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Medicare Medical NecessityDocumenting Medicare Medical Necessity of Laboratory Services

Noridian Healthcare Solutions Medicare Administrative Contractor

Jurisdiction FMarch 2020 Edition

This document is provided as an informational service to LabCorp accounts. The document contains certain Local Coverage Determinations issued at various times by the Medicare Administrative Contractor (MAC) and National Coverage Determinations issued by the Centers for Medicare and Medicaid Services. The information compiled herein is as of March 1, 2020. There can be no representation or warranty as to the accuracy or completeness of the information or that use of this information will comply with the local or national policies. To ensure the accurate and appropriate use of the information, it is recommended that the MAC be consulted. Primary sources (i.e. MAC publications, notices, and advice) should be consulted prior to the use of this information for purposes other than for submitting diagnosis codes to LabCorp. This is particularly important since information is often affected by ongoing developments.

Medicare Medical Necessity

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

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

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

subcategory.

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

The MAC, Noridian Healthcare Solutions, has established specific prepayment medical necessity documentation requirements for certain laboratory tests. These local tests plus the national ones are listed on the following pages. If you have any questions regarding the policies listed in this document, please contact the Noridian Healthcare Solutions Medicare Part B office at 877-908-8431.

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

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

Noridian Healthcare Solutions – Alaska, Arizona, Idaho, Montana, Oregon, South Dakota, Utah, Washington, Wyoming Medical Necessity Policies as of March 1, 2020

Laboratory Test CPT• *ICD-10-CM Codes Always Denied• Non-Covered Services 0111T, 83987, 84145, 84431, 86305• *Alpha-Fetoprotein 82105

• *Blood Counts 85004, 85007, 85008, 85013-85032,85048, 85049

• *Blood Glucose Testing %82947, %82948, %82962• B-type Natriuretic Peptide (BNP) 83880• *Carcinoembryonic Antigen (CEA) %82378• *Cardiovascular Disease Screening %80061, %82465, %83718, %84478• *Collagen Cross Links, Any Method %82523• *Colorectal Cancer Screening %82270, %G0328• *Cytogenetic Studies 88230-88299• *Diabetes Screening Tests %82947, %82950, %82951• *Digoxin Therapeutic Assay %80162• Foodborne Gastrointestinal Panels Indentified by Multiplex 87505, 87506, 87507, 0097U

Nucleic Acid (NAATs)• *Fecal Occult Blood %82272• *Gamma Glutamyl Transferase (GGT) %82977• *Glycated Hemoglobin/*Glycated Protein %83036, %82985• GlycoMark Testing for Glycemic Control 84378• Helicobacter Pylori Infection Testing 83013, 83014, 87338• *Hepatitis Panel/Acute Hepatitis Panel 80074• *Histocompatibility Testing 86812, 86813, 86816, 86817, 86821,

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

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

• *Human Immunodeficiency Virus (HIV) Testing (Prognosis Including 87536, 87539Monitoring)

• In Vitro Chemosensitivity and Chemoresistance Assays 84999, 89240• Lab: Bladder / Urothelial Tumor Markers %86294, %86316, %86386, %88120,

%88121• Lab: Coenzyme Q10 (CoQ10) Testing N/A• Lab: Controlled Substance Monitoring and Drugs of Abuse Testing %80305, %80306, %80307, %G0481-

%G0483, G0659• Lab: Flow Cytometry %88182-%88189, %86355-%86367• Lab: Special Histochemical Stains and Immunohistochemical Stains 88312, 88313, 88341, 88342, 88344,

88360, 88361• *Lipid Testing %80061, %82465, 83700, 83701,

83704, %83718, %83721, %84478• *Lymphocyte Mitogen Response Assays 86353• Measurement of Salivary Hormones 84999• MolDX: APC and MUTYH Gene Testing 81201, 81202, 81203, 81401, 81403,

81406, 81435, 81479• MolDX: Biomarkers in Cardiovascular Risk Assessment 82172, 82610, 83090, 83695, 83698,

83700, 83701, 83704, 83719, 83721,86141

• MolDX: BRCA1 and BRCA2 Genetic Testing %81162-%81167, %81212-%81217, %81432, %81445, %81455, %81479

• MolDX: Breast Cancer Assay: Prosigna 81520• MolDX: Circulating Tumor Cell Marker Assays 86152, 86153• MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing 81225-81227, 81355, 81479• MolDX: Cystatin C Measurement 82610• MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease 81206-81208, 81219, 81270, 81402,

81403, 81445, 81450, 81455, 81479• MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V 81240, 81241, 81291

Leiden, Factor II Prothrombin, and MTHFR)

Laboratory Test CPT• MolDX: Genetic Testing for Lynch Syndrome 81210, 81288, 81292-81301, 81317-

81319, 81403, 81435, 81445,81455, 81479

• MolDX: HLA-B*15:02 Genetic Testing 81381• MolDX: HLA-DQB1*06:02 Testing for Narcolepsy 81383• MolDX: MDS FISH 88271, 88273, 88274, 88275, 88291• MolDX: MGMT Promoter Methylation Analysis 81287• MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels 87631, 87632, 87633, 0099U • MolDX: NRAS Genetic Testing 81311, 81479• MolDX: ProMark Risk Score 81479• *Pap Smears, Diagnostic 88141-88175• *Pap Smears, Screening %G0123, %G0124, %G0141, %G0143,

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

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

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

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

• *Serum Iron Studies %82728, 83540, 83550, 84466• Serum Magnesium 83735• *Sweat Test 82438, 89230• *Thyroid Testing %84436, %84439, %84443, %84479• Treatment of Males with Low Testosterone 84410• *Tumor Antigen by Immunoassay CA15-3/CA 27.29 86300• *Tumor Antigen by Immunoassay CA 19-9 86301• *Tumor Antigen by Immunoassay CA125 %86304• *Urine Bacterial Culture 87086, 87088• Vitamin D Assay Testing 82306, 82652

* Indicates national policy%Indicates Frequency

CPT copyright American Medical Association

Noridian Healthcare Solutions – Alaska, Arizona, Idaho, Montana, Oregon, South Dakota, Utah, Washington, Wyoming Medical Necessity Policies as of March 1, 2020

Determining Necessity of Advance Beneficiary Notice (ABN) Completion*

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

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

Payment Denials and Advance Beneficiary Notices

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

ABNs may be obtained from your LabCorp representative.

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

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

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

Centers for Medicare and Medicaid Services — All States

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

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

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

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

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

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

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

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

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

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

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

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

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

Compiled: 03/2020


Alpha Sort—Continued


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

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

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

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

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

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

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

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

tissue

Compiled: 03/2020



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

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

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

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

Numeric Sort

Compiled: 03/2020

Noridian Healthcare Solutions — Alaska, Arizona, Hawaii, Idaho, Montana, Oregon, North Dakota, South Dakota, Utah, Washington, Wyoming

83987, 84431, 86305, 0111T

Non-Covered Services

Coverage IndicationsThis LCD contains listings of numerous non-covered services which have no specific CPT code. Adding difficulty to correct coding for such services is the fact that there are many where two or more specific unlisted codes could arguably be used to designate the service. Initial preparation of the LCD to cover every possible code use – and more importantly, maintenance of the LCD as code changes occur – is difficult if not impossible.

Therefore, providers must bear in mind that any service that is described in any Noridian LCD as “non-covered” will remain non-covered no matter which CPT code is selected for billing. Since many of the unlisted codes, however, are also correctly used for billing of covered services, it is likely that prepay denial edits cannot be implemented into the claims processing computer system. Because of this, clearly non-covered services can in some instances be paid. Providers are reminded that these paid services will be subject to recoupment by Noridian, as well as other review contractors, including the Recovery Audit Contractors (RACs).

