Medicare National and Local Coverage Determination Policy – …€¦ · Medicare National and...

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QuestDiagnostics.com Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved

Policies in this MLCP Reference Guide apply to testing performed at a Quest Diagnostics facility and apply to Medicare National Coverage Determination Policy. This diagnosis code reference guide is provided as an aid to physicians and office staff in determining when an ABN (Advance Beneficiary Notice) is necessary. Diagnosis codes must be applicable to the patient’s symptoms or conditions and must be consistent with documentation in the patient’s medical record. Quest Diagnostics does not recommend any diagnosis codes and will only submit diagnosis information provided to us by the ordering physician or his/her designated staff. The CPT codes provided are based on AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.

Please note this document has been updated with National Medicare changes effective 7/1/2015

Medicare National and Local Coverage Determination Policy – KS, MO, NE

08/25/2015

• Click policy below for Local MLCP Policy Tool Document contains the below Medicare Local Limited Coverage Policies for lab testing performed in KS, MO, NE

•Allergy Testing and Immunotherapy •Circulating Tumor Cell Marker Assays •Cytogenetic Studies •Drug Testing •Flow Cytometry •Molecular Diagnostic Testing •Vitamin D Assay Testing

• Click here for National MLCP Policies Tool Document contains information on National Medicare Limited Coverage Policies • Alpha-Fetoprotein • Blood Counts • Blood Glucose Testing • Carcinoembryonic Antigen • Collagen Crosslinks - Any Method • Digoxin Therapeutic Drug Assay • Fecal Occult Blood • Gamma Glutamyl Transferase • Glycated Hemoglobin - Glycated Protein • Hepatitis Panel/Acute Hepatitis Panel • Human Chorionic Gonadotropin • Human Immunodeficiency Virus (HIV) Testing

(Diagnosis) • Human Immunodeficiency Virus (HIV) Testing

(Prognosis Including Monitoring) • Lipids Testing • Partial Thromboplastin Time (PTT) • Prostate Specific Antigen • Prothrombin Time (PT) • Serum Iron Studies • Thyroid Testing • Tumor Antigen by Immunoassay CA 15-3 CA 27.29 • Tumor Antigen by Immunoassay CA 19-9 • Tumor Antigen by Immunoassay CA-125 • Urine Culture, Bacterial

http://corpwebcms.qdx.com/dms/Documents/mlcp/ICD9-MLCP/Tool1.pdf%23page=1

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Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com Allergy Testing and Allergy Immunotherapy (L30471) Page 1 of 2 Testing performed by Quest Diagnostics Nichols Institute CPT Code: 86003

LCD Description: These tests include the performance and evaluation of selective cutaneous and mucous membrane tests in correlation with history, physical examination, and other observations of the patient. The tests are performed to determine body sensitivity and reaction to the antigen for the purpose of diagnosing the presence of allergic reaction to antigenic stimuli. The number of tests performed should be judicious and dependent upon the history, physical finding and clinical judgment. All patients should not necessarily receive the same tests or the same number of sensitivity tests. Intradermal tests are injections of small amounts of antigen into the superficial layers of the skin. ICD-9-CM Codes that Support Medical Necessity Allergy testing is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 117.3 ASPERGILLOSIS 372.05 ACUTE ATOPIC CONJUNCTIVITIS 372.14 OTHER CHRONIC ALLERGIC CONJUNCTIVITIS 381.10 CHRONIC SEROUS OTITIS MEDIA SIMPLE OR UNSPECIFIED 381.19 OTHER CHRONIC SEROUS OTITIS MEDIA 381.3 OTHER AND UNSPECIFIED CHRONIC NONSUPPURATIVE OTITIS MEDIA 381.4 NONSUPPURATIVE OTITIS MEDIA NOT SPECIFIED AS ACUTE OR CHRONIC 381.50 - 381.52 EUSTACHIAN SALPINGITIS UNSPECIFIED - CHRONIC EUSTACHIAN SALPINGITIS 381.81 DYSFUNCTION OF EUSTACHIAN TUBE 382.9 UNSPECIFIED OTITIS MEDIA 466.0 ACUTE BRONCHITIS 471.0 POLYP OF NASAL CAVITY 471.8 OTHER POLYP OF SINUS 472.0 CHRONIC RHINITIS 474.00 - 474.02 CHRONIC TONSILLITIS - CHRONIC TONSILLITIS AND ADENOIDITIS 474.10 - 474.12 HYPERTROPHY OF TONSIL WITH ADENOIDS - HYPERTROPHY OF ADENOIDS ALONE 477.0 ALLERGIC RHINITIS DUE TO POLLEN 477.1 ALLERGIC RHINITIS DUE TO FOOD 477.2 ALLERGIC RHINITIS, DUE TO ANIMAL (CAT) (DOG) HAIR AND DANDER 477.8 ALLERGIC RHINITIS DUE TO OTHER ALLERGEN 477.9 ALLERGIC RHINITIS CAUSE UNSPECIFIED 478.11 NASAL MUCOSITIS (ULCERATIVE) 478.19 OTHER DISEASE OF NASAL CAVITY AND SINUSES 493.00 EXTRINSIC ASTHMA UNSPECIFIED 493.01 EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS 493.02 EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION 493.10 INTRINSIC ASTHMA UNSPECIFIED 493.11 INTRINSIC ASTHMA WITH STATUS ASTHMATICUS 493.12 NTRINSIC ASTHMA WITH (ACUTE) EXACERBATION 493.20 CHRONIC OBSTRUCTIVE ASTHMA UNSPECIFIED

08/25/2015

http://www.cms.gov/medicare-coverage-database/staticpages/icd9-code-range.aspx?DocType=LCD&DocID=30471&ver=&Group=2&RangeStart=381.50&RangeEnd=381.52



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Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com Allergy Testing and Allergy Immunotherapy (L30471) Page 2 of 2 Testing performed by Quest Diagnostics Nichols Institute CPT Code: 86003

LCD Description: These tests include the performance and evaluation of selective cutaneous and mucous membrane tests in correlation with history, physical examination, and other observations of the patient. The tests are performed to determine body sensitivity and reaction to the antigen for the purpose of diagnosing the presence of allergic reaction to antigenic stimuli. The number of tests performed should be judicious and dependent upon the history, physical finding and clinical judgment. All patients should not necessarily receive the same tests or the same number of sensitivity tests. Intradermal tests are injections of small amounts of antigen into the superficial layers of the skin. ICD-9-CM Codes that Support Medical Necessity Allergy testing is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided.

493.21 CHRONIC OBSTRUCTIVE ASTHMA WITH STATUS ASTHMATICUS 493.22 CHRONIC OBSTRUCTIVE ASTHMA WITH (ACUTE) EXACERBATION 493.82 COUGH VARIANT ASTHMA 493.90 ASTHMA UNSPECIFIED 493.91 ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS 493.92 ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION 518.6 ALLERGIC BRONCHOPULMONARY ASPERGILLIOSIS 691.8 OTHER ATOPIC DERMATITIS AND RELATED CONDITIONS 692.9 CONTACT DERMATITIS AND OTHER ECZEMA UNSPECIFIED CAUSE 693.0 DERMATITIS DUE TO DRUGS AND MEDICINES TAKEN INTERNALLY 693.1 DERMATITIS DUE TO FOOD TAKEN INTERNALLY 693.8 DERMATITIS DUE TO OTHER SPECIFIED SUBSTANCES TAKEN INTERNALLY 693.9 DERMATITIS DUE TO UNSPECIFIED SUBSTANCE TAKEN INTERNALLY 708.0 ALLERGIC URTICARIA 708.3 DERMATOGRAPHIC URTICARIA 708.8 OTHER SPECIFIED URTICARIA 708.9 UNSPECIFIED URTICARIA 781.1 DISTURBANCES OF SENSATION OF SMELL AND TASTE 782.1 RASH AND OTHER NONSPECIFIC SKIN ERUPTION 786.07 WHEEZING 989.5 TOXIC EFFECT OF VENOM 989.82 TOXIC EFFECT OF LATEX 995.0 OTHER ANAPHYLACTIC REACTION 995.1 ANGIONEUROTIC EDEMA NOT ELSEWHERE CLASSIFIED 995.27 OTHER DRUG ALLERGY 995.3 ALLERGY UNSPECIFIED NOT ELSEWHERE CLASSIFIED 995.60 - 995.69 ANAPHYLACTIC REACTION DUE TO UNSPECIFIED FOOD - ANAPHYLACTIC REACTION DUE TO OTHER SPECIFIED FOOD 995.7 OTHER ADVERSE FOOD REACTIONS NOT ELSEWHERE CLASSIFIED V15.09 PERSONAL HISTORY OF OTHER ALLERGY OTHER THAN TO MEDICINAL AGENTS V67.59 OTHER FOLLOW-UP EXAMINATION

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LCD Description:. The CellSearch assay, an independent predictor of progression-free survival and overall survival in patients with metastatic breast, colorectal and prostate cancer, involves the automated immunomagnetic selection of CTCs based on an anti-EpCAM antibody cell capture. To perform this assay, a 7.5 ml aliquot of blood is incubated with EpCAM antibody-covered ferroparticles (nanotechnology). Circulating epithelial cells that express EpCAM are isolated in a magnetic field without centrifugation. ICD – 9-CM Codes that Support Medical Necessity Circulating Tumor Cell Marker Assays is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided.

Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com Circulating Tumor Cell Marker Assays (L32218) Testing performed by Quest Diagnostics Nichols Institute Kansas, Missouri, Nebraska CPT Codes: 86152 and 86153

153.0 MALIGNANT NEOPLASM OF HEPATIC FLEXURE 153.1 MALIGNANT NEOPLASM OF TRANSVERSE COLON 153.2 MALIGNANT NEOPLASM OF DESCENDING COLON 153.3 MALIGNANT NEOPLASM OF SIGMOID COLON 153.4 MALIGNANT NEOPLASM OF CECUM 153.5 MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS 153.6 MALIGNANT NEOPLASM OF ASCENDING COLON 153.7 MALIGNANT NEOPLASM OF SPLENIC FLEXURE 153.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE 153.9 MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE 154.0 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION 154.1 MALIGNANT NEOPLASM OF RECTUM 154.2 MALIGNANT NEOPLASM OF ANAL CANAL 154.3 MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE 154.8 MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS 174.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST 174.1 MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST 174.2 MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST 174.3 MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST

174.4 MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST 174.5 MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST 174.6 MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST 174.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST 174.9 MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE 175.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST 175.9 MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST 185 MALIGNANT NEOPLASM OF PROSTATE This is a coverage policy for the CellSearch (Veridex) circulating tumor cell (CTC) assay. All other methods for circulating tumor cell detection, including reverse-transcription polymerase chain reaction PCR (RTPCR) Assays, are non-covered.

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LCD Description:. Cytogenetics is the study of chromosomes by light or fluorescent microscopy. Cytogenetic testing is used to study an individual s chromosome makeup. The term karyotyping refers to the arrangement of nuclear chromosomes in order from the largest to the smallest to analyze their number and structure. Variations in chromosome number or structure can produce a variety of clinical findings, including abnormalities of growth and intellect, congenital anomalies and, in the case of sex chromosome abnormalities ambiguous gender. Cytogenetic testing determines the number of chromosomes, defines the chromosome and examines the individual chromosomes for structural abnormalities such as deletions, duplications and translocations. ICD – 9-CM Codes that Support Medical Necessity Cytogenetic Analysis is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided.

Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com Cytogenetic Studies (L30487) Testing performed by Quest Diagnostics Nichols Institute Kansas, Missouri, Nebraska CPT Codes 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88299

Constitutional Cytogenetic Studies 88230, 88235, 88262, 88267, 88269, 88283, 88289 228.1 653.71 783.40 256.39 653.73 783.41 257.8 655.10-655.13 783.42 259.0 655.20-655.23 783.43 289.81 656.40 792.3 289.83 656.41 796.5 299.00-299.11 656.43 V13.61-V13.69 317-319 656.50 V18.4 334.8 656.51 V18.51 388.5 656.53 V18.61 606.0 656.60 V18.9 606.1 656.61 V19.5 611.1 656.63 V23.2 628.9 657.00-657.03 V23.81-V23.82 630-631.8 658.00-658.03 V28.0-V28.4 632 659.50-659.63 V83.01 634.00-634.92 740.0-759.9 V83.02 646.33 764.90-764.99 V83.81 653.70 779.9 V83.89

Acquired (cancer) chromosome studies 88230, 88237, 88239, 88262, 88271, 88272, 88273, 88274, 88275,

88280, 88283 143.9 200.00-202.98 209.00-209.69 239.3 152.1-152.8 203.00-203.02 223.3 239.4 158.0 203.10-203.12 225.2 273.1 162.0-165.9 203.80-203.82 230.0 273.3 170.0-170.9 204.00-204.02 231.0 281.0-281.9 171.0-171.9 204.10-204.12 232.9 284.01-284.09 173.00-173.99 204.20-204.22 233.0 284.19 173.9 204.80-204.82 233.30-233.39 284.2-284.9 174.0-174.9 204.90-204.92 233.7 285.0-285.9 175.0-175.9 205.00-205.92 233.9 287.30-287.39 188.0-188.9 206.00-206.92 234.0 287.5 189.0-189.9 207.00-207.82 236.7 288.09 190.1 208.00-208.02 238.4 288.50-288.59 191.0-191.9 208.10-208.12 238.5 288.60-288.69 192.3 208.20-208.22 238.6 289.89 197.0-197.8 208.80-208.82 238.71-238.79 198.0-198.89 208.90-208.92 239.2

Syndromes that predispose to malignancy 88230, 88245, 88248, 88249, 88283 284.01 284.09 334.8 757.39 759.89

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LCD Description:. ICD – 9-CM Codes that Support Medical Necessity A qualitative/presumptive drug screen is used to detect the presence of a drug in the body. A blood or urine sample may be used. However, urine is the best specimen for broad screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants. Common methods of drug analysis include chromatography, immunoassay, chemical ("spot") tests, and spectrometry.

Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com (Drug Testing (L32450) Testing performed by Quest Diagnostics Nichols Institute Kansas, Missouri, Nebraska CPT Codes G0431, G0434, G6058, 80300, 80301, 80302, 80303, 80304

CPT Codes: G0431, G0434, G6058 276.2 ACIDOSIS 295.00 - 295.30 SIMPLE TYPE SCHIZOPHRENIA UNSPECIFIED STATE - PARANOID TYPE SCHIZOPHRENIA UNSPECIFIED STATE 304.01 OPIOID TYPE DEPENDENCE CONTINUOUS USE 304.90 UNSPECIFIED DRUG DEPENDENCE UNSPECIFIED USE 305.90 OTHER MIXED OR UNSPECIFIED DRUG ABUSE UNSPECIFIED USE 345.10 - 345.11 GENERALIZED CONVULSIVE EPILEPSY WITHOUT INTRACTABLE EPILEPSY - GENERALIZED CONVULSIVE EPILEPSY WITH INTRACTABLE EPILEPSY 345.3 GRAND MAL STATUS EPILEPTIC 345.90 - 345.91 EPILEPSY UNSPECIFIED WITHOUT INTRACTABLE EPILEPSY - EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY 426.10 - 426.13 ATRIOVENTRICULAR BLOCK UNSPECIFIED - OTHER SECOND DEGREE ATRIOVENTRICULAR BLOCK 426.82 LONG QT SYNDROME 427.0 - 427.1 PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - PAROXYSMAL VENTRICULAR TACHYCARDIA 780.01 COMA 780.09 ALTERATION OF CONSCIOUSNESS OTHER 780.1 HALLUCINATIONS 780.39 OTHER CONVULSIONS 780.97 ALTERED MENTAL STATUS 963.0 POISONING BY ANTIALLERGIC AND ANTIEMETIC DRUGS 965.00 - 965.09 POISONING BY OPIUM (ALKALOIDS) UNSPECIFIED - POISONING BY OTHER OPIATES AND RELATED NARCOTICS 965.1 POISONING BY SALICYLATES 965.4 POISONING BY AROMATIC ANALGESICS NOT ELSEWHERE CLASSIFIED 965.5 POISONING BY PYRAZOLE DERIVATIVES 965.61 POISONING BY PROPIONIC ACID DERIVATIVES 966.1 POISONING BY HYDANTOIN DERIVATIVES 967.0 - 967.9 POISONING BY BARBITURATES - POISONING BY UNSPECIFIED SEDATIVE OR HYPNOTIC 969.00 - 969.9 POISONING BY ANTIDEPRESSANT, UNSPECIFIED - POISONING BY UNSPECIFIED PSYCHOTROPIC AGENT 970.81 POISONING BY COCAINE 972.1 POISONING BY CARDIOTONIC GLYCOSIDES AND DRUGS OF SIMILAR ACTION 977.9 POISONING BY UNSPECIFIED DRUG OR MEDICINAL SUBSTANCE V15.81 PERSONAL HISTORY OF NONCOMPLIANCE WITH MEDICAL TREATMENT PRESENTING HAZARDS TO HEALTH V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS V71.09 OBSERVATION OF OTHER SUSPECTED MENTAL CONDITION The following CPT codes are Non-Covered by Medicare 80300, 80301, 80302, 80303, 80304

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LCD Description:. Flow Cytometry is a cell analysis process performed by allowing cells in liquid suspension to pass through a laser-produced beam of light for the actual analysis of the cell. Specimens are usually treated with reagents that are chosen to amplify certain signals, such as antigens on a cell surface or within the cytoplasm or nucleus, or DNA content within a cell. Data is generated and organized by the instrument. Clinical analysis and interpretations are performed by an experienced physician, usually a hematopathologist. ICD-9-CM Codes that Support Medical Necessity Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided.

Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com Flow Cytometry (L30161) (Page 1 of 17 ) Testing performed by Quest Diagnostics Nichols Institute CPT Codes 88182, 88184, 88185, 88187, 88188, 88189

CPT 88184, 88185, 88187, 88188, 88189

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042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE 079.51 HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE I [HTLV-I] 079.52 HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE II [HTLV-II] 079.53 HUMAN IMMUNODEFICIENCY VIRUS TYPE 2 [HIV-2] 099.3 REITER'S DISEASE 200.00 RETICULOSARCOMA UNSPECIFIED SITE 200.01 RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK 200.02 RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES 200.03 RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

200.04 RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

200.05 RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.06 RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES 200.07 RETICULOSARCOMA INVOLVING SPLEEN 200.08 RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 200.10 LYMPHOSARCOMA UNSPECIFIED SITE 200.11 LYMPHOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK 200.12 LYMPHOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES 200.13 LYMPHOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES 200.14 LYMPHOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

200.15 LYMPHOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.16 LYMPHOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES

200.17 LYMPHOSARCOMA INVOLVING SPLEEN

200.18 LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

200.20 BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE

200.21 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.22 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES

200.23 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

200.24 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

200.25 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.26 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES

200.27 BURKITT'S TUMOR OR LYMPHOMA INVOLVING SPLEEN

200.28 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

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CPT Code 88184, 88185, 88187, 88188, 88189 200.30 MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND

SOLID ORGAN SITES 200.31 MARGINAL ZONE LYMPHOMA,LYMPH NODES OF HEAD, FACE, AND NECK 200.32 MARGINAL ZONE LYMPHOMA,INTRATHORACIC LYMPH NODES 200.33 MARGINAL ZONE LYMPHOMA, INTRAABDOMINAL LYMPH NODES 200.34 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.35 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.36 MARGINAL ZONE LYMPHOMA, INTRAPELVIC LYMPH NODES 200.37 MARGINAL ZONE LYMPHOMA, SPLEEN 200.38 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.40 MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.41 MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 200.42 MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES 200.43 MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES 200.44 MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.45 MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.46 MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 200.47 MANTLE CELL LYMPHOMA, SPLEEN 200.48 MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.50 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.51 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.52 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRATHORACIC LYMPH NODES

200.53 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES

200.54 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.55 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.56 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRAPELVIC LYMPH NODES

200.57 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, SPLEEN

200.58 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.60 ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.61 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.62 ANAPLASTIC LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES 200.63 ANAPLASTIC LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES

200.64 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.65 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

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CPT Code 88184, 88185, 88187, 88188, 88189 200.66 ANAPLASTIC LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 200.67 ANAPLASTIC LARGE CELL LYMPHOMA, SPLEEN 200.68 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.70 LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.71 LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 200.72 LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES 200.73 LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES 200.74 LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.75 LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.76 LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 200.77 LARGE CELL LYMPHOMA, SPLEEN 200.78 LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.80 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE

200.81 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.82 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES

200.83 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

200.84 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

200.85 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.86 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES

200.87 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING SPLEEN

200.88 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.00 HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE

201.01 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.02 HODGKIN'S PARAGRANULOMA INVOLVING INTRATHORACIC LYMPH NODES

201.03 HODGKIN'S PARAGRANULOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.04 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.05 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.06 HODGKIN'S PARAGRANULOMA INVOLVING INTRAPELVIC LYMPH NODES 201.07 HODGKIN'S PARAGRANULOMA INVOLVING SPLEEN

201.08 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

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CPT Code 88184, 88185, 88187, 88188, 88189 201.10 HODGKIN'S GRANULOMA UNSPECIFIED SITE

201.11 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.12 HODGKIN'S GRANULOMA INVOLVING INTRATHORACIC LYMPH NODES 201.13 HODGKIN'S GRANULOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.14 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.15 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.16 HODGKIN'S GRANULOMA INVOLVING INTRAPELVIC LYMPH NODES 201.17 HODGKIN'S GRANULOMA INVOLVING SPLEEN 201.18 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 201.20 HODGKIN'S SARCOMA UNSPECIFIED SITE

201.21 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.22 HODGKIN'S SARCOMA INVOLVING INTRATHORACIC LYMPH NODES 201.23 HODGKIN'S SARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.24 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.25 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.26 HODGKIN'S SARCOMA INVOLVING INTRAPELVIC LYMPH NODES 201.27 HODGKIN'S SARCOMA INVOLVING SPLEEN

201.28 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.40 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE

201.41 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.42 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRATHORACIC LYMPH NODES

201.43 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.44 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.45 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.46 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRAPELVIC LYMPH NODES

201.47 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING SPLEEN

201.48 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF MULTIPLE SITES

201.5 HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED SITE

201.51 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

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CPT Code 88184, 88185, 88187, 88188, 88189

201.52 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRATHORACIC LYMPH NODES

201.53 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.54 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.55 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.56 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRAPELVIC LYMPH NODES

201.57 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING SPLEEN

201.58 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

201.60 HODGKIN'S DISEASE MIXED CELLULARITY UNSPECIFIED SITE

201.61 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.62 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRATHORACIC LYMPH NODES

201.63 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.64 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.65 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.66 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRAPELVIC LYMPH NODES

201.67 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING SPLEEN

201.68 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF MULTIPLE SITES

201.70 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION UNSPECIFIED SITE

201.71 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.72 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRATHORACIC LYMPH NODES

201.73 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.74 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.75 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.76 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRAPELVIC LYMPH NODES

201.77 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING SPLEEN

201.78 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF MULTIPLE SITES

201.90 HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED SITE

201.91 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.92 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRATHORACIC LYMPH NODES

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CPT Code 88184, 88185, 88187, 88188 ,88189

201.93 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.94 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.95 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.96 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRAPELVIC LYMPH NODES

201.97 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING SPLEEN

201.98 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.00 NODULAR LYMPHOMA UNSPECIFIED SITE

202.01 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.02 NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES 202.03 NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.04 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.05 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.06 NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES 202.07 NODULAR LYMPHOMA INVOLVING SPLEEN

202.08 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

202.10 MYCOSIS FUNGOIDES UNSPECIFIED SITE

202.11 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.12 MYCOSIS FUNGOIDES INVOLVING INTRATHORACIC LYMPH NODES

202.13 MYCOSIS FUNGOIDES INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.14 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.15 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.16 MYCOSIS FUNGOIDES INVOLVING INTRAPELVIC LYMPH NODES

202.17 MYCOSIS FUNGOIDES INVOLVING SPLEEN

202.18 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES

202.20 SEZARY'S DISEASE UNSPECIFIED SITE

202.21 SEZARY'S DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.22 SEZARY'S DISEASE INVOLVING INTRATHORACIC LYMPH NODES

202.23 SEZARY'S DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.24 SEZARY'S DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

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CPT Code 88184, 88185, 88187, 88188, 88189 202.25 SEZARY'S DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND

LOWER LIMB

202.26 SEZARY'S DISEASE INVOLVING INTRAPELVIC LYMPH NODES

202.27 SEZARY'S DISEASE INVOLVING SPLEEN

202.28 SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.3 MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE

202.31 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.32 MALIGNANT HISTIOCYTOSIS INVOLVING INTRATHORACIC LYMPH NODES

202.33 MALIGNANT HISTIOCYTOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.34 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.35 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.36 MALIGNANT HISTIOCYTOSIS INVOLVING INTRAPELVIC LYMPH NODES

202.37 MALIGNANT HISTIOCYTOSIS INVOLVING SPLEEN

202.38 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.40 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE

202.41 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.42 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES

202.43 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.44 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM

202.45 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.46 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES

202.47 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN

202.48 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.50 LETTERER-SIWE DISEASE UNSPECIFIED SITE

