Ferritin and iron/TIBC (or transferrin) are affected by acute and
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REIMBURSEMENT POLICY
CMS-1500
Proprietary information of UnitedHealthcare Community and State. Copyright 2017 United Healthcare Services, Inc. 2018R7100A
chronic inflammatory conditions, and in patients with these disorders, tests of iron status may be difficult to interpret. UnitedHealthcare Community Plan reimburses for Serum Iron Studies (CPT codes 82728, 83540, 83550, and/or 84466), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Human Chorionic Gonadotropin (hCG)
Human Chorionic Gonadotropin (hCG) is useful for monitoring and diagnosis of germ cell neoplasms of the ovary, testis, mediastinum, retroperitoneum, and central nervous system. In addition, hCG is useful for monitoring pregnant patients with vaginal bleeding, hypertension and/or suspected fetal loss. UnitedHealthcare Community Plan reimburses for Human Chorionic Gonadotropin (hCG) (CPT code 84702), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Lipids Testing
Lipoproteins are a class of heterogeneous particles of varying sizes and densities containing lipid and protein. These lipoproteins include cholesterol esters and free cholesterol, triglycerides, phospholipids and A, C, and E apoproteins. Total cholesterol comprises all the cholesterol found in various lipoproteins. Factors that affect blood cholesterol levels include age, sex, body weight, diet, alcohol and tobacco use, exercise, genetic factors, family history, medications, menopausal status, the use of hormone replacement therapy, and chronic disorders such as hypothyroidism, obstructive liver disease, pancreatic disease (including diabetes), and kidney disease. In many individuals, an elevated blood cholesterol level constitutes an increased risk of developing coronary artery disease. Blood levels of total cholesterol and various fractions of cholesterol, especially low density lipoprotein cholesterol (LDL -C) and high density lipoprotein cholesterol (HDL-C) are useful in assessing and monitoring treatment for that risk in patients with cardiovascular and related diseases. Blood levels of the above cholesterol components including triglyceride have been separated into desirable, borderline and high-risk categories by the National Heart, Lung, and Blood Institute in their report in 1993. These categories form a useful basis for evaluation and treatment of patients with hyperlipidemia. Therapy to reduce these risk parameters includes diet, exercise and medication, and fat weight loss, which is particularly powerful when combined with diet and exercise. UnitedHealthcare Community Plan reimburses for Lipids Testing (CPT codes 80061, 83700, 83701, 83704, 83718, 83721, and 84478), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the and ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Thyroid Testing
Thyroid function studies are used to delineate the presence or absence of hormonal abnormalities of the thyroid and pituitary glands. These abnormalities may be either primary or secondary and often but not always accompany clinically defined signs and symptoms indicative of thyroid dysfunction. Laboratory evaluation of thyroid function has become more scientifically defined. Tests can be done with increased specificity, thereby reducing the number of tests needed to diagnose and follow treatment of most thyroid disease. Measurements of serum sensitive thyroid-stimulating hormone (TSH) levels, complemented by determination of thyroid hormone levels [free thyroxine (fT-4) or total thyroxine (T4) with Triiodothyronine (T3) uptake] are used for diagnosis and follow-up of patients with thyroid disorders.
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REIMBURSEMENT POLICY
CMS-1500
Proprietary information of UnitedHealthcare Community and State. Copyright 2017 United Healthcare Services, Inc. 2018R7100A
Additional tests may be necessary to evaluate certain complex diagnostic problems or on hospitalized patients, where many circumstances can skew tests results. When a test for total thyroxine (total T4 or T4 radioimmunoassay) or T3 uptake is performed, calculation of the free thyroxine index (FTI) is useful to correct for abnormal results for either total T4 or T3 uptake due to protein binding effects. UnitedHealthcare Community Plan reimburses for Thyroid Testing (CPT codes 84436, 84439, 84443, and 84479), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Prothrombin Time (PT)
Basic plasma coagulation function is readily assessed with a few simple laboratory tests: the Partial Thromboplastin Time (PTT), Prothrombin Time (PT), Thrombin Time (TT), or a quantitative fibrinogen determination. The PT test is one in-vitro laboratory test used to assess coagulation. While the PTT assesses the intrinsic limb of the coagulation system, the PT assesses the extrinsic or tissue factor dependent pathway. Both tests also evaluate the common coagulation pathway involving all the reactions that occur after the activation of factor X. Extrinsic pathway factors are produced in the liver and their production is dependent on adequate vitamin K activity. Deficiencies of factors may be related to decreased production or increased consumption of coagulation factors. The PT/INR is most commonly used to measure the effect of warfarin and regulate its dosing. Warfarin blocks the effect of vitamin K on hepatic production of extrinsic pathway factors. A PT is expressed in seconds and/or as an international normalized ratio (INR). The INR is the PT ratio that would result if the WHO reference thromboplastin was used in performing the test. Current medical information does not clarify the role of laboratory PT testing in patients who are self-monitoring. Therefore, the indications for testing apply regardless of whether or not the patient is also PT self-testing. UnitedHealthcare Community Plan reimburses for Prothrombin Time (CPT code 85610), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Tumor Antigen by Immunoassay CA 125
Immunoassay determinations of the serum levels of certain proteins or carbohydrates serve as tumor markers. When elevated, serum concentration of these markers may reflect tumor size and grade. This portion of the policy specifically addresses tumor antigen CA 125. These services are not covered for the evaluation of patients with signs or symptoms suggestive of malignancy. The service may be ordered at times necessary to assess either the presence of recurrent disease or the patient’s response to treatment with subsequent treatment cycles. UnitedHealthcare Community Plan reimburses for Tumor Antigen by Immunoassay CA 125 (CPT code 86304), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Tumor Antigen by Immunoassay CA 15-3/CA 27.29
Immunoassay determinations of the serum levels of certain proteins or carbohydrates serve as tumor markers. When elevated, serum concentration of markers may reflect tumor size & grade. This portion of the policy specifically addresses the following tumor antigens: CA 15-3 and CA 27.29.