Services that this contractor considers a component of another service and never separately billable or payable are also included here unless those services are already included in the mutually exclusive Correct Coding edits. For some services one or more of the Medicare payment systems (for example, the Physician Fee Schedule or the Outpatient Prospective Payment System) may indicate that the service is bundled or packaged or not paid forsome other reason, in which case those indicators take precedence over the placement in this policy.

This is not an all-inclusive list of services not covered or not paid separately by Medicare.

If you disagree with some aspects of a final LCD, you have the option of submitting a formalreconsideration to Noridian Medicare Part B. See www.noridianmedicare.com for the reconsideration process. This reconsideration must be accompanied by complete copies of relevant peer-reviewed literature that support the recommendation. Abstracts are not sufficient for this purpose. Keep in mind that no change will be made that will put the LCD in conflict with CMS regulations.

Removal of a service from this policy does not imply that the service is always covered. The service must meet Medicare coverage criteria and the documentation in the medical record must support the service as billed.

Noridian Non-Coverage Determinations:

Note: These lists of non-covered services are not all-inclusive:

Services that are not covered due to being investigational/experimental, not proven effective or are not reasonable and necessary:

To bill the patient for procedures and services that are not covered for these reasons will generally require an Advance Beneficiary Notice (ABN) to be obtained before the service is rendered.

All new Category III Codes, unless specifically approved for payment by CMS or the Noridian Medical Directors and listed as approved in our article, are non-covered. In most cases, in accordance with the CPT Manual, these codes have been created to track new, “emerging” unproven therapies and tests. If a provider or other interested party believes that a service described by a Category III code or any other code in this policy is medically reasonable and necessary, the provider or party should submit the peer-reviewed medical literature, supporting the safety and effectiveness of the service for Medical Director review. This request for coverage of the service may be made through the Noridian LCD Reconsideration Process.

Not Proven Effective, Not Medically Reasonable and Necessary

Note: The following services, as described below and billed with any CPT and or HCPCS code, are considered not proven effective or not medically reasonable and necessary and will be denied as such:

Claims for these services will always be reviewed when they are billed with an unlisted procedure code.

• Accu-Spina

• Analysis of patient-specific findings with quantifiable computer probablilty assessment, including report

• Antiprothrombin (phospholipid cofactor) antibody, each IG class• Bile duct extracorporeal shock-wave lithotripsy • Breast ductoscopy• BSGI, Breast Scintography• Carbon monoxide, expired gas analysis [eg. ETCO/hemolysis breath test]• Circular boot treatment• Clinical drug interaction testing• Coblation debridement of tendon and/or fascia• CT fusion• Decision DX-LEA Test• Destruction of macular drusen, photocoagulation• Electrical impedance breast scan• Flicker Fusion• Food scratch test• Gel platelet application• Head shaking test• Heidelberg Gastric Analysis Test• Hydrotherapy treatments (also known as hydromassage & hydrobed modality)• Hypertonic sinus irrigation• Inert gas rebreathing for cardiac output measurement; during rest • Inert gas rebreathing for cardiac output measurement; during exercise • Laser myringectomy• Laser treatment or low light laser therapy: of rotator cuff tendonitis, to stimulate circulation,

for pain and inflammation, for low level laser treatment including, but not limited to trigger points, knees, hips and other joints

• Leukocytes, stool• Lipoprotein, direct measurement, intermediate density lipoproteins [IDL][remnant

lipoprotein]• Lung spectroscopy• Mammary duct(s) catheter lavage• Microvas Treatments for all indications other than those allowed by NCD• Microdose therapy for arthritis or fibromyalgia• Microwave phased array thermotherapy for destruction/reduction of malignant breast tumor • M.O.S.T. protocol (Mental office-based stress test)• Neuroform® Stent placement for ischemic disease• Palate implant procedure (Pillar System)• Percutaneous neuromodulation therapy • PFL CO monitor• Phonophoresis• Platelet plasma mixed with laminate, protein bone growth stimulator• Platelet rich plasma injection for osteoarthrosis• Provocation and Neutralization Allergy Testing• Pulsed magnetic neuromodulation incontinence treatment• Pulsed radiofrequency treatment• Qcare• Reconstruction of iliac bone or crest• Rhinophototherapy, intranasal application of ultraviolet and visible light • Saccades eye test or Saccadic eye test• Secca® procedure • Sonorex treatment• Speculoscopy, including sampling• Splint mouth guard or night guard• Sublingual antigen drops• Suprachoroidial delivery of pharmacologic agent• Therabite appliance dispensed due to trismus• Therapy using Superluminous Diodes• Transoral Incisionless Fundoplication• Transmyocardial transcatheter closure of ventricular spetal defect, with implant, including

cardiopulmonary bypass if performed• Ultrafiltration in heart failure• Urinalysis infectious agent detection, semi quantitative analysis of volatile compounds• Vagal nerve stimulation for depression• von Willebrand Propetide Ag

Compiled: 03/2020

Noridian Healthcare Solutions — Alaska, Arizona, Hawaii, Idaho, Montana, Oregon, North Dakota, South Dakota, Utah, Washington, Wyoming

83987, 84431, 86305, 0111T

Non-Covered Services

*NOTE: NCD 150.10 prohibits payment for individuals over 60 years of age for the following CPT/HCPCS codes: 22857, 22862, 0098T, 0163T and 0165T. Noridian has also determined these codes do not meet medically necessary criteria for individuals under 60 years of age.

83987 PH; EXHALED BREATH CONDENSATE84431 THROMBOXANE METABOLITE(S), INCLUDING THROMBOXANE IF PERFORMED, URINE86305 HUMAN EPIDIDYMIS PROTEIN 4 (HE4)0111T LONG-CHAIN (C20-22) OMEGA-3 FATTY ACIDS IN RED BLOOD CELL (RBC) MEMBRANES

Components of Another Service, Never Separately Billable to the Contractor or the Patient

• Allergy - AG prep• Anesthesia IV start or intubation• Angiojet thrombectomy any artery or vein• Application of mitomycin• Cast mold• Cormatrix• Coronary sinus venography• Embolic protection device • Eye retractor advancement• Gliasite balloon placement• Implantation/placement of antibiotic beads• Implantation of Doppler device• Intrapericardial defibrillator coil• Intraoperative blood flow measurement• On Q pain pump placement and/or management• Pentacam• PICC removal (when billed by same provider)• Pin fixation• Pope earwick• Potential acuity meter• Preferential hyperacuity perimeter• Pump catheter placement• Pupillography or measure of alertness by pupillometry• Resection/ligation of atrial appendage• Schirmer test (ophthalmic mucous membrane test)• Stat fee• Stryker pain pump insertion• Suture removal (when billed by same provider)• Symphony system for procedure• Two week home auto CPAP titration study• Ultrasound guidance for fiducial marker placement• Via modem transmission telemedicine• Visiometer testing

Statutorily Non-covered Service, the Patient is Liable for Payment

• Astigmatic keratotomy• CO2 laser resurfacing of lip• INTIMA-MEDIA Thickness (IMT) Scan• Occlusal orthotic appliance• Orthomolecular medicine• Validated, statistically reliable, randomized, controlled, single- patient clinical investigation

of FDA approved chronic care drugs, provided by a pharmacist, interpretation and report to the prescribing health care professional

Compiled: 03/2020


Alpha-Fetoprotein82105

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

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

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

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

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

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

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

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

Alpha Sort

Compiled: 03/2020


Alpha-Fetoprotein82105

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

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

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

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

Compiled: 03/2020


Blood Counts85004, 85007, 85008, 85013, 85014, 85018, 85025, 85027, 85032, 85048, 85049

ICD-10-CM codes that DO NOT Support Medical Necessity ICD-10-CM codes that DO NOT Support Medical NecessityAlpha Sort