202.51 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.52 LETTERER-SIWE DISEASE INVOLVING INTRATHORACIC LYMPH NODES 202.53 LETTERER-SIWE DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.54 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.55 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.56 LETTERER-SIWE DISEASE INVOLVING INTRAPELVIC LYMPH NODES

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CPT Code 88184, 88185, 88187, 88188, 88189 202.57 LETTERER-SIWE DISEASE INVOLVING SPLEEN

202.58 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.60 MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE

202.61 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.62 MALIGNANT MAST CELL TUMORS INVOLVING INTRATHORACIC LYMPH NODES

202.63 MALIGNANT MAST CELL TUMORS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.64 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.65 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.66 MALIGNANT MAST CELL TUMORS INVOLVING INTRAPELVIC LYMPH NODES

202.67 MALIGNANT MAST CELL TUMORS INVOLVING SPLEEN

202.68 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.7 PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

202.71 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

202.72 PERIPHERAL T CELL LYMPHOMA, INTRATHORACIC LYMPH NODES

202.73 PERIPHERAL T CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES

202.74 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

202.75 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.76 PERIPHERAL T CELL LYMPHOMA, INTRAPELVIC LYMPH NODES

202.77 PERIPHERAL T CELL LYMPHOMA, SPLEEN

202.78 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

202.80 OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE

202.81 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.82 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRATHORACIC LYMPH NODES

202.83 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.84 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

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CPT Code 88184, 88185, 88187, 88188, 88189

202.85 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.86 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRAPELVIC LYMPH NODES

202.87 OTHER MALIGNANT LYMPHOMAS INVOLVING SPLEEN

202.88 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.90 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE

202.91 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.92 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRATHORACIC LYMPH NODES

202.93 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.94 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.95 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.96 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRAPELVIC LYMPH NODES

202.97 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING SPLEEN

202.98 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES

203.00 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

203.01 MULTIPLE MYELOMA IN REMISSION

203.02 MULTIPLE MYELOMA, IN RELAPSE

203.10 PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

203.11 PLASMA CELL LEUKEMIA IN REMISSION

203.12 PLASMA CELL LEUKEMIA, IN RELAPSE

203.80 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

203.81 OTHER IMMUNOPROLIFERATIVE NEOPLASMS IN REMISSION

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CPT Code 88184, 88185, 88187, 88188, 88189 203.82 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE

204.00 ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.01 LYMPHOID LEUKEMIA ACUTE IN REMISSION

204.02 ACUTE LYMPHOID LEUKEMIA, IN RELAPSE

204.1 CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.11 LYMPHOID LEUKEMIA CHRONIC IN REMISSION

204.12 CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE

204.2 SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.21 LYMPHOID LEUKEMIA SUBACUTE IN REMISSION

204.22 SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE

204.8 OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.81 OTHER LYMPHOID LEUKEMIA IN REMISSION

204.82 OTHER LYMPHOID LEUKEMIA, IN RELAPSE

204.90 UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.91 UNSPECIFIED LYMPHOID LEUKEMIA IN REMISSION

204.92 UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE

205.00 ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.01 MYELOID LEUKEMIA ACUTE IN REMISSION

205.02 ACUTE MYELOID LEUKEMIA, IN RELAPSE

205.10 CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.11 MYELOID LEUKEMIA CHRONIC IN REMISSION

205.12 CHRONIC MYELOID LEUKEMIA, IN RELAPSE

205.20 SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.21 MYELOID LEUKEMIA SUBACUTE IN REMISSION

205.22 SUBACUTE MYELOID LEUKEMIA, IN RELAPSE

205.30 MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.31 MYELOID SARCOMA IN REMISSION

205.32 MYELOID SARCOMA, IN RELAPSE

205.80 OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.81 OTHER MYELOID LEUKEMIA IN REMISSION

205.82 OTHER MYELOID LEUKEMIA, IN RELAPSE

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CPT Code 88184, 88185, 88187, 88188, 88189

205.90 UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.91 UNSPECIFIED MYELOID LEUKEMIA IN REMISSION

205.92 UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE

206.00 ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

206.01 MONOCYTIC LEUKEMIA ACUTE IN REMISSION

206.02 ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE

206.10 CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

206.11 MONOCYTIC LEUKEMIA CHRONIC IN REMISSION

206.12 CHRONIC MONOCYTIC LEUKEMIA, IN RELAPSE

206.20 SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

206.21 MONOCYTIC LEUKEMIA SUBACUTE IN REMISSION

206.22 SUBACUTE MONOCYTIC LEUKEMIA, IN RELAPSE

206.80 OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

206.81 OTHER MONOCYTIC LEUKEMIA IN REMISSION

206.82 OTHER MONOCYTIC LEUKEMIA, IN RELAPSE

206.90 UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

206.91 UNSPECIFIED MONOCYTIC LEUKEMIA IN REMISSION

206.92 UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE

207.00 ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

207.01 ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA IN REMISSION

207.02 ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, IN RELAPSE

207.10 CHRONIC ERYTHREMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

207.11 CHRONIC ERYTHREMIA IN REMISSION

207.12 CHRONIC ERYTHREMIA, IN RELAPSE

207.20 MEGAKARYOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

207.21 MEGAKARYOCYTIC LEUKEMIA IN REMISSION

207.22 MEGAKARYOCYTIC LEUKEMIA, IN RELAPSE

207.80 OTHER SPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

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CPT Code 88184, 88185, 88187, 88188, 88189

207.81 OTHER SPECIFIED LEUKEMIA IN REMISSION

207.82 OTHER SPECIFIED LEUKEMIA, IN RELAPSE

208.00 ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

208.01 LEUKEMIA OF UNSPECIFIED CELL TYPE ACUTE IN REMISSION

208.02 ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE

208.10 CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

208.11 LEUKEMIA OF UNSPECIFIED CELL TYPE CHRONIC IN REMISSION

208.12 CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE

208.20 SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

208.21 LEUKEMIA OF UNSPECIFIED CELL TYPE SUBACUTE IN REMISSION

208.22 SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE

208.80 OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

208.81 OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE IN REMISSION

208.82 OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE

208.90 UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

208.91 UNSPECIFIED LEUKEMIA IN REMISSION

208.92 UNSPECIFIED LEUKEMIA, IN RELAPSE

238.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS

238.71 ESSENTIAL THROMBOCYTHEMIA

238.72 LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS

238.73 HIGH GRADE MYELODYSPLASTIC SYNDROME LESIONS

238.74 MYELODYSPLASTIC SYNDROME WITH 5Q DELETION

238.75 MYELODYSPLASTIC SYNDROME, UNSPECIFIED

238.76 MYELOFIBROSIS WITH MYELOID METAPLASIA

238.77 POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD)

238.79 OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES

273.1 MONOCLONAL PARAPROTEINEMIA

273.3 MACROGLOBULINEMIA

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CPT Code 88184, 88185, 88187, 88188, 88189

279.10 IMMUNODEFICIENCY WITH PREDOMINANT T-CELL DEFECT UNSPECIFIED

279.11 DIGEORGE'S SYNDROME

279.12 WISKOTT-ALDRICH SYNDROME

279.13 NEZELOF'S SYNDROME

279.19 OTHER DEFICIENCY OF CELL-MEDIATED IMMUNITY

279.2 COMBINED IMMUNITY DEFICIENCY

279.3 UNSPECIFIED IMMUNITY DEFICIENCY

279.41 AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME

279.49 AUTOIMMUNE DISEASE, NOT ELSEWHERE CLASSIFIED

279.50 GRAFT-VERSUS-HOST DISEASE, UNSPECIFIED

279.51 ACUTE GRAFT-VERSUS-HOST DISEASE

279.52 CHRONIC GRAFT-VERSUS-HOST DISEASE

279.53 ACUTE ON CHRONIC GRAFT-VERSUS-HOST DISEASE

279.8 OTHER SPECIFIED DISORDERS INVOLVING THE IMMUNE MECHANISM

279.9 UNSPECIFIED DISORDER OF IMMUNE MECHANISM

282.0 HEREDITARY SPHEROCYTOSIS

282.5 SICKLE-CELL TRAIT

282.60 SICKLE-CELL DISEASE UNSPECIFIED

282.61 HB-SS DISEASE WITHOUT CRISIS

282.62 HB-SS DISEASE WITH CRISIS

282.63 SICKLE-CELL/HB-C DISEASE WITHOUT CRISIS

282.64 SICKLE-CELL/HB C DISEASE WITH CRISIS

282.68 OTHER SICKLE-CELL DISEASE WITHOUT CRISIS

282.69 OTHER SICKLE-CELL DISEASE WITH CRISIS

282.7 OTHER HEMOGLOBINOPATHIES

283.2 HEMOGLOBINURIA DUE TO HEMOLYSIS FROM EXTERNAL CAUSES

283.9 ACQUIRED HEMOLYTIC ANEMIA UNSPECIFIED

284.01 CONSTITUTIONAL RED BLOOD CELL APLASIA

284.09 OTHER CONSTITUTIONAL APLASTIC ANEMIA

284.19 OTHER PANCYTOPENIA

284.2 MYELOPHTHISIS

284.89 OTHER SPECIFIED APLASTIC ANEMIAS

284.9 APLASTIC ANEMIA UNSPECIFIED

285.0 SIDEROBLASTIC ANEMIA

285.22 ANEMIA IN NEOPLASTIC DISEASE

285.8 OTHER SPECIFIED ANEMIAS

285.9 ANEMIA UNSPECIFIED

287.1 QUALITATIVE PLATELET DEFECTS

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CPT Code 88184, 88185, 88187, 88188, 88189 287.30 PRIMARY THROMBOCYTOPENIA,UNSPECIFIED