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REIMBURSEMENT POLICY
CMS-1500
Proprietary information of UnitedHealthcare Community and State. Copyright 2017 United Healthcare Services, Inc. 2018R7100A
These services are not covered for the evaluation of patients with signs or symptoms suggestive of malignancy. The service may be ordered at times necessary to assess either the presence of recurrent disease or the patient’s response to treatment with subsequent treatment cycles. UnitedHealthcare Community Plan reimburses for Tumor Antigen by Immunoassay CA 15-3/CA 27.29 (CPT code 86300), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Tumor Antigen by Immunoassay CA 19-9
Immunoassay determinations of the serum levels of certain proteins or carbohydrates serve as tumor markers. When elevated, serum concentration of these markers may reflect tumor size and grade. This portion of the policy specifically addresses the following tumor antigen: CA19-9. These services are not covered for the evaluation of patients with signs or symptoms suggestive of malignancy. The service may be ordered at times necessary to assess either the presence of recurrent disease or the patient’s response to treatment with subsequent treatment cycles. UnitedHealthcare Community Plan reimburses for Tumor Antigen by Immunoassay CA 19-9 (CPT code 86301), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Gamma Glutamyl Transferase (GGT)
Gamma glutamyl transferase (GGT) is an intracellular enzyme that appears in blood following leakage from cells. Renal tubules, liver, and pancreas contain high amounts, although the measurement of GGT in serum is almost always used for assessment of Hepatobiliary function. Unlike other enzymes which are found in heart, skeletal muscle, and intestinal mucosa as well as liver, the appearance of an elevated level of GGT in serum is almost always the result of liver disease or injury. It is specifically useful to differentiate elevated alkaline phosphatase levels when the source of the alkaline phosphatase increase (bone, liver, or placenta) is unclear. The combination of high alkaline phosphatase and a normal GGT does not, however, rule out liver disease completely. As well as being a very specific marker of Hepatobiliary function, GGT is also a very sensitive marker for hepatocellular damage. Abnormal concentrations typically appear before elevations of other liver enzymes or biliuria are evident. Obstruction of the biliary tract, viral infection (e.g., hepatitis, mononucleosis), metastatic cancer, exposure to hepatotoxins (e.g., organic solvents, drugs, alcohol), and use of drugs that induce microsomal enzymes in the liver (e.g., cimetidine, barbiturates, phenytoin, and carbamazepine) all can cause a moderate to marked increase in GGT serum concentration. In addition, some drugs can cause or exacerbate liver dysfunction (e.g., atorvastatin, troglitazone, and others as noted in FDA Contraindications and Warnings.) GGT is useful for diagnosis of liver disease or injury, exclusion of hepatobiliary involvement related to other diseases, and patient management during the resolution of existing disease or following injury. UnitedHealthcare Community Plan reimburses for Gamma Glutamyl Transferase (CPT code 82977), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Hepatitis Panel/Acute Hepatitis Panel
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REIMBURSEMENT POLICY
CMS-1500
Proprietary information of UnitedHealthcare Community and State. Copyright 2017 United Healthcare Services, Inc. 2018R7100A
This panel consists of the following tests:
Hepatitis A antibody (HAAb), IgM antibody;
Hepatitis B core antibody (HBcAb), IgM antibody;
Hepatitis B surface antigen (HBsAg) and;
Hepatitis C antibody.
Hepatitis is an inflammation of the liver resulting from viruses, drugs, toxins, and other etiologies. Viral hepatitis can be due to one of at least five different viruses, designated hepatitis A, B, C, and E. Most cases are caused by hepatitis A virus (HAV), hepatitis B virus (HBV), or hepatitis C virus (HCV). HAV is the most common cause of hepatitis in children and adolescents in the United States. Prior exposure is indicated by a positive IgG anti-HAV. Acute HAV is diagnosed by IgM anti-HAV, which typically appears within four weeks of exposure, and which disappears within three months of its appearance. IgG anti-HAV is similar in the timing of its appearance, but it persists indefinitely. Its detection indicates prior effective immunization or recovery from infection. Although HAV is spread most commonly by fecal-oral exposure, standard immune globulin may be effective as a prophylaxis. HBV produces three separate antigens (surface, core, and e (envelope) antigens) when it infects the liver, although only hepatitis B surface antigen (HBsAg) is included as part of this panel. Following exposure, the body normally responds by producing antibodies to each of these antigens; one of which is included in this panel: hepatitis B surface antibody (HBsAb)-IgM antibody. HBsAg is the earlier marker, appearing in serum four to eight weeks after exposure, and typically disappearing within six months after its appearance. If HBsAg remains detectable for greater than six months, this indicates chronic HBV infection. HBcAb, in the form of both IgG and IgM antibodies, are next to appear in serum, typically becoming detectable two to three months following exposure. The IgM antibody gradually declines or disappears entirely one to two years following exposure, but the IgG usually remains detectable for life. Because HBsAg is present for a relatively short period and usually displays a low titer, a negative result does not exclude an HBV diagnosis. HBcAb, on the other hand, rises to a much higher titer and remains elevated for a longer period of time, but a positive result is not diagnostic of acute disease, since it may be the result of a prior infection. The last marker to appear in the course of a typical infection is HBsAb, which appears in serum four to six months following exposure to infected blood or body fluids; in the U.S., sexual transmission accounts for 30% to 60% of new cases of HBV infection. The diagnosis of acute HBV infection is best established by documentation of positive IgM antibody against the core antigen (HBcAb-IgM) and by identification of a positive hepatitis B surface antigen (HBsAg). The diagnosis of chronic HBV infection is established primarily by identifying a positive hepatitis B surface antigen (HBsAg) and demonstrating positive IgG antibody directed against the core antigen (HBcAb-IgG). Additional tests such as hepatitis B e antigen (HBeAg) and hepatitis B e antibody (HBeAb), the envelope antigen and antibody, are not included in the hepatitis panel, but may be of importance in assessing the infectivity of patients with HBV. Following completion of a HBV vaccination series, HBsAb alone may be used