In March 1998, the United States Department of Health and Human Services, Office of the Inspector General, stated that "a physician who orders medically unnecessary tests for which Medicare or Medicaid reimbursement is claimed may be subject to civil penalties".    Thus Medicare carriers/intermediaries developed systems using ICD-9 diagnosis codes to prevent payment of claims that they determined as not medically necessary. At that time it became necessary to use the ICD-9 codes when ordering laboratory studies. Below is a list of acceptable codes which our group has used since that date. The codes used, as part of the order, must be consistent with the documentation in the patient's medical records, so that the medical necessity is clear and apparent in the event of a post-payment review.


MEDICARE ICD-9 LAB CODES/Revised October 13, 1998

CBC/H/H/Differential
789.00     Abdominal pain, NOS
566          Anal & rectal abscess
535.0       Acute Gastritis
533.3       Acute Peptic Ulcer NOS
281.9       Anemia, ACD
280.9       Anemia, IDA
285.9       Anemia NOS
569.84     Angiodysplagia, intestine
V58.61    Anticoagulant use
716.90     Arthropathy, unspecified site
466.0       Bronchitis, acute
490          Bronchitis, chronic
188.9       CA Bladder
174.9       CA breast
230.3       CA Colon
155.2       CA Liver
162.9       CA Lung, bronchus
157.9       CA Pancreas
686.9       Cellulitis,NOS
V58.1      Chemotherapy
575.10     Cholecystitis
574.50     Cholelithiasis
204.1       CLL
205.10     CML
V58.69    Current long term use high risk med
562.11     Diverticulitis
562.10     Diverticulosis
780.4       Dizzy, giddy,vertigo
995.2       Drug (adverse) effect
782.7       Ecchymosis, purpura
780.6       Fever
537.89     Gastroduodenal Dx NEC
578.9       GI bleed, unspecified
578.0       Hematemesis
599.7       Hematuria
042          HIV
719.40     Joint pain - unspecified
208.20     Leukemia, subacute
780.7       Malaise & fatigue
263.9       Malnutrition -caloric
578.1       Melena
410.9       MI acute
203.00     Multiple myeloma
237.8       Myelodysplasia
730.20     Osteomyelitis
782.61     Pallor
577.0       Pancreatitis
533.9       Peptic ulcer NOS
782.9       Petechia
486          Pneumonia
238.4       Polycythemia vera
V72.84    Pre-op
714.0       RA
790.0       RBC abnormality
038.9       Septicemia NOS
792.1       Stool-occult blood
287.1       TCP
282.4       Thalassemia
289.9       Thrombocytosis
556.8       Ulcerative colitis

CEA
174.9       CA breast
230.3       CA colon
230.7       CA intestine, unspecified
230.4       CA rectum

CHOL/LDL/HDL/TRIG
434.9       Cerebral Artery Occlusion
414.00     Coronary Atherosclerosis
272.4       Hyperlipidemia NEC/NOS
401.9       Hypertension, unspecified

DIGOXIN
995.2       Adverse drug effect
427.31     AF
413.9       Angina
783.0       Anorexia
275.40     Calcium metabolism, NOS
427.9       Cardiac dysrhythmias
425.9       Cardiomyopathy
429.2       CV disease
426.9       Conduction disorders
428.1       CHF-left
428.9       CHF, NOS
276.7       Hyperkalemia
588.8       Impaired renal function
414.9       Ischemic heart disease
412          MI, old
787.01     Nausea/vomiting
V72.81    Pre-op
584.9       Renal failure, acute
585          Renal failure, chronic
586          Renal failure, NOS

FERRITIN/FE/TIBC/TRANSFERR
425.4       Cardiomyopathy
585          CRF
250.01     DM, Type I
275.0       Hemochromatosis
280.9       IDA
790.6       Other Abnormal Blood Chemistry