287.31 IMMUNE THROMBOCYTOPENIC

287.32 EVANS’ SYNDROME

287.33 CONGENITAL AND HEREDITARY THROMBOCYTOPENIC PURPURA

287.39 OTHER PRIMARY THROMBOCYTOPENIA

287.41 POSTTRANSFUSION PURPURA

287.49 OTHER SECONDARY THROMBOCYTOPENIA

287.5 THROMBOCYTOPENIA UNSPECIFIED

288 NEUTROPENIA, UNSPECIFIED

288.01 CONGENITAL NEUTROPENIA

288.02 CYCLIC NEUTROPENIA

288.03 DRUG INDUCED NEUTROPENIA

288.04 NEUTROPENIA DUE TO INFECTION

288.09 OTHER NEUTROPENIA

288.1 FUNCTIONAL DISORDERS OF POLYMORPHONUCLEAR NEUTROPHILS

288.2 GENETIC ANOMALIES OF LEUKOCYTES

288.3 EOSINOPHILIA

288.4 HEMOPHAGOCYTIC SYNDROMES

288.50 LEUKOCYTOPENIA, UNSPECIFIED

288.51 LYMPHOCYTOPENIA

288.59 OTHER DECREASED WHITE BLOOD CELL COUNT

288.60 LEUKOCYTOSIS, UNSPECIFIED

288.61 LYMPHOCYTOSIS (SYMPTOMATIC)

288.62 LEUKEMOID REACTION

288.63 MONOCYTOSIS (SYMPTOMATIC)

288.64 PLASMACYTOSIS

288.65 BASOPHILIA

288.69 OTHER ELEVATED WHITE BLOOD CELL COUNT

288.8 OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS

288.9 UNSPECIFIED DISEASE OF WHITE BLOOD CELLS

334.8 OTHER SPINOCEREBELLAR DISEASES

364.3 UNSPECIFIED IRIDOCYCLITIS

452 PORTAL VEIN THROMBOSIS

453.9 EMBOLISM AND THROMBOSIS OF UNSPECIFIED SITE

555.0 REGIONAL ENTERITIS OF SMALL INTESTINE

555.1 REGIONAL ENTERITIS OF LARGE INTESTINE

555.2 REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE

555.9 REGIONAL ENTERITIS OF UNSPECIFIED SITE

556.0 ULCERATIVE (CHRONIC) ENTEROCOLITIS

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CPT Code 88184, 88185, 88187, 88188, 88189

556.1 ULCERATIVE (CHRONIC) ILEOCOLITIS

556.2 ULCERATIVE (CHRONIC) PROCTITIS

556.3 ULCERATIVE (CHRONIC) PROCTOSIGMOIDITIS

556.4 PSEUDOPOLYPOSIS OF COLON

556.5 LEFT-SIDED ULCERATIVE (CHRONIC) COLITIS

556.6 UNIVERSAL ULCERATIVE (CHRONIC) COLITIS

556.8 OTHER ULCERATIVE COLITIS

556.9 ULCERATIVE COLITIS UNSPECIFIED

696.0 PSORIATIC ARTHROPATHY

714.30 CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS

720.0 ANKYLOSING SPONDYLITIS

720.1 SPINAL ENTHESOPATHY

720.2 SACROILIITIS NOT ELSEWHERE CLASSIFIED

720.81 INFLAMMATORY SPONDYLOPATHIES IN DISEASES CLASSIFIED ELSEWHERE

720.89 OTHER INFLAMMATORY SPONDYLOPATHIES

720.9 UNSPECIFIED INFLAMMATORY SPONDYLOPATHY

785.6 ENLARGEMENT OF LYMPH NODES

789.2 SPLENOMEGALY

789.31 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP UNSPECIFIED SITE

789.31 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP RIGHT UPPER QUARDANT

789.32 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP LEFT UPPER QUADRANT

789.33 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP RIGHT LOWER QUADRANT

789.34 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP LEFT LOWER QUADRANT

789.35 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP PERIUMBILIC

789.36 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP EPIGASTRIC

789.37 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP GENERALIZED

789.39 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP OTHER SPECIFIED SITE

795.4 OTHER NONSPECIFIC ABNORMAL HISTOLOGICAL FINDINGS

795.71 NONSPECIFIC SEROLOGIC EVIDENCE OF HUMAN IMMUNODEFICIENCY VIRUS (HIV)

996.80 COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN

996.81 COMPLICATIONS OF TRANSPLANTED KIDNEY

996.82 COMPLICATIONS OF TRANSPLANTED LIVER

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CPT Code 88184, 88185, 88187, 88188, 88189

996.83 COMPLICATIONS OF TRANSPLANTED HEART

996.84 COMPLICATIONS OF TRANSPLANTED LUNG

996.85 COMPLICATIONS OF TRANSPLANTED BONE MARROW

996.86 COMPLICATIONS OF TRANSPLANTED PANCREAS

996.87 COMPLICATIONS OF TRANSPLANTED ORGAN INTESTINE

996.88 COMPLICATIONS OF TRANSPLANTED ORGAN, STEM CELL

996.89 COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN

V08 ASYMPTOMATIC HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION STATUS

V42.0 KIDNEY REPLACED BY TRANSPLANT

V42.1 HEART REPLACED BY TRANSPLANT

V42.2 HEART VALVE REPLACED BY TRANSPLANT

V42.3 SKIN REPLACED BY TRANSPLANT

V42.4 BONE REPLACED BY TRANSPLANT

V42.5 CORNEA REPLACED BY TRANSPLANT

V42.6 LUNG REPLACED BY TRANSPLANT

V42.7 LIVER REPLACED BY TRANSPLANT

V42.81 BONE MARROW REPLACED BY TRANSPLANT

V42.82 PERIPHERAL STEM CELLS REPLACED BY TRANSPLANT

V42.83 PANCREAS REPLACED BY TRANSPLANT

V42.84 ORGAN OR TISSUE REPLACED BY TRANSPLANT INTESTINES

V42.89 OTHER SPECIFIED ORGAN OR TISSUE REPLACED BY TRANSPLANT

V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS

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CPT Code 88182 164.2 MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM 191.7 MALIGNANT NEOPLASM OF BRAIN STEM 164.3 MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUM 191.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRAIN 182.0 MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS 630 HYDATIDIFORM MOLE 183.0 MALIGNANT NEOPLASM OF OVARY 183.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA 185 MALIGNANT NEOPLASM OF PROSTATE 188.0 MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER 188.1 MALIGNANT NEOPLASM OF DOME OF URINARY BLADDER 188.2 MALIGNANT NEOPLASM OF LATERAL WALL OF URINARY BLADDER 188.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF URINARY BLADDER 188.4 MALIGNANT NEOPLASM OF POSTERIOR WALL OF URINARY BLADDER 188.5 MALIGNANT NEOPLASM OF BLADDER NECK 188.6 MALIGNANT NEOPLASM OF URETERIC ORIFICE 188.7 MALIGNANT NEOPLASM OF URACHUS 188.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BLADDER 188.9 MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED 189.0 MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS 189.1 MALIGNANT NEOPLASM OF RENAL PELVIS 191.0 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES 191.2 MALIGNANT NEOPLASM OF TEMPORAL LOBE 191.3 MALIGNANT NEOPLASM OF PARIETAL LOBE 191.4 MALIGNANT NEOPLASM OF OCCIPITAL LOBE 191.5 MALIGNANT NEOPLASM OF VENTRICLES 191.6 MALIGNANT NEOPLASM OF CEREBELLUM NOS