monthly for up to six months, or until a positive result is obtained, to verify an adequate antibody response. HCV is the most common cause of post-transfusion hepatitis; overall HCV is responsible for 15% to 20% of all cases of acute hepatitis, and is the most common cause of chronic liver disease. The test most commonly used to identify HCV measures HCV antibodies, which appear in blood two to four months after infection. False positive HCV results can occur. For example, a patient with a recent yeast infection may produce a false positive anti-HCV result. For this reason, at present positive results usually are confirmed by a more specific technique. Like HBV, HCV is spread exclusively through exposure to infected blood or body fluids. This panel of tests is used for differential diagnosis in a patient with symptoms of liver disease or injury. When the time of exposure or the stage of the disease is not known, a patient with continued symptoms of liver disease despite a completely negative hepatitis panel may need a repeat panel approximately two
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REIMBURSEMENT POLICY
CMS-1500
Proprietary information of UnitedHealthcare Community and State. Copyright 2017 United Healthcare Services, Inc. 2018R7100A
weeks to two months later to exclude the possibility of hepatitis. Once a diagnosis is established, specific tests can be used to monitor the course of the disease. UnitedHealthcare Community Plan reimburses for Hepatitis Panel/Acute Hepatits Panel (CPT code 80074), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Collagen Crosslinks
Collagen crosslinks, part of the matrix of bone upon which bone mineral is deposited, are biochemical markers the excretion of which provides a quantitative measurement of bone resorption. Elevated levels of urinary collagen crosslinks indicate elevated bone resorption. Elevated bone resorption contributes to age-related and postmenopausal loss of bone leading to osteoporosis and increased risk of fracture. The collagen crosslinks assay can be performed by immunoassay or by high performance liquid chromatography (HPLC). Collagen crosslink immunoassays measure the pyridinoline crosslinks and associated telopeptides in urine. Bone is constantly undergoing a metabolic process called turnover or remodeling. This includes a degradation process, bone resorption, mediated by the action of osteoclasts, and a building process, bone formation, mediated by the action of osteoblasts. Remodeling is required for the maintenance and overall health of bone and is tightly coupled; that is, resorption and formation must be in balance. In abnormal states of bone remodeling, when resorption exceeds formation, it results in a net loss of bone. The measurement of specific, bone-derived resorption products provides analytical data about the rate of bone resorption. Osteoporosis is a condition characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fractures of the hip, spine, and wrist. The term primary osteoporosis is applied where the causal factor in the disease is menopause or aging. The term secondary osteoporosis is applied where the causal factor is something other than menopause or aging, such as long-term administration of glucocorticosteroids, endocrine-related disorders (other than loss of estrogen due to menopause), and certain bone diseases such as cancer of the bone. With respect to quantifying bone resorption, collagen crosslink tests can provide adjunct diagnostic information in concert with bone mass measurements. Bone mass measurements and biochemical markers may have complementary roles to play in assessing effectiveness of osteoporosis treatment. Proper management of osteoporosis patients, who are on long-term therapeutic regimens, may include laboratory testing of biochemical markers of bone turnover, such as collagen crosslinks, that provide a profile of bone turnover responses within weeks of therapy. Changes in collagen crosslinks are determined following commencement of antiresorptive therapy. These can be measured over a shorter time interval when compared to bone mass density. If bone resorption is not elevated, repeat testing is not medically necessary. UnitedHealthcare Community Plan reimburses for Collagen Crosslinks Testing (CPT code 82523), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Digoxin Therapeutic Drug Assay
A digoxin therapeutic drug assay is useful for diagnosis and prevention of digoxin toxicity, and/or prevention for under dosage of digoxin. Digoxin levels may be performed to monitor drug levels of individuals receiving digoxin therapy because the margin of safety between side effects and toxicity is narrow or because the blood level may not be
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REIMBURSEMENT POLICY
CMS-1500
Proprietary information of UnitedHealthcare Community and State. Copyright 2017 United Healthcare Services, Inc. 2018R7100A
high enough to achieve the desired clinical effect. Clinical indications may include individuals on digoxin:
With symptoms, signs or electrocardiogram (ECG) suggestive of digoxin toxicity
Taking medications that influence absorption, bioavailability, distribution, and/or elimination of digoxin
With impaired renal, hepatic, gastrointestinal, or thyroid function
With pH and/or electrolyte abnormalities
With unstable cardiovascular status, including myocarditis
Requiring monitoring of patient compliance Clinical indications may include individuals:
Suspected of accidental or intended overdose
Who have an acceptable cardiac diagnosis (as listed) and for whom an accurate history of use of digoxin is unobtainable
The value of obtaining regular serum digoxin levels is uncertain, but it may be reasonable to check levels once yearly after a steady state is achieved. In addition, it may be reasonable to check the level if:
Heart failure status worsens
Renal function deteriorates
Additional medications are added that could affect the digoxin level
Signs or symptoms of toxicity develop Steady state will be reached in approximately 1 week in patients with normal renal function, although 2-3 weeks may be needed in patients with renal impairment. After changes in dosages or the addition of a medication that could affect the digoxin level, it is reasonable to check the digoxin level one week after the change or addition. Based on the clinical situation, in cases of digoxin toxicity, testing may need to be done more than once a week. Digoxin is indicated for the treatment of patients with heart failure due to systolic dysfunction and for reduction of the ventricular response in patients with atrial fibrillation or flutter. Digoxin may also be indicated to treat other supraventricular arrhythmias, particularly with heart failure. UnitedHealthcare Community Plan reimburses for Digoxin Therapeutic Drug Assay Testing (CPT code 80162), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.