Z3A.10 10 weeks gestation of pregnancyZ3A.11 11 weeks gestation of pregnancyZ3A.12 12 weeks gestation of pregnancyZ3A.13 13 weeks gestation of pregnancyZ3A.14 14 weeks gestation of pregnancyZ3A.15 15 weeks gestation of pregnancyZ3A.16 16 weeks gestation of pregnancyZ3A.17 17 weeks gestation of pregnancyZ3A.18 18 weeks gestation of pregnancyZ3A.19 19 weeks gestation of pregnancyZ3A.20 20 weeks gestation of pregnancyZ3A.21 21 weeks gestation of pregnancyZ3A.22 22 weeks gestation of pregnancyZ3A.23 23 weeks gestation of pregnancyZ3A.24 24 weeks gestation of pregnancyZ3A.25 25 weeks gestation of pregnancyZ3A.26 26 weeks gestation of pregnancyZ3A.27 27 weeks gestation of pregnancyZ3A.28 28 weeks gestation of pregnancyZ3A.29 29 weeks gestation of pregnancyS42.222S 2-part displaced fracture of surgical neck of left humerus, sequelaS42.222G 2-part displaced fracture of surgical neck of left humerus, subsequent encounter

for fracture with delayed healingS42.222D 2-part displaced fracture of surgical neck of left humerus, subsequent encounter

for fracture with routine healingS42.221S 2-part displaced fracture of surgical neck of right humerus, sequelaS42.221G 2-part displaced fracture of surgical neck of right humerus, subsequent encounter

for fracture with delayed healingS42.221D 2-part displaced fracture of surgical neck of right humerus, subsequent encounter

for fracture with routine healingS42.223S 2-part displaced fracture of surgical neck of unspecified humerus, sequelaS42.223G 2-part displaced fracture of surgical neck of unspecified humerus, subsequent

encounter for fracture with delayed healingS42.223D 2-part displaced fracture of surgical neck of unspecified humerus, subsequent

encounter for fracture with routine healingS42.225S 2-part nondisplaced fracture of surgical neck of left humerus, sequelaS42.225G 2-part nondisplaced fracture of surgical neck of left humerus, subsequent

encounter for fracture with delayed healingS42.225D 2-part nondisplaced fracture of surgical neck of left humerus, subsequent

encounter for fracture with routine healingS42.224S 2-part nondisplaced fracture of surgical neck of right humerus, sequelaS42.224G 2-part nondisplaced fracture of surgical neck of right humerus, subsequent

encounter for fracture with delayed healingS42.224D 2-part nondisplaced fracture of surgical neck of right humerus, subsequent

encounter for fracture with routine healingS42.226S 2-part nondisplaced fracture of surgical neck of unspecified humerus, sequelaS42.226G 2-part nondisplaced fracture of surgical neck of unspecified humerus, subsequent

encounter for fracture with delayed healingS42.226D 2-part nondisplaced fracture of surgical neck of unspecified humerus, subsequent

encounter for fracture with routine healingZ3A.30 30 weeks gestation of pregnancyZ3A.31 31 weeks gestation of pregnancyZ3A.32 32 weeks gestation of pregnancyZ3A.33 33 weeks gestation of pregnancyZ3A.34 34 weeks gestation of pregnancyZ3A.35 35 weeks gestation of pregnancy

Z3A.36 36 weeks gestation of pregnancyZ3A.37 37 weeks gestation of pregnancyZ3A.38 38 weeks gestation of pregnancyZ3A.39 39 weeks gestation of pregnancyS42.232S 3-part fracture of surgical neck of left humerus, sequelaS42.232G 3-part fracture of surgical neck of left humerus, subsequent encounter for fracture

with delayed healingS42.232D 3-part fracture of surgical neck of left humerus, subsequent encounter for fracture

with routine healingS42.231S 3-part fracture of surgical neck of right humerus, sequelaS42.231G 3-part fracture of surgical neck of right humerus, subsequent encounter for

fracture with delayed healingS42.231D 3-part fracture of surgical neck of right humerus, subsequent encounter for

fracture with routine healingS42.239S 3-part fracture of surgical neck of unspecified humerus, sequelaS42.239G 3-part fracture of surgical neck of unspecified humerus, subsequent encounter for

fracture with delayed healingS42.239D 3-part fracture of surgical neck of unspecified humerus, subsequent encounter for

fracture with routine healingZ3A.40 40 weeks gestation of pregnancyZ3A.41 41 weeks gestation of pregnancyZ3A.42 42 weeks gestation of pregnancyS42.242S 4-part fracture of surgical neck of left humerus, sequelaS42.242G 4-part fracture of surgical neck of left humerus, subsequent encounter for fracture

with delayed healingS42.242D 4-part fracture of surgical neck of left humerus, subsequent encounter for fracture

with routine healingS42.241S 4-part fracture of surgical neck of right humerus, sequelaS42.241G 4-part fracture of surgical neck of right humerus, subsequent encounter for

fracture with delayed healingS42.241D 4-part fracture of surgical neck of right humerus, subsequent encounter for

fracture with routine healingS42.249S 4-part fracture of surgical neck of unspecified humerus, sequelaS42.249G 4-part fracture of surgical neck of unspecified humerus, subsequent encounter for

fracture with delayed healingS42.249D 4-part fracture of surgical neck of unspecified humerus, subsequent encounter for

fracture with routine healingZ3A.08 8 weeks gestation of pregnancyZ3A.09 9 weeks gestation of pregnancyM26.51 Abnormal jaw closureK00.2 Abnormalities of size and form of teethT80.30XS ABO incompatibility reaction due to transfusion of blood or blood products,

unspecified, sequelaT80.310S ABO incompatibility with acute hemolytic transfusion reaction, sequelaT80.311S ABO incompatibility with delayed hemolytic transfusion reaction, sequelaT80.319S ABO incompatibility with hemolytic transfusion reaction, unspecified, sequelaS30.811A Abrasion of abdominal wall, initial encounterS30.811S Abrasion of abdominal wall, sequelaS30.817A Abrasion of anus, initial encounterS30.817S Abrasion of anus, sequelaS20.112A Abrasion of breast, left breast, initial encounterS20.112S Abrasion of breast, left breast, sequelaS20.111A Abrasion of breast, right breast, initial encounterS20.111S Abrasion of breast, right breast, sequelaS20.119A Abrasion of breast, unspecified breast, initial encounterS20.119S Abrasion of breast, unspecified breast, sequela

Compiled: 03/2020



Blood Counts85004, 85007, 85008, 85013, 85014, 85018, 85025, 85027, 85032, 85048, 85049