08/25/2015

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Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com Molecular Diagnostic Testing (L33219) (Page 1 of 10) Testing performed by Quest Diagnostics Nichols Institute CPT Codes 81201, 81202, 81203, 81206, 81207, 81208, 81210, 81211, 81212, 81213, 81214, 81217, 81226, 81235, 81270, 81275, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81381, 81403, 81405, 81406,88341, 88342, 88363 LCD Description: Genetic tests for cancer are only a covered benefit for a beneficiary with a personal history of an illness, injury, or signs/symptoms thereof (i.e. clinically affected). A person with a personal history of a relevant cancer is a clinically affected person, even if the cancer is considered cured. Genetic testing is considered a non-covered screening test for patients unaffected by a relevant illness, injury, or signs/symptoms thereof. ICD-9-CM Codes that Support Medical Necessity Molecular Diagnostic Testing is potentially medically reasonable and necessary “therapy-directing” genetic tests, either currently available or in the development “pipeline” for emerging use in the coming months and years. Many questions remain, among them the lack of – and difficulty in establishing – good medical literature support of medical necessity; lack of standardized testing protocols; lack of good data for establishing patient-selection criteria; absence of test-specific CPT coding, which we believe to be essential for future development of this potentially monumental enhancement to patient care. Providers are reminded that we will allow payment for such tests, either those currently available or those to be brought into use in the future, based on applicable approval such as FDA labeling, if such exists, CLIA and appropriate Medicare regulations and its standards of medical reasonableness and necessity.

Group 1 Paragraph: CPT codes 81201, 81202, 81203 81210, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, and 81403, 81405, 81406 (that meet coverage criteria as indications for testing for lynch syndrome). V12.72 should be used to denote any of the polyposis conditions as described under Indications and Limitations section. 151.0 – 151.6 MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED 151.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH 151.9 MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE 152.0 – 152.3 MALIGNANT NEOPLASM OF DUODENUM - MALIGNANT NEOPLASM OF MECKEL'S DIVERTICULUM 152.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SMALL INTESTINE 152.9 MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE 153.0 MALIGNANT NEOPLASM OF HEPATIC FLEXURE 153.1 MALIGNANT NEOPLASM OF TRANSVERSE COLON 153.2 MALIGNANT NEOPLASM OF DESCENDING COLON 153.3 MALIGNANT NEOPLASM OF SIGMOID COLON 153.4 MALIGNANT NEOPLASM OF CECUM 153.5 MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS 153.6 MALIGNANT NEOPLASM OF ASCENDING COLON 153.7 MALIGNANT NEOPLASM OF SPLENIC FLEXURE 153.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE 153.9 MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE 153.9 MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE 154.0 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION 154.1 MALIGNANT NEOPLASM OF RECTUM 154.2 MALIGNANT NEOPLASM OF ANAL CANAL

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Group 1 Paragraph Continued: CPT codes 81201, 81202, 81203 81210, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, and 81403, 81405, 81406 (that meet coverage criteria as indications for testing for lynch syndrome). V12.72 should be used to denote any of the polyposis conditions as described under Indications and Limitations section. 154.8 MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS 155.0 – 155.2 MALIGNANT NEOPLASM OF LIVER PRIMARY - MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY 156.1 MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCTS 156.9 MALIGNANT NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE 157.0 – 157.4 MALIGNANT NEOPLASM OF HEAD OF PANCREAS - MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS 157.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS 157.9 MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED 158.8 MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM 158.9 MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED 179 MALIGNANT NEOPLASM OF UTERUS-PART UNS 182.0 MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS 182.1 MALIGNANT NEOPLASM OF ISTHMUS 182.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BODY OF UTERUS 183.0 MALIGNANT NEOPLASM OF OVARY 183.2 – 183.5 MALIGNANT NEOPLASM OF FALLOPIAN TUBE - MALIGNANT NEOPLASM OF ROUND LIGAMENT OF UTERUS 183.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA 183.9 MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE 189.0 – 189.2 MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS - MALIGNANT NEOPLASM OF URETER 189.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF URINARY ORGANS

08/25/2015

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Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com Molecular Diagnostic Testing (L33219) (Page 3 of 10) Testing performed by Quest Diagnostics Nichols Institute CPT Codes 81201, 81202, 81203, 81206, 81207, 81208, 81210, 81211, 81212, 81213, 81214, 81217, 81226, 81235, 81270, 81275, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81381, 81403, 81405, 81406, 88341, 88342, 88363 LCD Description: Genetic tests for cancer are only a covered benefit for a beneficiary with a personal history of an illness, injury, or signs/symptoms thereof (i.e. clinically affected). A person with a personal history of a relevant cancer is a clinically affected person, even if the cancer is considered cured. Genetic testing is considered a non-covered screening test for patients unaffected by a relevant illness, injury, or signs/symptoms thereof. ICD-9-CM Codes that Support Medical Necessity Molecular Diagnostic Testing is potentially medically reasonable and necessary “therapy-directing” genetic tests, either currently available or in the development “pipeline” for emerging use in the coming months and years. Many questions remain, among them the lack of – and difficulty in establishing – good medical literature support of medical necessity; lack of standardized testing protocols; lack of good data for establishing patient-selection criteria; absence of test-specific CPT coding, which we believe to be essential for future development of this potentially monumental enhancement to patient care. Providers are reminded that we will allow payment for such tests, either those currently available or those to be brought into use in the future, based on applicable approval such as FDA labeling, if such exists, CLIA and appropriate Medicare regulations and its standards of medical reasonableness and necessity.

Group 1 Paragraph Continued: CPT codes 81201, 81202, 81203 81210, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, and 81403, 81405, 81406 (that meet coverage criteria as indications for testing for lynch syndrome). V12.72 should be used to denote any of the polyposis conditions as described under Indications and Limitations section. 191.0 – 191.9 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE 197.5 SECONDARY MALIGNANT NEOPLASM OF LARGE INTESTINE AND RECTUM V10.00 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED SITE IN GASTROINTESTINAL TRACT V10.05 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARGE INTESTINE V10.06 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF RECTUM RECTOSIGMOID JUNCTION AND ANUS V10.42 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER PARTS OF UTERUS V10.43 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OVARY V10.53 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF RENAL PELVIS V10.59 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER URINARY ORGANS V10.85 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BRAIN V12.72 PERSONAL HISTORY OF COLONIC POLYPS CPT 81210 172.0 - 172.9 MALIGNANT MELANOMA OF SKIN OF LIP - MELANOMA OF SKIN SITE UNSPECIFIED Group 2 Paragraph: 81301 153.0 - 153.9 MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE V10.05 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARGE INTESTINE V10.06 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF RECTUM RECTOSIGMOID JUNCTION AND ANUS V10.42 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER PARTS OF UTERUS

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Group 2 Paragraph: continued 81301 V16.0 FAMILY HISTORY OF MALIGNANT NEOPLASM OF GASTROINTESTINAL TRACT V84.04 GENETIC SUSCEPTIBILITY TO MALIGNANT NEOPLASM OF ENDOMETRIUM V84.09 GENETIC SUSCEPTIBILITY TO OTHER MALIGNANT NEOPLASM Group 3 Paragraph: CPT codes 81211, 81212, 81213, 81214, 81215 and 81217 and meet the coverage criteria for BRCA1 and BRCA2 gene mutation testing. 158.0 MALIGNANT NEOPLASM OF RETROPERITONEUM 158.8 MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM 174.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST 174.1 MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST 174.2 MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST 174.3 MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST 174.4 MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST 174.5 MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST 174.6 MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST 174.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST 174.9 MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE 175.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST 175.9 MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST 183.0 MALIGNANT NEOPLASM OF OVARY 183.2 MALIGNANT NEOPLASM OF FALLOPIAN TUBE 233.0 CARCINOMA IN SITU OF BREAST V10.3 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST V10.43 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OVARY

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Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com Molecular Diagnostic Testing (L33219) (Page 5 of 10) Testing performed by Quest Diagnostics Nichols Institute CPT Codes 81201, 81202, 81203, 81206, 81207, 81208, 81210, 81211, 81212, 81213, 81214, 81217, 81226, 81235, 81270, 81275, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81381, 81403, 81405, 81406,88341, 88342, 88363 LCD Description: Genetic tests for cancer are only a covered benefit for a beneficiary with a personal history of an illness, injury, or signs/symptoms thereof (i.e. clinically affected). A person with a personal history of a relevant cancer is a clinically affected person, even if the cancer is considered cured. Genetic testing is considered a non-covered screening test for patients unaffected by a relevant illness, injury, or signs/symptoms thereof.. ICD-9-CM Codes that Support Medical Necessity Molecular Diagnostic Testing is potentially medically reasonable and necessary “therapy-directing” genetic tests, either currently available or in the development “pipeline” for emerging use in the coming months and years. Many questions remain, among them the lack of – and difficulty in establishing – good medical literature support of medical necessity; lack of standardized testing protocols; lack of good data for establishing patient-selection criteria; absence of test-specific CPT coding, which we believe to be essential for future development of this potentially monumental enhancement to patient care. Providers are reminded that we will allow payment for such tests, either those currently available or those to be brought into use in the future, based on applicable approval such as FDA labeling, if such exists, CLIA and appropriate Medicare regulations and its standards of medical reasonableness and necessity.