Glycated Hemoglobin/Glycated Protein
The management of diabetes mellitus requires regular determinations of blood glucose levels. Glycated hemoglobin/protein levels are used to assess long-term glucose control in diabetes. Alternative names for these tests include glycated or glycosylated hemoglobin or Hgb, hemoglobin glycated or glycosylated protein, and fructosamine. Glycated hemoglobin (equivalent to hemoglobin A1) refers to total glycosylated hemoglobin present in erythrocytes, usually determined by affinity or ion-exchange chromatographic methodology. Hemoglobin A1c refers to the major component of hemoglobin A1, usually determined by ion-exchange affinity chromatography, immunoassay or agar gel electrophoresis. Fructosamine or glycated protein refers to glycosylated protein present in a serum or plasma sample. Glycated protein refers to measurement of the component of the specific protein that is glycated usually by colorimetric method or affinity chromatography. Glycated hemoglobin in whole blood assesses glycemic control over a period of 4-8 weeks and appears
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REIMBURSEMENT POLICY
CMS-1500
Proprietary information of UnitedHealthcare Community and State. Copyright 2017 United Healthcare Services, Inc. 2018R7100A
to be the more appropriate test for monitoring a patient who is capable of maintaining long-term, stable control. Measurement may be medically necessary every 3 months to determine whether a patient’s metabolic control has been on average within the target range. More frequent assessments, every 1-2 months, may be appropriate in the patient whose diabetes regimen has been altered to improve control or in whom evidence is present that intercurrent events may have altered a previously satisfactory level of control (for example, post-major surgery or as a result of glucocorticoid therapy). Glycated protein in serum/plasma assesses glycemic control over a period of 1-2 weeks. It may be reasonable and necessary to monitor glycated protein monthly in pregnant diabetic women. Glycated hemoglobin/protein test results may be low, indicating significant, persistent hypoglycemia, in nesidioblastosis or insulinoma, conditions which are accompanied by inappropriate hyperinsulinemia. A below normal test value is helpful in establishing the patient’s hypoglycemic state in those conditions. UnitedHealthcare Community Plan reimburses for Glycated Hemoglobin/Glycated Protein Testing (CPT codes 82985 and 83036), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.
State Exceptions
California California Medicaid uses state specific ICD-10 diagnosis codes lists for CPT codes 86304, 82728, and 84702 which are included in this policy.
Kansas Kansas is excluded from this policy based on state requirements.
Louisiana Louisiana Medicaid is excluded from the diagnosis requirement when CPT 84443 is billed for newborns age 0-28 days based on state requirements for newborn screenings.
Washington Washington Medicaid is excluded from the Thyroid Testing section of the policy based on state requirements.
Definitions
Screening The testing for disease or disease precursors so that early detection and treatment can be provided for those who test positive for the disease. Screening tests are performed when no specific sign, symptom, or diagnosis is present and the patient has not been exposed to a disease. The testing of a person to rule out or to confirm a suspected diagnosis because the patient has a sign and/or symptom is a diagnostic test, not a screening.
Questions and Answers
1
Q: What is a National Coverage Policy?
A: A national coverage policy for diagnostic laboratory test(s) is a document stating CMS’s policy with respect to the circumstances under which the test(s) will be considered reasonable and necessary, and not screening, for Medicare purposes. Such a policy applies nationwide. A national coverage policy is neither a practice parameter nor a statement of the accepted standard of medical practice.
Codes
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REIMBURSEMENT POLICY
CMS-1500
Proprietary information of UnitedHealthcare Community and State. Copyright 2017 United Healthcare Services, Inc. 2018R7100A
CPT code section
82378 Carcinoembryonic antigen (CEA)
82105 Alpha-fetoprotein (AFP); serum
85730 Thromboplastin time, partial (PTT); plasma or whole blood
84153 Prostate Specific Antigen (PSA), total
87086 Culture, bacterial; quantitative, colony count, urine.
87088 Culture, bacterial; with isolation and presumptive identification of each isolates, urine.
82728 Ferritin
83540 Iron
83550 Iron Binding Capacity
84466 Transferrin
84702 Gonadotropin, chorionic (hCG); quantitative
80061 Lipid panel
83700 Lipoprotein, blood; electrophoretic separation and quantitation
83701 High resolution fractionation and quantitation of lipoprotein subclasses when performed (e.g., electrophoresis, ultracentrifugation)
83704 Lipoprotein, blood; quantitation of lipoprotein particle numbers and lipoprotein particle subclasses
83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
83721 LDL cholesterol
84478 Triglycerides
84436 Thyroxine; total
84439 Thyroxine; total free
84443 Thyroid stimulating hormone (TSH)
84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR)
85610 Prothrombin time (PT)
86304 Immunoassay for tumor antigen, quantitative; CA 125
86300 Immunoassay for tumor antigen, quantitative; CA 15-3
86301 Immunoassay for tumor antigen, quantitative; CA 19-9
82977 Glutamyltransferase, gamma (GGT)
80074 Acute hepatitis panel
82523 Collagen crosslinks, any method
80162 Digoxin; total
82985 Glycated protein
-
REIMBURSEMENT POLICY
CMS-1500
Proprietary information of UnitedHealthcare Community and State. Copyright 2017 United Healthcare Services, Inc. 2018R7100A
83036 Hemoglobin; glycosylated (A1C)
Attachments: Please right-click on the icon to open the file
UnitedHealthcare Community Plan ICD-10 Codes approved with CPT code 82378 (CEA) (Effective 01/1/18)
List of ICD-10 codes for which CPT code 82378 will be reimbursed.