ICD-10-CM codes that DO NOT Support Medical Necessity ICD-10-CM codes that DO NOT Support Medical NecessityS50.811A Abrasion of right forearm, initial encounterS50.811S Abrasion of right forearm, sequelaS20.311A Abrasion of right front wall of thorax, initial encounterS20.311S Abrasion of right front wall of thorax, sequelaS60.511A Abrasion of right hand, initial encounterS60.511S Abrasion of right hand, sequelaS60.410A Abrasion of right index finger, initial encounterS60.410S Abrasion of right index finger, sequelaS60.416A Abrasion of right little finger, initial encounterS60.416S Abrasion of right little finger, sequelaS60.412A Abrasion of right middle finger, initial encounterS60.412S Abrasion of right middle finger, sequelaS60.414A Abrasion of right ring finger, initial encounterS60.414S Abrasion of right ring finger, sequelaS40.211A Abrasion of right shoulder, initial encounterS40.211S Abrasion of right shoulder, sequelaS60.311A Abrasion of right thumb, initial encounterS60.311S Abrasion of right thumb, sequelaS40.811A Abrasion of right upper arm, initial encounterS40.811S Abrasion of right upper arm, sequelaS60.811A Abrasion of right wrist, initial encounterS60.811S Abrasion of right wrist, sequelaS00.01XA Abrasion of scalp, initial encounterS00.01XS Abrasion of scalp, sequelaS30.813A Abrasion of scrotum and testes, initial encounterS30.813S Abrasion of scrotum and testes, sequelaK03.1 Abrasion of teethS10.11XA Abrasion of throat, initial encounterS10.11XS Abrasion of throat, sequelaS20.419A Abrasion of unspecified back wall of thorax, initial encounterS20.419S Abrasion of unspecified back wall of thorax, sequelaS00.419A Abrasion of unspecified ear, initial encounterS00.419S Abrasion of unspecified ear, sequelaS50.319A Abrasion of unspecified elbow, initial encounterS50.319S Abrasion of unspecified elbow, sequelaS30.816A Abrasion of unspecified external genital organs, female, initial encounterS30.816S Abrasion of unspecified external genital organs, female, sequelaS30.815A Abrasion of unspecified external genital organs, male, initial encounterS30.815S Abrasion of unspecified external genital organs, male, sequelaS00.219A Abrasion of unspecified eyelid and periocular area, initial encounterS00.219S Abrasion of unspecified eyelid and periocular area, sequelaS60.419A Abrasion of unspecified finger, initial encounterS60.419S Abrasion of unspecified finger, sequelaS50.819A Abrasion of unspecified forearm, initial encounterS50.819S Abrasion of unspecified forearm, sequelaS20.319A Abrasion of unspecified front wall of thorax, initial encounterS20.319S Abrasion of unspecified front wall of thorax, sequelaS60.519A Abrasion of unspecified hand, initial encounterS60.519S Abrasion of unspecified hand, sequelaS00.91XA Abrasion of unspecified part of head, initial encounterS00.91XS Abrasion of unspecified part of head, sequelaS10.91XA Abrasion of unspecified part of neck, initial encounterS10.91XS Abrasion of unspecified part of neck, sequelaS20.91XA Abrasion of unspecified parts of thorax, initial encounter

S20.412A Abrasion of left back wall of thorax, initial encounterS20.412S Abrasion of left back wall of thorax, sequelaS00.412A Abrasion of left ear, initial encounterS00.412S Abrasion of left ear, sequelaS50.312A Abrasion of left elbow, initial encounterS50.312S Abrasion of left elbow, sequelaS00.212A Abrasion of left eyelid and periocular area, initial encounterS00.212S Abrasion of left eyelid and periocular area, sequelaS50.812A Abrasion of left forearm, initial encounterS50.812S Abrasion of left forearm, sequelaS20.312A Abrasion of left front wall of thorax, initial encounterS20.312S Abrasion of left front wall of thorax, sequelaS60.512A Abrasion of left hand, initial encounterS60.512S Abrasion of left hand, sequelaS60.411A Abrasion of left index finger, initial encounterS60.411S Abrasion of left index finger, sequelaS60.417A Abrasion of left little finger, initial encounterS60.417S Abrasion of left little finger, sequelaS60.413A Abrasion of left middle finger, initial encounterS60.413S Abrasion of left middle finger, sequelaS60.415A Abrasion of left ring finger, initial encounterS60.415S Abrasion of left ring finger, sequelaS40.212A Abrasion of left shoulder, initial encounterS40.212S Abrasion of left shoulder, sequelaS60.312A Abrasion of left thumb, initial encounterS60.312S Abrasion of left thumb, sequelaS40.812A Abrasion of left upper arm, initial encounterS40.812S Abrasion of left upper arm, sequelaS60.812A Abrasion of left wrist, initial encounterS60.812S Abrasion of left wrist, sequelaS00.511A Abrasion of lip, initial encounterS00.511S Abrasion of lip, sequelaS30.810A Abrasion of lower back and pelvis, initial encounterS30.810S Abrasion of lower back and pelvis, sequelaS00.31XA Abrasion of nose, initial encounterS00.31XS Abrasion of nose, sequelaS00.512A Abrasion of oral cavity, initial encounterS00.512S Abrasion of oral cavity, sequelaS60.418A Abrasion of other finger, initial encounterS60.418S Abrasion of other finger, sequelaS00.81XA Abrasion of other part of head, initial encounterS00.81XS Abrasion of other part of head, sequelaS10.81XA Abrasion of other specified part of neck, initial encounterS10.81XS Abrasion of other specified part of neck, sequelaS30.812A Abrasion of penis, initial encounterS30.812S Abrasion of penis, sequelaS20.411A Abrasion of right back wall of thorax, initial encounterS20.411S Abrasion of right back wall of thorax, sequelaS00.411A Abrasion of right ear, initial encounterS00.411S Abrasion of right ear, sequelaS50.311A Abrasion of right elbow, initial encounterS50.311S Abrasion of right elbow, sequelaS00.211A Abrasion of right eyelid and periocular area, initial encounterS00.211S Abrasion of right eyelid and periocular area, sequela

Compiled: 03/2020



Blood Counts85004, 85007, 85008, 85013, 85014, 85018, 85025, 85027, 85032, 85048, 85049

ICD-10-CM codes that DO NOT Support Medical Necessity ICD-10-CM codes that DO NOT Support Medical NecessityS90.416S Abrasion, unspecified lesser toe(s), sequelaS80.819A Abrasion, unspecified lower leg, initial encounterS80.819S Abrasion, unspecified lower leg, sequelaS70.319A Abrasion, unspecified thigh, initial encounterS70.319S Abrasion, unspecified thigh, sequelaM71.072 Abscess of bursa, left ankle and footM71.022 Abscess of bursa, left elbowM71.042 Abscess of bursa, left handM71.052 Abscess of bursa, left hipM71.062 Abscess of bursa, left kneeM71.012 Abscess of bursa, left shoulderM71.032 Abscess of bursa, left wristM71.09 Abscess of bursa, multiple sitesM71.08 Abscess of bursa, other siteM71.071 Abscess of bursa, right ankle and footM71.021 Abscess of bursa, right elbowM71.041 Abscess of bursa, right handM71.051 Abscess of bursa, right hipM71.061 Abscess of bursa, right kneeM71.011 Abscess of bursa, right shoulderM71.031 Abscess of bursa, right wristM71.079 Abscess of bursa, unspecified ankle and footM71.029 Abscess of bursa, unspecified elbowM71.049 Abscess of bursa, unspecified handM71.059 Abscess of bursa, unspecified hipM71.069 Abscess of bursa, unspecified kneeM71.019 Abscess of bursa, unspecified shoulderM71.00 Abscess of bursa, unspecified siteM71.039 Abscess of bursa, unspecified wristH00.036 Abscess of eyelid left eye, unspecified eyelidH00.033 Abscess of eyelid right eye, unspecified eyelidH00.039 Abscess of eyelid unspecified eye, unspecified eyelidH00.035 Abscess of left lower eyelidH00.034 Abscess of left upper eyelidH00.032 Abscess of right lower eyelidH00.031 Abscess of right upper eyelidM65.072 Abscess of tendon sheath, left ankle and footM65.032 Abscess of tendon sheath, left forearmM65.042 Abscess of tendon sheath, left handM65.062 Abscess of tendon sheath, left lower legM65.012 Abscess of tendon sheath, left shoulderM65.052 Abscess of tendon sheath, left thighM65.022 Abscess of tendon sheath, left upper armM65.08 Abscess of tendon sheath, other siteM65.071 Abscess of tendon sheath, right ankle and footM65.031 Abscess of tendon sheath, right forearmM65.041 Abscess of tendon sheath, right handM65.061 Abscess of tendon sheath, right lower legM65.011 Abscess of tendon sheath, right shoulderM65.051 Abscess of tendon sheath, right thighM65.021 Abscess of tendon sheath, right upper armM65.079 Abscess of tendon sheath, unspecified ankle and footM65.039 Abscess of tendon sheath, unspecified forearmM65.049 Abscess of tendon sheath, unspecified hand