Group 4 Paragraph: CPT 81235 162.0 – 162.9 MALIGNANT NEOPLASM OF TRACHEA - MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED 163.0 – 163.9 MALIGNANT NEOPLASM OF PARIETAL PLEURA - MALIGNANT NEOPLASM OF PLEURA UNSPECIFIED Group 5 Paragraph: CPT codes 81270 and 81403 (that meet coverage criteria for JAK2 testing). 204.00 ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 204.10 CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 204.11 LYMPHOID LEUKEMIA CHRONIC IN REMISSION 204.12 CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE 205.00 ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 205.10 CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 238.4 POLYCYTHEMIA VERA 238.71 ESSENTIAL THROMBOCYTHEMIA 238.75 MYELODYSPLASTIC SYNDROME, UNSPECIFIED 238.76 MYELOFIBROSIS WITH MYELOID METAPLASIA 238.79 OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES 238.9 NEOPLASM OF UNCERTAIN BEHAVIOR SITE UNSPECIFIED 288.51 LYMPHOCYTOPENIA 288.61 LYMPHOCYTOSIS (SYMPTOMATIC) 288.8 OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS 453.0 BUDD-CHIARI SYNDROME Group 6 Paragraph: CPT code 81381 when meeting coverage criteria 042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE V08 ASYMPTOMATIC HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION STATUS

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Group 7 Paragraph: Multiple codes exist for the various molecular tests for lymphoma and leukemia. The appropriate code should be selected from the most current manual. The following diagnosis codes meet coverage criteria as indications for molecular testing of lymphoma and leukemia, so long as documentation of medical necessity for the specific test in question is present in the medical record, as noted elsewhere in this LCD. 81206, 81207, 81208 and 81403 (that meet coverage criteria as indications for testing for BCR/ABL fusion gene ). Group 7 Codes: 200.40 MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES 200.41 MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 200.42 MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES 200.43 MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES 200.44 MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB 200.45 MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB 200.46 MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 200.47 MANTLE CELL LYMPHOMA, SPLEEN 200.48 MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 200.70 LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES 200.71 LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 200.72 LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES 200.73 LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES 200.74 LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB 200.75–200.76 LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB - LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 200.77 LARGE CELL LYMPHOMA, SPLEEN 200.78 LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

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Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com Molecular Diagnostic Testing (L33219) (Page 7 of 10) Testing performed by Quest Diagnostics Nichols Institute CPT Codes 81201, 81202, 81203, 81206, 81207, 81208, 81210, 81211, 81212, 81213, 81214, 81217, 81226, 81235, 81270, 81275, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81381, 81403, 81405, 81406, 88342, 88363 LCD Description: Genetic tests for cancer are only a covered benefit for a beneficiary with a personal history of an illness, injury, or signs/symptoms thereof (i.e. clinically affected). A person with a personal history of a relevant cancer is a clinically affected person, even if the cancer is considered cured. Genetic testing is considered a non-covered screening test for patients unaffected by a relevant illness, injury, or signs/symptoms thereof. ICD-9-CM Codes that Support Medical Necessity Molecular Diagnostic Testing is potentially medically reasonable and necessary “therapy-directing” genetic tests, either currently available or in the development “pipeline” for emerging use in the coming months and years. Many questions remain, among them the lack of – and difficulty in establishing – good medical literature support of medical necessity; lack of standardized testing protocols; lack of good data for establishing patient-selection criteria; absence of test-specific CPT coding, which we believe to be essential for future development of this potentially monumental enhancement to patient care. Providers are reminded that we will allow payment for such tests, either those currently available or those to be brought into use in the future, based on applicable approval such as FDA labeling, if such exists, CLIA and appropriate Medicare regulations and its standards of medical reasonableness and necessity.

Group 7 Paragraph Continued: Multiple codes exist for the various molecular tests for lymphoma and leukemia. The appropriate code should be selected from the most current manual. The following diagnosis codes meet coverage criteria as indications for molecular testing of lymphoma and leukemia, so long as documentation of medical necessity for the specific test in question is present in the medical record, as noted elsewhere in this LCD. 81206, 81207, 81208 and 81403 (that meet coverage criteria as indications for testing for BCR/ABL fusion gene ). Group 7 Codes: 202.00 NODULAR LYMPHOMA UNSPECIFIED SITE 202.01 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK 202.02 NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES 202.03 NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES 202.04 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB 202.05 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB 202.06 NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES 202.07 NODULAR LYMPHOMA INVOLVING SPLEEN 202.08 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 204.00 ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 204.01 LYMPHOID LEUKEMIA ACUTE IN REMISSION 204.02 ACUTE LYMPHOID LEUKEMIA, IN RELAPSE 204.10 CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 204.11 LYMPHOID LEUKEMIA CHRONIC IN REMISSION 204.12 CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE 204.20 SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 204.21 LYMPHOID LEUKEMIA SUBACUTE IN REMISSION 204.22 SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE 204.80 OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

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Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com Molecular Diagnostic Testing (L33219) (Page 8 of 10) Testing performed by Quest Diagnostics Nichols Institute CPT Codes 81201, 81202, 81203, 81206, 81207, 81208, 81210, 81211, 81212, 81213, 81214, 81217, 81226, 81235, 81270, 81275, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81381, 81403, 81405, 81406, 88341, 88342, 88363 LCD Description: Genetic tests for cancer are only a covered benefit for a beneficiary with a personal history of an illness, injury, or signs/symptoms thereof (i.e. clinically affected). A person with a personal history of a relevant cancer is a clinically affected person, even if the cancer is considered cured. Genetic testing is considered a non-covered screening test for patients unaffected by a relevant illness, injury, or signs/symptoms thereof. Molecular Diagnostic Testing is potentially medically reasonable and necessary “therapy-directing” genetic tests, either currently available or in the development “pipeline” for emerging use in the coming months and years. Many questions remain, among them the lack of – and difficulty in establishing – good medical literature support of medical necessity; lack of standardized testing protocols; lack of good data for establishing patient-selection criteria; absence of test-specific CPT coding, which we believe to be essential for future development of this potentially monumental enhancement to patient care. Providers are reminded that we will allow payment for such tests, either those currently available or those to be brought into use in the future, based on applicable approval such as FDA labeling, if such exists, CLIA and appropriate Medicare regulations and its standards of medical reasonableness and necessity.

Group 7 Paragraph Continued: Multiple codes exist for the various molecular tests for lymphoma and leukemia. The appropriate code should be selected from the most current manual. The following diagnosis codes meet coverage criteria as indications for molecular testing of lymphoma and leukemia, so long as documentation of medical necessity for the specific test in question is present in the medical record, as noted elsewhere in this LCD. 81206, 81207, 81208 and 81403 (that meet coverage criteria as indications for testing for BCR/ABL fusion gene ). Group 7 Codes: 204.81 OTHER LYMPHOID LEUKEMIA IN REMISSION 204.82 OTHER LYMPHOID LEUKEMIA, IN RELAPSE 204.90 UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 204.91 UNSPECIFIED LYMPHOID LEUKEMIA IN REMISSION 204.92 UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE 205.00 ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 205.01 MYELOID LEUKEMIA ACUTE IN REMISSION 205.02 ACUTE MYELOID LEUKEMIA, IN RELAPSE 205.10 CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 205.11 MYELOID LEUKEMIA CHRONIC IN REMISSION 205.12 CHRONIC MYELOID LEUKEMIA, IN RELAPSE 205.20 SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 205.21 MYELOID LEUKEMIA SUBACUTE IN REMISSION 205.22 SUBACUTE MYELOID LEUKEMIA, IN RELAPSE 205.30 MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 205.31 MYELOID SARCOMA IN REMISSION 205.32 MYELOID SARCOMA, IN RELAPSE 205.80 OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 205.81 OTHER MYELOID LEUKEMIA IN REMISSION