UnitedHealthcare Community Plan ICD-10 Codes approved with CPT code 82105 (AFP) (Effective 01/1/18)
List of ICD-10 codes for which CPT code 82105 will be reimbursed.
UnitedHealthcare Community Plan ICD-10 Codes approved with CPT code 85730 (PTT) (Effective 01/1/18)
List of ICD-10 codes for which CPT code 85730 will be reimbursed.
UnitedHealthcare Community Plan ICD-10 Codes approved with CPT code 84153 (PSA) (Effective 01/1/18)
List of ICD-10 codes for which CPT code 84153 will be reimbursed.
UnitedHealthcare Community Plan ICD-10 Codes approved with CPT codes 87086 and 87088 (Urine Culture, Bacterial) (Effective 01/1/18)
List of ICD-10 codes for which CPT codes 87086 and 87088 will be reimbursed.
UnitedHealthcare Community Plan ICD-10 Codes approved with CPT codes 82728, 83540, 83550, and/or 84466 (Serum Iron) (Effective 01/1/18)
List of ICD-10 codes for which CPT codes 82728, 83540, 83550, and/or 84466 will be reimbursed.
List of ICD-10 codes for which CPT code 82728 will be
-
2018A
UnitedHealthc
are Community
Plan ICD-10
Codes
approved with
CPT code
82378 (CEA)
(Effective
01/1/18)
C15.3
C15.4
C15.5
C15.8
C15.9
C16.0
C16.1
C16.2
C16.3
C16.4
C16.5
C16.6
C16.8
C16.9
C17.0
C17.2
C17.3
C17.8
C17.9
C18.0
C18.1
C18.2
C18.3
C18.4
C18.5
C18.6
C18.7
C18.8
C18.9
C19
C20
-
C21.0
C21.1
C21.2
C21.8
C25.0
C25.1
C25.2
C25.3
C25.4
C25.7
C25.8
C25.9
C26.0
C33
C34.00
C34.01
C34.02
C34.10
C34.11
C34.12
C34.2
C34.30
C34.31
C34.32
C34.80
C34.81
C34.82
C34.90
C34.91
C34.92
C50.011
C50.012
C50.019
C50.021
C50.022
C50.029
C50.111
C50.112
C50.119
C50.121
C50.122
C50.129
C50.211
C50.212
-
C50.219
C50.221
C50.222
C50.229
C50.311
C50.312
C50.319
C50.321
C50.322
C50.329
C50.411
C50.412
C50.419
C50.421
C50.422
C50.429
C50.511
C50.512
C50.519
C50.521
C50.522
C50.529
C50.611
C50.612
C50.619
C50.621
C50.622
C50.629
C50.811
C50.812
C50.819
C50.821
C50.822
C50.829
C50.911
C50.912
C50.919
C50.921
C50.922
C50.929
C56.1
C56.2
C56.9
C7A.00
-
C7A.010
C7A.011
C7A.012
C7A.019
C7A.020
C7A.021
C7A.022
C7A.023
C7A.024
C7A.025
C7A.026
C7A.029
C7A.090
C7A.091
C7A.092
C7A.093
C7A.094
C7A.095
C7A.096
C7A.098
C7B.00
C7B.01
C7B.02
C7B.03
C7B.04
C7B.09
C7B.1
C7B.8
C78.00
C78.01
C78.02
C78.4
C78.5
D01.0
D01.1
D01.2
D01.40
D01.49
D01.7
D01.9
D37.1
D37.2
D37.3
D37.4
-
D37.5
G89.3
R70.1
R77.0
R77.1
R77.2
R77.8
R77.9
R78.89
R78.9
R79.89
R97.0
R97.8
Z08
Z09
Z85.00
Z85.038
Z85.048
Z85.118
Z85.3
Z85.43
avinc11File Attachment2018A UnitedHealthcare Community Plan ICD-10 Codes approved with CPT code 82378 (CEA) .pdf
-
2018A
UnitedHealthcar
e Community
Plan ICD-10
Codes approved
with CPT code
82105 (AFP)
(Effective
01/1/18)
A52.74
B18.0
B18.1
B18.2
B66.1
B66.3
C22.0
C22.1
C22.2
C22.3
C22.4
C22.7
C22.8
C22.9
C38.1
C38.2
C38.3
C38.8
C56.1
C56.2
C56.9
C62.00
C62.01
C62.02
C62.10
C62.11
C62.12
C62.90
C62.91
C62.92
C78.1
C78.7
C79.60
-
C79.61
C79.62
C79.82
C7A.00
C7A.090
C7A.091
C7A.092
C7A.093
C7A.094
C7A.095
C7A.096
C7A.098
C7B.00
C7B.01
C7B.02
C7B.03
C7B.04
C7B.09
C7B.1
C7B.8
D13.4
D13.5
D37.6
D64.0
D64.1
D64.2
D64.3
D81.810
D84.1
E78.2
E83.00
E83.01
E83.09
E83.10
E83.110
E83.111
E83.118
E83.119
E83.19
E84.19
E84.9
E88.01
G89.3
I25.84
-
I74.01
I74.09
I74.10
I74.19
J98.59
K70.2
K70.30
K70.31
K73.0
K73.1
K73.2
K73.8
K73.9
K74.0
K74.60
K74.69
K75.4
K76.81
N44.1
N44.2
N44.8
N50.3
N50.811
N50.812
N50.819
N50.82
N50.89
N53.12
N53.8
N53.9
*Q53.111
*Q53.112
*Q53.13
*Q53.211
*Q53.212
*Q53.23
*R39.83
*R39.84
R91.1
R91.8
R93.1
R93.2
R93.5
R93.8
-
R97.8
Z17.0
Z17.1
Z85.05
Z85.43
Z85.47
avinc11File Attachment2018A UnitedHealthcare Community Plan ICD-10 Codes approved with CPT code 82105 (AFP) .pdf
-
2018A
UnitedHealthca
re Community
Plan ICD-10
Codes approved
with CPT code
85730 (PTT)
(Effective
01/1/18)
A01.00
A01.01
A01.02
A01.03
A01.04
A01.05
A01.09
A01.1
A01.2
A01.3
A01.4
A02.0
A02.1
A02.20
A02.21
A02.22
A02.23
A02.24
A02.25
A02.29
A02.8
A02.9
A41.9
A91
A92.0
A95.0
A95.1
A95.9
A96.0
A96.1
A96.8
A96.9
A98.0
A98.1
A98.2
A98.5
-
A98.8
A99
B15.0
B15.9
B16.0
B16.1
B16.2
B16.9
B17.0
B17.10
B17.11
B17.2
B17.8
B17.9
B18.0