S20.91XS Abrasion of unspecified parts of thorax, sequelaS40.219A Abrasion of unspecified shoulder, initial encounterS40.219S Abrasion of unspecified shoulder, sequelaS60.319A Abrasion of unspecified thumb, initial encounterS60.319S Abrasion of unspecified thumb, sequelaS40.819A Abrasion of unspecified upper arm, initial encounterS40.819S Abrasion of unspecified upper arm, sequelaS60.819A Abrasion of unspecified wrist, initial encounterS60.819S Abrasion of unspecified wrist, sequelaS30.814A Abrasion of vagina and vulva, initial encounterS30.814S Abrasion of vagina and vulva, sequelaS90.512A Abrasion, left ankle, initial encounterS90.512S Abrasion, left ankle, sequelaS90.812A Abrasion, left foot, initial encounterS90.812S Abrasion, left foot, sequelaS90.412A Abrasion, left great toe, initial encounterS90.412S Abrasion, left great toe, sequelaS70.212A Abrasion, left hip, initial encounterS70.212S Abrasion, left hip, sequelaS80.212A Abrasion, left knee, initial encounterS80.212S Abrasion, left knee, sequelaS90.415A Abrasion, left lesser toe(s), initial encounterS90.415S Abrasion, left lesser toe(s), sequelaS80.812A Abrasion, left lower leg, initial encounterS80.812S Abrasion, left lower leg, sequelaS70.312A Abrasion, left thigh, initial encounterS70.312S Abrasion, left thigh, sequelaS90.511A Abrasion, right ankle, initial encounterS90.511S Abrasion, right ankle, sequelaS90.811A Abrasion, right foot, initial encounterS90.811S Abrasion, right foot, sequelaS90.411A Abrasion, right great toe, initial encounterS90.411S Abrasion, right great toe, sequelaS70.211A Abrasion, right hip, initial encounterS70.211S Abrasion, right hip, sequelaS80.211A Abrasion, right knee, initial encounterS80.211S Abrasion, right knee, sequelaS90.414A Abrasion, right lesser toe(s), initial encounterS90.414S Abrasion, right lesser toe(s), sequelaS80.811A Abrasion, right lower leg, initial encounterS80.811S Abrasion, right lower leg, sequelaS70.311A Abrasion, right thigh, initial encounterS70.311S Abrasion, right thigh, sequelaS90.519A Abrasion, unspecified ankle, initial encounterS90.519S Abrasion, unspecified ankle, sequelaS90.819A Abrasion, unspecified foot, initial encounterS90.819S Abrasion, unspecified foot, sequelaS90.413A Abrasion, unspecified great toe, initial encounterS90.413S Abrasion, unspecified great toe, sequelaS70.219A Abrasion, unspecified hip, initial encounterS70.219S Abrasion, unspecified hip, sequelaS80.219A Abrasion, unspecified knee, initial encounterS80.219S Abrasion, unspecified knee, sequelaS90.416A Abrasion, unspecified lesser toe(s), initial encounter

Compiled: 03/2020



Blood Counts85004, 85007, 85008, 85013, 85014, 85018, 85025, 85027, 85032, 85048, 85049

ICD-10-CM codes that DO NOT Support Medical Necessity ICD-10-CM codes that DO NOT Support Medical NecessityZ90.722 Acquired absence of ovaries, bilateralZ90.721 Acquired absence of ovaries, unilateralZ89.441 Acquired absence of right ankleZ90.11 Acquired absence of right breast and nippleZ89.021 Acquired absence of right finger(s)Z89.431 Acquired absence of right footZ89.411 Acquired absence of right great toeZ89.111 Acquired absence of right handZ89.621 Acquired absence of right hip jointZ89.611 Acquired absence of right leg above kneeZ89.511 Acquired absence of right leg below kneeZ89.231 Acquired absence of right shoulderZ89.011 Acquired absence of right thumbZ89.221 Acquired absence of right upper limb above elbowZ89.211 Acquired absence of right upper limb below elbowZ89.201 Acquired absence of right upper limb, unspecified levelZ89.121 Acquired absence of right wristZ90.81 Acquired absence of spleenZ90.3 Acquired absence of stomach [part of]Z89.449 Acquired absence of unspecified ankleZ90.10 Acquired absence of unspecified breast and nippleZ89.029 Acquired absence of unspecified finger(s)Z89.439 Acquired absence of unspecified footZ89.419 Acquired absence of unspecified great toeZ89.119 Acquired absence of unspecified handZ89.629 Acquired absence of unspecified hip jointZ89.619 Acquired absence of unspecified leg above kneeZ89.519 Acquired absence of unspecified leg below kneeZ89.239 Acquired absence of unspecified shoulderZ89.019 Acquired absence of unspecified thumbZ89.229 Acquired absence of unspecified upper limb above elbowZ89.219 Acquired absence of unspecified upper limb below elbowZ89.209 Acquired absence of unspecified upper limb, unspecified levelZ89.129 Acquired absence of unspecified wristN83.329 Acquired atrophy of fallopian tube, unspecified sideN83.322 Acquired atrophy of left fallopian tubeN83.312 Acquired atrophy of left ovaryN83.332 Acquired atrophy of left ovary and fallopian tubeN83.339 Acquired atrophy of ovary and fallopian tube, unspecified sideN83.319 Acquired atrophy of ovary, unspecified sideN83.321 Acquired atrophy of right fallopian tubeN83.311 Acquired atrophy of right ovaryN83.331 Acquired atrophy of right ovary and fallopian tubeM21.532 Acquired clawfoot, left footM21.531 Acquired clawfoot, right footM21.539 Acquired clawfoot, unspecified footM21.512 Acquired clawhand, left handM21.511 Acquired clawhand, right handM21.519 Acquired clawhand, unspecified handM21.542 Acquired clubfoot, left footM21.541 Acquired clubfoot, right footM21.549 Acquired clubfoot, unspecified footM21.522 Acquired clubhand, left handM21.521 Acquired clubhand, right hand

M65.069 Abscess of tendon sheath, unspecified lower legM65.019 Abscess of tendon sheath, unspecified shoulderM65.00 Abscess of tendon sheath, unspecified siteM65.059 Abscess of tendon sheath, unspecified thighM65.029 Abscess of tendon sheath, unspecified upper armJ34.0 Abscess, furuncle and carbuncle of noseZ63.31 Absence of family member due to military deploymentL11.9 Acantholytic disorder, unspecifiedL83 Acanthosis nigricansZ60.3 Acculturation difficultyM76.62 Achilles tendinitis, left legM76.61 Achilles tendinitis, right legM76.60 Achilles tendinitis, unspecified legL70.1 Acne conglobataL70.5 Acne excorieeL73.0 Acne keloidL70.3 Acne tropicaL70.2 Acne varioliformisL70.0 Acne vulgarisL70.9 Acne, unspecifiedH94.03 Acoustic neuritis in infectious and parasitic diseases classified elsewhere, bilateralH94.02 Acoustic neuritis in infectious and parasitic diseases classified elsewhere, left earH94.01 Acoustic neuritis in infectious and parasitic diseases classified elsewhere, right earH94.00 Acoustic neuritis in infectious and parasitic diseases classified elsewhere,

unspecified earZ90.13 Acquired absence of bilateral breasts and nipplesZ90.01 Acquired absence of eyeZ90.5 Acquired absence of kidneyZ90.02 Acquired absence of larynxZ89.442 Acquired absence of left ankleZ90.12 Acquired absence of left breast and nippleZ89.022 Acquired absence of left finger(s)Z89.432 Acquired absence of left footZ89.412 Acquired absence of left great toeZ89.112 Acquired absence of left handZ89.622 Acquired absence of left hip jointZ89.612 Acquired absence of left leg above kneeZ89.512 Acquired absence of left leg below kneeZ89.232 Acquired absence of left shoulderZ89.012 Acquired absence of left thumbZ89.222 Acquired absence of left upper limb above elbowZ89.212 Acquired absence of left upper limb below elbowZ89.202 Acquired absence of left upper limb, unspecified levelZ89.122 Acquired absence of left wristZ89.9 Acquired absence of limb, unspecifiedZ90.2 Acquired absence of lung [part of]Z90.79 Acquired absence of other genital organ(s)Z89.422 Acquired absence of other left toe(s)Z90.89 Acquired absence of other organsZ90.09 Acquired absence of other part of head and neckZ90.6 Acquired absence of other parts of urinary tractZ89.421 Acquired absence of other right toe(s)Z90.49 Acquired absence of other specified parts of digestive tractZ89.429 Acquired absence of other toe(s), unspecified side