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Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com Molecular Diagnostic Testing (L33219) (Page 9 of 10) Testing performed by Quest Diagnostics Nichols Institute CPT Codes 81201, 81202, 81203, 81206, 81207, 81208, 81210, 81211, 81212, 81213, 81214, 81217, 81226, 81235, 81270, 81275, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81381, 81403, 81405, 81406, 88341, 88342, 88363 LCD DescriptionGenetic tests for cancer are only a covered benefit for a beneficiary with a personal history of an illness, injury, or signs/symptoms thereof (i.e. clinically affected). A person with a personal history of a relevant cancer is a clinically affected person, even if the cancer is considered cured. Genetic testing is considered a non-covered screening test for patients unaffected by a relevant illness, injury, or signs/symptoms thereof.. ICD-9-CM Codes that Support Medical Necessity Molecular Diagnostic Testing is potentially medically reasonable and necessary “therapy-directing” genetic tests, either currently available or in the development “pipeline” for emerging use in the coming months and years. Many questions remain, among them the lack of – and difficulty in establishing – good medical literature support of medical necessity; lack of standardized testing protocols; lack of good data for establishing patient-selection criteria; absence of test-specific CPT coding, which we believe to be essential for future development of this potentially monumental enhancement to patient care. Providers are reminded that we will allow payment for such tests, either those currently available or those to be brought into use in the future, based on applicable approval such as FDA labeling, if such exists, CLIA and appropriate Medicare regulations and its standards of medical reasonableness and necessity.

Group 7 Paragraph Continued: Multiple codes exist for the various molecular tests for lymphoma and leukemia. The appropriate code should be selected from the most current manual. The following diagnosis codes meet coverage criteria as indications for molecular testing of lymphoma and leukemia, so long as documentation of medical necessity for the specific test in question is present in the medical record, as noted elsewhere in this LCD. 81206, 81207, 81208 and 81403 (that meet coverage criteria as indications for testing for BCR/ABL fusion gene ). Group 7 Codes: 205.82 OTHER MYELOID LEUKEMIA, IN RELAPSE 205.90 UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 205.91 UNSPECIFIED MYELOID LEUKEMIA IN REMISSION 205.92 UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE 206.00 ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 206.01 MONOCYTIC LEUKEMIA ACUTE IN REMISSION 206.02 ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE 206.10 CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 206.11 MONOCYTIC LEUKEMIA CHRONIC IN REMISSION 206.12 CHRONIC MONOCYTIC LEUKEMIA, IN RELAPSE 206.20 SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 206.21 MONOCYTIC LEUKEMIA SUBACUTE IN REMISSION 206.22 SUBACUTE MONOCYTIC LEUKEMIA, IN RELAPSE 206.80 OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 206.81 OTHER MONOCYTIC LEUKEMIA IN REMISSION 206.82 OTHER MONOCYTIC LEUKEMIA, IN RELAPSE 206.90 UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 206.91 UNSPECIFIED MONOCYTIC LEUKEMIA IN REMISSION 206.92 UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE

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Group 7 Paragraph Continued: Multiple codes exist for the various molecular tests for lymphoma and leukemia. The appropriate code should be selected from the most current manual. The following diagnosis codes meet coverage criteria as indications for molecular testing of lymphoma and leukemia, so long as documentation of medical necessity for the specific test in question is present in the medical record, as noted elsewhere in this LCD. 81206, 81207, 81208 and 81403 (that meet coverage criteria as indications for testing for BCR/ABL fusion gene ). Group 7 Codes: 208.00 ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 208.01 LEUKEMIA OF UNSPECIFIED CELL TYPE ACUTE IN REMISSION 208.02 ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE 208.10 CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 208.11 LEUKEMIA OF UNSPECIFIED CELL TYPE CHRONIC IN REMISSION 208.12 CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE 208.20 SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 208.21 LEUKEMIA OF UNSPECIFIED CELL TYPE SUBACUTE IN REMISSION 208.22 SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE 208.80 OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 208.81 OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE IN REMISSION 208.82 OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE 208.90 UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 208.91 UNSPECIFIED LEUKEMIA IN REMISSION 208.92 UNSPECIFIED LEUKEMIA, IN RELAPSE 288.69 OTHER ELEVATED WHITE BLOOD CELL COUNT 288.8 OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS

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LCD Description: Vitamin D is a hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these services.

ICD-9-CM Codes that Support Medical Necessity The Vitamin D Assay test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided.

Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com Vitamin D Assay Testing (L31076) (Page 1 of 2) Testing performed by Quest Diagnostics Nichols Institute CPT Code: 82306, 82652

CPT 82306 Note: Use V58.65, to describe current long term use of glucocorticoids and V58.69 to

describe long term use of anticonvulsants and other medication known to lower vitamin D levels.

010.00–018.96 Primary Tuberculous complex unspecified examination – Unspecified Miliary Tuberculosis Tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (Inoculation of animals) 135 Sarcoidosis 252.00-252.9 Hyperparathyroidism, unspecified – Unspecified disorder of Parathyroid Gland 268.0– 268.9 Rickets Active-Unspecified Vitamin D Deficiency 275.3 Disorders of Phosphorus Metabolism 275.41 Hypocalcemia 275.42 Hypercalcemia 277.00-277.09 Cystic Fibrosis without Meconium Ileus-Cystic Fibrosis with other manifestations 278.8 Other Hyperalimentation 359.5 Myopathy in Endocrine Diseases classified elsewhere 555.0-555.9 Regional Enteritis of Small Intestine-Regional Enteritis of unspecified site 556.0-556.9 Ulcerative (Chronic)Enterocolitis-Ulcerative Colitis unspecified 571.2 Alcoholic Cirrhosis of Liver 571.5 Cirrhosis of Liver without Alcohol 571.6 Biliary Cirrhosis 571.8 Other Chronic Nonalcoholic Liver Disease 579.0-579.9 Celiac Disease-Unspecified Intestinal Malabsorption 585.3 Chronic Kidney Disease Stage III (Moderate)

585.4 Chronic Kidney Disease Stage IV (Severe) 585.5 Chronic Kidney Disease Stage V 585.6 End Stage Renal Disease 588.81 Secondary Hyperparathyroidism (of renal origin 649.20-649.24 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable-bariatric surgery status complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication 696.1 Other Psoriasis and similar disorders 701.0 Circumscribed Scleroderma 710.0 Systemic Lupus Erythematosus 710.3 Dermatomyositis 729.1 Myalgia and Myositis unspecified 731.0 Osteitis Deformans without bone tumor 733.00-733.09 Osteoporosis unspecified-other osteoporosis 733.90 Disorder of bone and cartilage unspecified 756.51 Osteogenesis Imperfecta 756.52 Osteopetrosis 949.2-949.5 Blisters with epidermal loss due to burn (second degree) unspecified site-Deep necrosis of underlying tissues due to burn (deep third degree unspecified site with loss of a body part) V45.86 Bariatric Surgery status V58.65 Long Term (current) use of steroids V58.69 Long Term (current) use of other medications

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LCD Description: Vitamin D is a hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these services. ICD-9-CM Codes that Support Medical Necessity The Vitamin D Assay test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided.

CPT 82652 010.00–018.96 Primary Tuberculous complex unspecified examination – Unspecified Miliary Tuberculosis Tubercle bacilli not found by bacteriological or histological examination but tuberculosis confirmed by other methods (Inoculation of animals) 135 Sarcoidosis 200.30-200.38 Marginal Zone Lymphoma, unspecified site, extranodal and solid organ sites-Marginal Zone Lymphoma, lymph nodes of multiple sites 202.10-202.28 Mycosis Fungoides unspecified site-Sezary’s Disease involving lymph nodes of multiple sites 252.00-252.9 Hyperparathyroidism, unspecified – Unspecified disorder of Parathyroid Gland 268.0 Rickets Active 278.8 Other Hyperalimentation 585.3 Chronic Kidney Disease Stage III (Moderate) 585.4 Chronic Kidney Disease Stage IV (Severe) 585.5 Chronic Kidney Disease Stage V 585.6 End Stage Renal Disease 588.81 Secondary Hyperparathyroidism (of renal origin) 756.51 Osteogenesis Imperfecta 756.52 Osteopetrosis

Medicare Local Coverage Determination Policy (KS, MO, NE) Data Source: http://www.wpsmedicare.com Vitamin D Assay Testing (L31076) (Page 2 of 2) Testing performed by Quest Diagnostics Nichols Institute CPT Code: 82306, 82652

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