B18.1
B18.2
B18.8
B18.9
B19.0
B19.10
B19.11
B19.20
B19.21
B19.9
B20
B25.1
B25.2
B27.00
B27.01
B27.02
B27.09
B27.10
B27.11
B27.12
B27.19
B27.80
B27.81
B27.82
B27.89
B27.90
B27.91
B27.92
B27.99
-
B52.0
B65.0
B66.1
B66.3
B75
C22.0
C22.1
C22.2
C22.3
C22.4
C22.7
C22.8
C22.9
C78.7
C88.0
C88.8
C94.40
C94.41
C94.42
C94.6
D45
D46.0
D46.1
D46.20
D46.21
D46.22
D46.4
D46.9
D46.A
D46.B
D46.C
D46.Z
D47.1
D47.2
D47.3
D47.9
D47.Z1
D47.Z2
D47.Z9
D49.9
D62
D65
D66
D67
-
D68.0
D68.1
D68.2
D68.311
D68.312
D68.318
D68.32
D68.4
D68.51
D68.52
D68.59
D68.61
D68.62
D68.8
D68.9
D69.0
D69.1
D69.2
D69.3
D69.41
D69.42
D69.49
D69.51
D69.59
D69.6
D69.8
D69.9
D75.1
D78.01
D78.02
D78.21
D78.22
D78.31
D78.32
D86.0
D86.1
D86.2
D86.3
D86.81
D86.82
D86.83
D86.84
D86.85
D86.86
-
D86.87
D86.89
D86.9
D89.0
D89.1
D89.2
E07.89
E08.21
E08.22
E08.29
E08.52
E08.65
E09.21
E09.22
E09.29
E09.52
E10.21
E10.22
E10.29
E10.52
E10.65
E11.21
E11.22
E11.29
E11.52
E11.65
E13.21
E13.22
E13.29
E13.52
E20.1
E36.01
E36.02
E56.1
E80.0
E80.1
E80.20
E80.21
E80.29
E83.00
E83.01
E83.09
E83.10
E83.110
-
E83.111
E83.118
E83.119
E83.19
E83.30
E83.31
E83.32
E83.39
E83.40
E83.41
E83.42
E83.49
E83.50
E83.51
E83.52
E83.59
E83.81
E83.89
E83.9
E85.0
E85.1
E85.2
E85.3
E85.4
E85.81
E85.9
E88.09
E89.810
E89.811
E89.820
E89.821
G08
G45.3
G45.9
G97.31
G97.32
G97.51
G97.52
G97.61
G97.62
H02.89
H05.231
H05.232
H05.233
-
H05.239
H11.30
H11.31
H11.32
H11.33
H31.301
H31.302
H31.303
H31.309
H31.311
H31.312
H31.313
H31.319
H31.321
H31.322
H31.323
H31.329
H31.411
H31.412
H31.413
H31.419
H34.00
H34.01
H34.02
H34.03
H34.10
H34.11
H34.12
H34.13
H34.211
H34.212
H34.213
H34.219
H34.231
H34.232
H34.233
H34.239
H34.8110
H34.8111
H34.8112
H34.8120
H34.8121
H34.8122
H34.8130
-
H34.8131
H34.8132
H34.8190
H34.8191
H34.8192
H34.821
H34.822
H34.823
H34.829
H34.8310
H34.8311
H34.8312
H34.8320
H34.8321
H34.8322
H34.8330
H34.8331
H34.8332
H34.8390
H34.8391
H34.8392
H34.9
H35.60
H35.61
H35.62
H35.63
H35.731
H35.732
H35.733
H35.739
H43.10
H43.11
H43.12
H43.13
H44.2E1
H44.2E2
H44.2E3
H44.811
H44.812
H44.813
H44.819
H47.021
H47.022
H47.023
-
H47.029
H53.9
H59.111
H59.112
H59.113
H59.119
H59.121
H59.122
H59.123
H59.129
H59.311
H59.312
H59.313
H59.319
H59.321
H59.322
H59.323
H59.329
H59.331
H59.332
H59.333
H59.339
H59.341
H59.342
H59.343
H59.349
H61.121
H61.122
H61.123
H61.129
H95.21
H95.22
H95.41
H95.42
H95.51
H95.52
I12.0
I13.11
I16.0
I16.1
I16.9
I21.01
I21.02
I21.09
-
I21.11
I21.19
I21.21
I21.29
I21.3
I21.4
I21.9
I21.A1
I21.A9
I22.0
I22.1
I22.2
I22.8
I22.9
I23.0
I23.3
I23.6
I23.7
I23.8
*I27.83
I31.2
I48.0
I48.1
I48.2
I48.91
I49.9
I50.20
I50.21
I50.22
I50.23
I50.30
I50.31
I50.32
I50.33
I50.40
I50.41
I50.42
I50.43
I50.9
I60.00
I60.01
I60.02
I60.10
I60.11
-
I60.12
I60.2
I60.30
I60.31
I60.32
I60.4
I60.50
I60.51
I60.52
I60.6
I60.7
I60.8
I60.9
I61.0
I61.1
I61.2
I61.3
I61.4
I61.5
I61.6
I61.8
I61.9
I62.00
I62.01
I62.02
I62.03
I62.1
I62.9
I63.00
I63.011
I63.012
I63.013
I63.019
I63.02
I63.031
I63.032
I63.033
I63.039
I63.09
I63.10
I63.111
I63.112
I63.113
I63.119
-
I63.12
I63.131
I63.132
I63.133
I63.139
I63.19
I63.20
I63.211
I63.212
I63.213
I63.219
I63.22
I63.231
I63.232
I63.233
I63.239
I63.29
I63.30
I63.311
I63.312
I63.313
I63.319
I63.321
I63.322
I63.323
I63.329
I63.331
I63.332
I63.333
I63.339
I63.341
I63.342
I63.343
I63.349
I63.39
I63.40
I63.411
I63.412
I63.413
I63.419
I63.421
I63.422
I63.423
I63.429
-
I63.431
I63.432
I63.433
I63.439
I63.441
I63.442
I63.443
I63.449
I63.49
I63.50
I63.511
I63.512
I63.513
I63.519
I63.521
I63.522
I63.523
I63.529
I63.531
I63.532
I63.533
I63.539
I63.541
I63.542
I63.543
I63.549
I63.59
I63.6
I63.8
I63.9
I65.01
I65.02
I65.03
I65.09
I65.1
I65.21
I65.22
I65.23
I65.29
I65.8
I65.9
I66.01
I66.02
I66.03
-
I66.09
I66.11
I66.12
I66.13
I66.19
I66.21
I66.22
I66.23
I66.29
I66.3
I66.8
I66.9
I67.841
I67.848
I70.361
I70.362
I70.363
I70.368
I70.369
I70.461
I70.462
I70.463
I70.468
I70.469
I70.561
I70.562
I70.563
I70.568
I70.569
I70.661
I70.662
I70.663
I70.668
I70.669
I70.761
I70.762
I70.763
I70.768
I70.769
I73.01
I74.01
I74.09
I74.10
I74.11
-
I74.19