Compiled: 03/2020



Blood Counts85004, 85007, 85008, 85013, 85014, 85018, 85025, 85027, 85032, 85048, 85049

ICD-10-CM codes that DO NOT Support Medical Necessity ICD-10-CM codes that DO NOT Support Medical NecessityM26.619 Adhesions and ankylosis of temporomandibular joint, unspecified sideT81.516S Adhesions due to foreign body accidentally left in body following aspiration,

puncture or other catheterization, sequelaT81.514S Adhesions due to foreign body accidentally left in body following endoscopic

examination, sequelaT81.515S Adhesions due to foreign body accidentally left in body following heart

catheterization, sequelaT81.511S Adhesions due to foreign body accidentally left in body following infusion or

transfusion, sequelaT81.513S Adhesions due to foreign body accidentally left in body following injection or

immunization, sequelaT81.512S Adhesions due to foreign body accidentally left in body following kidney dialysis,

sequelaT81.518S Adhesions due to foreign body accidentally left in body following other procedure,

sequelaT81.517S Adhesions due to foreign body accidentally left in body following removal of

catheter or packing, sequelaT81.510S Adhesions due to foreign body accidentally left in body following surgical

operation, sequelaT81.519S Adhesions due to foreign body accidentally left in body following unspecified

procedure, sequelaN47.5 Adhesions of prepuce and glans penisM75.02 Adhesive capsulitis of left shoulderM75.01 Adhesive capsulitis of right shoulderM75.00 Adhesive capsulitis of unspecified shoulderH74.12 Adhesive left middle ear diseaseH74.13 Adhesive middle ear disease, bilateralH74.19 Adhesive middle ear disease, unspecified earH74.11 Adhesive right middle ear diseaseM41.122 Adolescent idiopathic scoliosis, cervical regionM41.123 Adolescent idiopathic scoliosis, cervicothoracic regionM41.126 Adolescent idiopathic scoliosis, lumbar regionM41.127 Adolescent idiopathic scoliosis, lumbosacral regionM41.129 Adolescent idiopathic scoliosis, site unspecifiedM41.124 Adolescent idiopathic scoliosis, thoracic regionM41.125 Adolescent idiopathic scoliosis, thoracolumbar regionZ72.811 Adult antisocial behaviorT74.61XA Adult forced labor exploitation, confirmed, initial encounterT74.61XS Adult forced labor exploitation, confirmed, sequelaT74.61XD Adult forced labor exploitation, confirmed, subsequent encounterT76.61XA Adult forced labor exploitation, suspected, initial encounterT76.61XS Adult forced labor exploitation, suspected, sequelaT76.61XD Adult forced labor exploitation, suspected, subsequent encounterT74.51XA Adult forced sexual exploitation, confirmed, initial encounterT74.51XS Adult forced sexual exploitation, confirmed, sequelaT74.51XD Adult forced sexual exploitation, confirmed, subsequent encounterT76.51XA Adult forced sexual exploitation, suspected, initial encounterT76.51XS Adult forced sexual exploitation, suspected, sequelaT76.51XD Adult forced sexual exploitation, suspected, subsequent encounterT74.01XS Adult neglect or abandonment, confirmed, sequelaT76.01XS Adult neglect or abandonment, suspected, sequelaF98.5 Adult onset fluency disorderM42.12 Adult osteochondrosis of spine, cervical regionM42.13 Adult osteochondrosis of spine, cervicothoracic regionM42.16 Adult osteochondrosis of spine, lumbar region

M21.529 Acquired clubhand, unspecified handM20.62 Acquired deformities of toe(s), unspecified, left footM20.61 Acquired deformities of toe(s), unspecified, right footM20.60 Acquired deformities of toe(s), unspecified, unspecified footM95.4 Acquired deformity of chest and ribM95.9 Acquired deformity of musculoskeletal system, unspecifiedM95.3 Acquired deformity of neckM95.0 Acquired deformity of noseM95.5 Acquired deformity of pelvisL85.0 Acquired ichthyosisL85.1 Acquired keratosis [keratoderma] palmaris et plantarisL11.0 Acquired keratosis follicularisH04.553 Acquired stenosis of bilateral nasolacrimal ductH04.552 Acquired stenosis of left nasolacrimal ductH04.551 Acquired stenosis of right nasolacrimal ductH04.559 Acquired stenosis of unspecified nasolacrimal ductL90.4 Acrodermatitis chronica atrophicansL57.5 Actinic granulomaL57.0 Actinic keratosisL57.1 Actinic reticuloidH04.013 Acute dacryoadenitis, bilateral lacrimal glandsH04.012 Acute dacryoadenitis, left lacrimal glandH04.011 Acute dacryoadenitis, right lacrimal glandH04.019 Acute dacryoadenitis, unspecified lacrimal glandH04.323 Acute dacryocystitis of bilateral lacrimal passagesH04.322 Acute dacryocystitis of left lacrimal passageH04.321 Acute dacryocystitis of right lacrimal passageH04.329 Acute dacryocystitis of unspecified lacrimal passageT80.910S Acute hemolytic transfusion reaction, unspecified incompatibility, sequelaT80.22XS Acute infection following transfusion, infusion, or injection of blood and blood

products, sequelaH04.333 Acute lacrimal canaliculitis of bilateral lacrimal passagesH04.332 Acute lacrimal canaliculitis of left lacrimal passageH04.331 Acute lacrimal canaliculitis of right lacrimal passageH04.339 Acute lacrimal canaliculitis of unspecified lacrimal passageM93.032 Acute on chronic slipped upper femoral epiphysis (nontraumatic), left hipM93.031 Acute on chronic slipped upper femoral epiphysis (nontraumatic), right hipM93.033 Acute on chronic slipped upper femoral epiphysis (nontraumatic), unspecified hipG89.11 Acute pain due to traumaG89.12 Acute post-thoracotomy painL58.0 Acute radiodermatitisR06.03 Acute respiratory distressL56.9 Acute skin change due to ultraviolet radiation, unspecifiedM93.012 Acute slipped upper femoral epiphysis (nontraumatic), left hipM93.011 Acute slipped upper femoral epiphysis (nontraumatic), right hipM93.013 Acute slipped upper femoral epiphysis (nontraumatic), unspecified hipH17.03 Adherent leukoma, bilateralH17.02 Adherent leukoma, left eyeH17.01 Adherent leukoma, right eyeH17.00 Adherent leukoma, unspecified eyeN47.0 Adherent prepuce, newbornM26.613 Adhesions and ankylosis of bilateral temporomandibular jointM26.612 Adhesions and ankylosis of left temporomandibular jointM26.611 Adhesions and ankylosis of right temporomandibular joint