I74.2
I74.3
I74.4
I74.5
I74.8
I74.9
I77.2
I78.0
I80.00
I80.01
I80.02
I80.03
I80.10
I80.11
I80.12
I80.13
I80.201
I80.202
I80.203
I80.209
I80.211
I80.212
I80.213
I80.219
I80.221
I80.222
I80.223
I80.229
I80.231
I80.232
I80.233
I80.239
I80.291
I80.292
I80.293
I80.299
I80.3
I80.8
I80.9
I82.0
I82.1
I82.210
I82.211
-
I82.220
I82.221
I82.290
I82.291
I82.3
I82.401
I82.402
I82.403
I82.409
I82.411
I82.412
I82.413
I82.419
I82.421
I82.422
I82.423
I82.429
I82.431
I82.432
I82.433
I82.439
I82.441
I82.442
I82.443
I82.449
I82.491
I82.492
I82.493
I82.499
I82.4Y1
I82.4Y2
I82.4Y3
I82.4Y9
I82.4Z1
I82.4Z2
I82.4Z3
I82.4Z9
I82.501
I82.502
I82.503
I82.509
I82.511
I82.512
I82.513
-
I82.519
I82.521
I82.522
I82.523
I82.529
I82.531
I82.532
I82.533
I82.539
I82.541
I82.542
I82.543
I82.549
I82.591
I82.592
I82.593
I82.599
I82.5Y1
I82.5Y2
I82.5Y3
I82.5Y9
I82.5Z1
I82.5Z2
I82.5Z3
I82.5Z9
I82.601
I82.602
I82.603
I82.609
I82.611
I82.612
I82.613
I82.619
I82.621
I82.622
I82.623
I82.629
I82.701
I82.702
I82.703
I82.709
I82.711
I82.712
I82.713
-
I82.719
I82.721
I82.722
I82.723
I82.729
I82.811
I82.812
I82.813
I82.819
I82.890
I82.891
I82.90
I82.91
I82.A11
I82.A12
I82.A13
I82.A19
I82.A21
I82.A22
I82.A23
I82.A29
I82.B11
I82.B12
I82.B13
I82.B19
I82.B21
I82.B22
I82.B23
I82.B29
I82.C11
I82.C12
I82.C13
I82.C19
I82.C21
I82.C22
I82.C23
I82.C29
I85.00
I85.01
I86.4
I86.8
I87.8
I96
I97.410
-
I97.411
I97.418
I97.42
I97.610
I97.611
I97.618
I97.620
I97.621
I97.630
I97.631
I97.638
I97.810
I97.811
I97.820
I97.821
I99.8
J95.61
J95.62
J95.830
J95.831
J95.860
J95.861
K22.6
K22.8
K25.0
K25.1
K25.2
K25.3
K25.4
K25.5
K25.6
K25.7
K25.9
K26.0
K26.1
K26.2
K26.3
K26.4
K26.5
K26.6
K26.7
K26.9
K27.0
K27.1
-
K27.2
K27.3
K27.4
K27.5
K27.6
K27.7
K27.9
K28.0
K28.1
K28.2
K28.3
K28.4
K28.5
K28.6
K28.7
K28.9
K29.00
K29.01
K29.20
K29.21
K29.30
K29.31
K29.40
K29.41
K29.50
K29.51
K29.60
K29.61
K29.70
K29.71
K29.80
K29.81
K29.90
K29.91
K31.811
K31.82
K51.00
K51.011
K51.012
K51.013
K51.014
K51.018
K51.019
K51.20
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K51.30
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K51.40
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K51.50
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K51.80
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K51.90
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K51.913
K51.914
K51.918
K51.919
K52.81
K55.011
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K55.019
K55.021
K55.022
K55.029
K55.031
K55.032
K55.039
K55.041
K55.042
K55.049
K55.051
K55.052
K55.059
K55.061
K55.062
K55.069
K55.1
K55.30
K55.31
K55.32
K55.33
K55.8
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K57.01
K57.11
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K57.21
K57.31
K57.33
K57.41
K57.51
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K57.81
K57.91
K57.93
K59.31
K62.5
K66.1
K70.0
K70.10
K70.11
K70.2
K70.30
K70.31
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K70.40
K70.41
K70.9
K71.0
K71.10
K71.11
K71.2
K71.3
K71.4
K71.50
K71.51
K71.6
K71.7
K71.8
K71.9
K72.00
K72.01
K72.10
K72.11
K72.90
K72.91
K73.0
K73.1
K73.2
K73.8
K73.9
K74.0
K74.1
K74.2
K74.3
K74.4
K74.5
K74.60
K74.69
K75.0
K75.1
K75.2
K75.3
K75.4
K75.81
K75.89
K75.9
K76.0
K76.1
-
K76.2
K76.3
K76.4
K76.5
K76.6
K76.7
K76.81
K76.89
K76.9
K77
K80.30
K80.31
K80.32
K80.33
K80.34
K80.35
K80.36
K80.37
K83.0
K83.1
K83.2
K83.3
K83.4
K83.5
K83.8
K83.9
K85.00
K85.01
K85.02
K85.10
K85.11
K85.12
K85.20
K85.21
K85.22
K85.30
K85.31
K85.32
K85.80
K85.81
K85.82
K85.90
K85.91
K85.92
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K87
K90.0
K90.1
K90.2
K90.3
K90.41
K90.49
K90.89
K90.9
K91.2
K91.5
K91.61
K91.62
K91.840
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K92.1
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L76.01
L76.02
L76.21
L76.22
L76.31
L76.32
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M02.211
M02.212
M02.219
M02.221
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M02.269
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M25.019