Compiled: 03/2020



Blood Counts85004, 85007, 85008, 85013, 85014, 85018, 85025, 85027, 85032, 85048, 85049

ICD-10-CM codes that DO NOT Support Medical Necessity ICD-10-CM codes that DO NOT Support Medical NecessityT40.7X5S Adverse effect of cannabis (derivatives), sequelaT50.2X5S Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other

diuretics, sequelaT46.0X5S Adverse effect of cardiac-stimulant glycosides and drugs of similar action, sequelaT44.8X5S Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, sequelaT36.1X5S Adverse effect of cephalosporins and other beta-lactam antibiotics, sequelaT36.2X5S Adverse effect of chloramphenicol group, sequelaT40.5X5S Adverse effect of cocaine, sequelaT46.3X5S Adverse effect of coronary vasodilators, sequelaT49.7X5S Adverse effect of dental drugs, topically applied, sequelaT50.8X5S Adverse effect of diagnostic agents, sequelaT47.5X5S Adverse effect of digestants, sequelaT50.4X5S Adverse effect of drugs affecting uric acid metabolism, sequelaT50.3X5S Adverse effect of electrolytic, caloric and water-balance agents, sequelaT47.7X5S Adverse effect of emetics, sequelaT49.3X5S Adverse effect of emollients, demulcents and protectants, sequelaT45.3X5S Adverse effect of enzymes, sequelaT48.4X5S Adverse effect of expectorants, sequelaT44.2X5S Adverse effect of ganglionic blocking drugs, sequelaT38.0X5S Adverse effect of glucocorticoids and synthetic analogues, sequelaT45.625S Adverse effect of hemostatic drug, sequelaT47.0X5S Adverse effect of histamine H2-receptor blockers, sequelaT42.0X5S Adverse effect of hydantoin derivatives, sequelaT42.1X5S Adverse effect of iminostilbenes, sequelaT50.Z15S Adverse effect of immunoglobulin, sequelaT41.0X5S Adverse effect of inhaled anesthetics, sequelaT38.3X5S Adverse effect of insulin and oral hypoglycemic [antidiabetic] drugs, sequelaT41.1X5S Adverse effect of intravenous anesthetics, sequelaT45.4X5S Adverse effect of iron and its compounds, sequelaT49.4X5S Adverse effect of keratolytics, keratoplastics, and other hair treatment drugs and

preparations, sequelaT41.3X5S Adverse effect of local anesthetics, sequelaT49.0X5S Adverse effect of local antifungal, anti-infective and anti-inflammatory drugs,

sequelaT49.2X5S Adverse effect of local astringents and local detergents, sequelaT50.1X5S Adverse effect of loop [high-ceiling] diuretics, sequelaT36.3X5S Adverse effect of macrolides, sequelaT40.3X5S Adverse effect of methadone, sequelaT43.635S Adverse effect of methylphenidate, sequelaT50.0X5S Adverse effect of mineralocorticoids and their antagonists, sequelaT42.5X5S Adverse effect of mixed antiepileptics, sequelaT50.A25S Adverse effect of mixed bacterial vaccines without a pertussis component, sequelaT43.1X5S Adverse effect of monoamine-oxidase-inhibitor antidepressants, sequelaT50.915S Adverse effect of multiple unspecified drugs, medicaments and biological

substances, sequelaT49.5X5S Adverse effect of ophthalmological drugs and preparations, sequelaT40.0X5S Adverse effect of opium, sequelaT38.4X5S Adverse effect of oral contraceptives, sequelaT48.995S Adverse effect of other agents primarily acting on the respiratory system, sequelaT47.8X5S Adverse effect of other agents primarily affecting gastrointestinal system, sequelaT46.995S Adverse effect of other agents primarily affecting the cardiovascular system,

sequelaT47.1X5S Adverse effect of other antacids and anti-gastric-secretion drugs, sequelaT48.5X5S Adverse effect of other anti-common-cold drugs, sequela

M42.17 Adult osteochondrosis of spine, lumbosacral regionM42.19 Adult osteochondrosis of spine, multiple sites in spineM42.11 Adult osteochondrosis of spine, occipito-atlanto-axial regionM42.18 Adult osteochondrosis of spine, sacral and sacrococcygeal regionM42.10 Adult osteochondrosis of spine, site unspecifiedM42.14 Adult osteochondrosis of spine, thoracic regionM42.15 Adult osteochondrosis of spine, thoracolumbar regionT74.11XS Adult physical abuse, confirmed, sequelaT76.11XS Adult physical abuse, suspected, sequelaT74.31XS Adult psychological abuse, confirmed, sequelaT76.31XS Adult psychological abuse, suspected, sequelaT74.21XS Adult sexual abuse, confirmed, sequelaT76.21XS Adult sexual abuse, suspected, sequelaT39.1X5S Adverse effect of 4-Aminophenol derivatives, sequelaT44.6X5S Adverse effect of alpha-adrenoreceptor antagonists, sequelaT36.5X5S Adverse effect of aminoglycosides, sequelaT43.625S Adverse effect of amphetamines, sequelaT50.7X5S Adverse effect of analeptics and opioid receptor antagonists, sequelaT38.7X5S Adverse effect of androgens and anabolic congeners, sequelaT46.4X5S Adverse effect of angiotensin-converting-enzyme inhibitors, sequelaT38.815S Adverse effect of anterior pituitary [adenohypophyseal] hormones, sequelaT37.4X5S Adverse effect of anthelminthics, sequelaT45.0X5S Adverse effect of antiallergic and antiemetic drugs, sequelaT48.6X5S Adverse effect of antiasthmatics, sequelaT44.0X5S Adverse effect of anticholinesterase agents, sequelaT45.7X5S Adverse effect of anticoagulant antagonists, vitamin K and other coagulants,

sequelaT45.515S Adverse effect of anticoagulants, sequelaT47.6X5S Adverse effect of antidiarrheal drugs, sequelaT50.6X5S Adverse effect of antidotes and chelating agents, sequelaT36.7X5S Adverse effect of antifungal antibiotics, systemically used, sequelaT38.6X5S Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not

elsewhere classified, sequelaT46.6X5S Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, sequelaT37.2X5S Adverse effect of antimalarials and drugs acting on other blood protozoa, sequelaT37.1X5S Adverse effect of antimycobacterial drugs, sequelaT45.1X5S Adverse effect of antineoplastic and immunosuppressive drugs, sequelaT42.8X5S Adverse effect of antiparkinsonism drugs and other central muscle-tone

depressants, sequelaT49.1X5S Adverse effect of antipruritics, sequelaT39.4X5S Adverse effect of antirheumatics, not elsewhere classified, sequelaT45.525S Adverse effect of antithrombotic drugs, sequelaT38.2X5S Adverse effect of antithyroid drugs, sequelaT48.3X5S Adverse effect of antitussives, sequelaT46.8X5S Adverse effect of antivaricose drugs, including sclerosing agents, sequelaT37.5X5S Adverse effect of antiviral drugs, sequelaT50.5X5S Adverse effect of appetite depressants, sequelaT39.015S Adverse effect of aspirin, sequelaT42.3X5S Adverse effect of barbiturates, sequelaT42.4X5S Adverse effect of benzodiazepines, sequelaT44.7X5S Adverse effect of beta-adrenoreceptor antagonists, sequelaT43.4X5S Adverse effect of butyrophenone and thiothixene neuroleptics, sequelaT43.615S Adverse effect of caffeine, sequelaT46.1X5S Adverse effect of calcium-channel blockers, sequela

Compiled: 03/2020



Blood Counts85004, 85007, 85008, 85013, 85014, 85018, 85025, 85027, 85032, 85048, 85049