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M25.069
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M25.072
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M31.1
M32.0
M32.10
M32.11
M32.12
M32.13
M32.14
M32.15
M32.19
M32.8
M32.9
M36.2
-
M36.3
M36.4
M48.50XA
M48.51XA
M48.52XA
M48.53XA
M48.54XA
M48.55XA
M48.56XA
M48.57XA
M48.58XA
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M80.88XA
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N02.1
N02.2
N02.3
N02.4
N02.5
-
N02.6
N02.7
N02.8
N02.9
N04.0
N04.1
N04.2
N04.3
N04.4
N04.5
N04.6
N04.7
N04.8
N04.9
N05.9
N06.9
N07.9
N08
N15.9
N17.0
N17.1
N17.2
N17.8
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N18.4
N18.5
N18.6
N18.9
N19
N28.0
N28.82
N28.89
N32.89
N33
N50.1
N64.89
N83.7
N85.7
N88.8
N89.8
N90.89
N92.1
N92.4
N93.0
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N94.89
N95.0
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N99.512
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N99.61
N99.62
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O03.0
O03.1
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O03.30
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O03.6
O03.7
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O07.1
O08.1
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O08.2
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O11.1
O11.2
O11.3
O11.9
O12.04
O12.05
O12.14
-
O12.15
O12.24
O12.25
O13.1
O13.2
O13.3
O13.4
O13.5
O13.9
O14.00
O14.02
O14.03
O14.04
O14.05
O14.10
O14.12
O14.13
O14.14
O14.15
O14.20
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O14.24
O14.25
O14.90
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O14.93
O14.94
O14.95
O15.00
O15.02
O15.03
O15.1
O15.2
O15.9
O16.1
O16.2
O16.3
O16.4
O16.5
O16.9
O20.0
O20.8
O20.9
-
O22.20
O22.21
O22.22
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O44.00
O44.01
O44.02
O44.03
O44.10
O44.11
O44.12
O44.13
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O44.20
O44.21
O44.22
O44.23
O44.30
O44.31
O44.32
O44.33
O44.40
O44.41
O44.42
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O44.50
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O45.001
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O45.8X9
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O46.001
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O88.02
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O88.111
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O99.111
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O99.13
P02.1
P05.9
P10.0
P10.1
P10.2
P10.3
P10.4
P10.8
P10.9
P11.0
P11.1
P11.2
P11.9
P12.2
P15.0
P15.1
P15.2
P15.3
P15.4
P15.5
-
P15.6
P15.8
P26.0
P26.1
P26.8
P26.9
P50.0
P50.1
P50.2
P50.3
P50.4
P50.5
P50.8
P50.9
P51.0
P51.8
P51.9
P52.0
P52.1
P52.21
P52.22
P52.3
P52.4
P52.5
P52.6
P52.8
P52.9
P53
P54.0
P54.1
P54.2
P54.3
P54.4
P54.5
P54.6
P54.8
P54.9
P57.8
P57.9
P58.0
P58.1
P58.2
P58.3
P58.41
-
P58.42
P58.5
P58.8
P58.9
P59.0
P59.1
P59.20
P59.29
P59.3
P59.8
P59.9
P60
P61.0
P61.1
P61.2
P61.3
P61.4
P61.5
P61.6
P61.8
P61.9
R04.0
R04.1
R04.2
R04.81
R04.89
R04.9
R06.02
R07.82
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R07.9
R10.0
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R10.13
R10.2
R10.30
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R10.32
R10.33
R10.83
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R10.9
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R17
R23.3
R29.700
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R29.704
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R31.1
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R31.9
R40.2410
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R40.2420
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R40.2442
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R55
R57.9
R79.1
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S00.10XA
S00.11XA
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S00.33XA
S00.431A
S00.432A
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