ICD-10-CM codes that DO NOT Support Medical Necessity ICD-10-CM codes that DO NOT Support Medical NecessityT50.B15S Adverse effect of smallpox vaccines, sequelaT47.2X5S Adverse effect of stimulant laxatives, sequelaT42.2X5S Adverse effect of succinimides and oxazolidinediones, sequelaT37.0X5S Adverse effect of sulfonamides, sequelaT43.025S Adverse effect of tetracyclic antidepressants, sequelaT36.4X5S Adverse effect of tetracyclines, sequelaT41.5X5S Adverse effect of therapeutic gases, sequelaT45.615S Adverse effect of thrombolytic drugs, sequelaT38.1X5S Adverse effect of thyroid hormones and substitutes, sequelaT43.015S Adverse effect of tricyclic antidepressants, sequelaT48.905S Adverse effect of unspecified agents primarily acting on the respiratory system,

sequelaT46.905S Adverse effect of unspecified agents primarily affecting the cardiovascular system,

sequelaT47.95XS Adverse effect of unspecified agents primarily affecting the gastrointestinal

system, sequelaT41.45XS Adverse effect of unspecified anesthetic, sequelaT43.205S Adverse effect of unspecified antidepressants, sequelaT42.75XS Adverse effect of unspecified antiepileptic and sedative-hypnotic drugs, sequelaT43.505S Adverse effect of unspecified antipsychotics and neuroleptics, sequelaT48.205S Adverse effect of unspecified drugs acting on muscles, sequelaT44.905S Adverse effect of unspecified drugs primarily affecting the autonomic nervous

system, sequelaT50.905S Adverse effect of unspecified drugs, medicaments and biological substances,

sequelaT45.605S Adverse effect of unspecified fibrinolysis-affecting drugs, sequelaT41.205S Adverse effect of unspecified general anesthetics, sequelaT38.905S Adverse effect of unspecified hormone antagonists, sequelaT38.805S Adverse effect of unspecified hormones and synthetic substitutes, sequelaT40.605S Adverse effect of unspecified narcotics, sequelaT39.95XS Adverse effect of unspecified nonopioid analgesic, antipyretic and antirheumatic,

sequelaT45.95XS Adverse effect of unspecified primarily systemic and hematological agent, sequelaT40.905S Adverse effect of unspecified psychodysleptics [hallucinogens], sequelaT43.605S Adverse effect of unspecified psychostimulants, sequelaT43.95XS Adverse effect of unspecified psychotropic drug, sequelaT36.95XS Adverse effect of unspecified systemic antibiotic, sequelaT37.95XS Adverse effect of unspecified systemic anti-infective and antiparasitic, sequelaT49.95XS Adverse effect of unspecified topical agent, sequelaT45.2X5S Adverse effect of vitamins, sequelaZ47.32 Aftercare following explantation of hip joint prosthesisZ47.33 Aftercare following explantation of knee joint prosthesisZ47.31 Aftercare following explantation of shoulder joint prosthesisZ47.1 Aftercare following joint replacement surgeryZ31.42 Aftercare following sterilization reversalO92.3 AgalactiaH25.23 Age-related cataract, morgagnian type, bilateralH25.22 Age-related cataract, morgagnian type, left eyeH25.21 Age-related cataract, morgagnian type, right eyeH25.20 Age-related cataract, morgagnian type, unspecified eyeH31.113 Age-related choroidal atrophy, bilateralH31.112 Age-related choroidal atrophy, left eyeH31.111 Age-related choroidal atrophy, right eyeH31.119 Age-related choroidal atrophy, unspecified eyeH25.13 Age-related nuclear cataract, bilateral

T43.295S Adverse effect of other antidepressants, sequelaT46.2X5S Adverse effect of other antidysrhythmic drugs, sequelaT42.6X5S Adverse effect of other antiepileptic and sedative-hypnotic drugs, sequelaT46.5X5S Adverse effect of other antihypertensive drugs, sequelaT37.3X5S Adverse effect of other antiprotozoal drugs, sequelaT43.595S Adverse effect of other antipsychotics and neuroleptics, sequelaT50.A95S Adverse effect of other bacterial vaccines, sequelaT44.995S Adverse effect of other drug primarily affecting the autonomic nervous system,

sequelaT48.295S Adverse effect of other drugs acting on muscles, sequelaT50.995S Adverse effect of other drugs, medicaments and biological substances, sequelaT38.5X5S Adverse effect of other estrogens and progestogens, sequelaT45.695S Adverse effect of other fibrinolysis-affecting drugs, sequelaT41.295S Adverse effect of other general anesthetics, sequelaT38.995S Adverse effect of other hormone antagonists, sequelaT38.895S Adverse effect of other hormones and synthetic substitutes, sequelaT47.4X5S Adverse effect of other laxatives, sequelaT40.695S Adverse effect of other narcotics, sequelaT39.8X5S Adverse effect of other nonopioid analgesics and antipyretics, not elsewhere

classified, sequelaT39.395S Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], sequelaT40.2X5S Adverse effect of other opioids, sequelaT44.3X5S Adverse effect of other parasympatholytics [anticholinergics and antimuscarinics]

and spasmolytics, sequelaT44.1X5S Adverse effect of other parasympathomimetics [cholinergics], sequelaT45.8X5S Adverse effect of other primarily systemic and hematological agents, sequelaT40.995S Adverse effect of other psychodysleptics [hallucinogens], sequelaT43.695S Adverse effect of other psychostimulants, sequelaT43.8X5S Adverse effect of other psychotropic drugs, sequelaT37.8X5S Adverse effect of other specified systemic anti-infectives and antiparasitics,

sequelaT40.4X5S Adverse effect of other synthetic narcotics, sequelaT36.8X5S Adverse effect of other systemic antibiotics, sequelaT49.8X5S Adverse effect of other topical agents, sequelaT50.Z95S Adverse effect of other vaccines and biological substances, sequelaT50.B95S Adverse effect of other viral vaccines, sequelaT49.6X5S Adverse effect of otorhinolaryngological drugs and preparations, sequelaT48.0X5S Adverse effect of oxytocic drugs, sequelaT36.0X5S Adverse effect of penicillins, sequelaT46.7X5S Adverse effect of peripheral vasodilators, sequelaT50.A15S Adverse effect of pertussis vaccine, including combinations with a pertussis

component, sequelaT43.3X5S Adverse effect of phenothiazine antipsychotics and neuroleptics, sequelaT44.4X5S Adverse effect of predominantly alpha-adrenoreceptor agonists, sequelaT44.5X5S Adverse effect of predominantly beta-adrenoreceptor agonists, sequelaT39.315S Adverse effect of propionic acid derivatives, sequelaT39.2X5S Adverse effect of pyrazolone derivatives, sequelaT36.6X5S Adverse effect of rifampicins, sequelaT39.095S Adverse effect of salicylates, sequelaT47.3X5S Adverse effect of saline and osmotic laxatives, sequelaT43.215S Adverse effect of selective serotonin and norepinephrine reuptake inhibitors,

sequelaT43.225S Adverse effect of selective serotonin reuptake inhibitors, sequelaT48.1X5S Adverse effect of skeletal muscle relaxants [neuromuscular blocking agents],

sequela

Compiled: 03/2020



Blood Counts85004, 85007, 85008, 85013, 85014, 85018, 85025, 85027, 85032, 85048, 85049

ICD-10-CM codes that DO NOT Support Medical Necessity ICD-10-CM codes that DO NOT Support Medical NecessityM80.041S Age-related osteoporosis with current pathological fracture, right hand, sequelaM80.041G Age-related osteoporosis with current pathological fracture, right hand,

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

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

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

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

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

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

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

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

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

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

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

foot, sequelaM80.079G Age-related osteoporosis with current pathological fracture, u

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