GLUCOSE
783.2       Abnormal weight loss
680.9       Carbuncle
681.10     Cellulitis/abscess, NOS
682.7       Cellulitis foot, not toes
345.10     Convulsive epilepsy
780.4       Dizzy, giddy
250.01     DM, Type I
250.00     DM, Type II
276.9       Electrolyte/fluid disorder,  
348.3       Encephalopathy, NOS
788.41     Frequency, urination
791.5       Glycosuria
790.6       Hyperglycemia
276.0       Hyperosmolality &/or hypernatremia
276.7       Hyperkalemia
251.2       Hypoglycemia
276.8       Hypokalemia
788.43     Nocturia
577.0       Pancreatitis, acute
783.5       Polydipsia
783.6       Polyphagia
788.42     Polyuria
782.0       Skin tingling, numbness
780.2       Syncope, collapse
707.1       Ulcer lower limb
276.5       Volume depletion

HGB-A1C
250.01     DM, Type I
250.00     DM, Type II

IONIZED CALCIUM
275.4       Disorder Ca Metabolism
276.7       Hyperkalemia
252.8       Parathyroid Disorder NEC
780.3       Seizure, new
585          CRF

MAGNESIUM
293.0       Acute delirium
275.4       Calcium metabolism disorder
586          Renal failure NOS

OCCULT BLOOD*
V76.9      Screening
V10.05    Hx CA Lg. Intestine
V10.06    Hx CA Rectum, anus, rectosigmoid junction

PAP/ Prostatic Acid Phosphatase
222.2       Benign neoplasm prostate
233.4       CA in situ; prostate
790.93     Elevated PSA
185          Malignant neoplasm prostate
198.5       Malignant neoplasm, secondary of bone
V10.46    Personal Hx malignancy prostate

PSA/Prostate Specific Antigen
600          BPH
185          CA Prostate
790.93     Elevated PSA
V71.1      Evaluation Suspected CA
788.41     Frequency, urinary
599.7       Hematuria
788.43     Nocturia
601.1       Prostatitis, chronic
788.62     Slow urinary stream
599.6       Urinary obstruction, NOS
788.29     Urinary retention
599.0       UTI

PT/INR
790.92     Abnormal Coag Profile
E934.2     Anticoagulants
789.5       Ascites
427.31     Atrial Fib
286.5       Bleed 2nd to anticoagulants
578.1       Blood in stool
427.9       Cardiac Arrhythmia NOS
426          CVA, acute
453.9       DVT
784.7       Epistaxis
V67.4      Fracture, post tx
599.7       Hematuria
786.3       Hemoptysis
459.0       Hemorrhage, unspecified
789.1       Hepatomegaly
V43.60    Joint replaced, unspecified
V58.61    Long term Use of Anticoagulant + ICD-9 for Specific Diagnosis
V72.84    Preoperative Exam
415.19     Pulmonary Embolism
287.0       Purpura, allergic
410.9       MI, acute
435.9       TIA
451.9       Thrombophlebitis

PTT
287.0       Allergic purpura
E934.2     Anticoagulants
286.9       Coagulation defects
599.7       Hematuria
571.3       Liver failure,chronic
V72.84    Preoperative exam

TSH/T4/T3
783.1       Abnormal Weight Gain
783.2       Abnormal Weight Loss
704.00     Alopecia, unspecified
780.09     Altered LOC
300.00     Anxiety State NOS
427.31     Atrial Fibrillation
193          CA thyroid
275.4       Calcium metabolic disorder
427.9       Cardiac Arrythmia NOS
428.0       CHF
564.0       Constipation
293.0       Delirium
311          Depressive disorder, NEC
701.1       Dry skin
787.2       Dysphagia
240.9       Goiter
242.9       Hyperthyroidism
244.9       Hypothyroidism
780.7       Malaise & fatigue
290.40     MID
278.00     Morbid obesity
729.82     Muscle cramps
729.1       Myalgia & myositis
799.2       Nervousness
785.1       Palpitations          
290.10     Presenile dementia
331.0       SDAT
782.8       Skin texture, change
780.8       Sweating, excessive
785.0       Tachycardia NOS
242.9       Thyroiditis, unspecified

COMMON ORGAN PANELS
REQUIRE MEDICAL REASON BUT  NO ICD-9 CODES

BASIC METABOLIC PANEL
CO2
Chloride
Creatinine
Glucose
Potassium
Sodium
BUN

COMPREHENSIVE METABOLIC PANEL
Albumin, Bilirubin, Total or Direct
Calcium, Chloride
Creatinine
Glucose
Phosphatase Alkaline
Potassium
Protein, total
Sodium
SGOT/AST
BUN

HEPATIC FUNCTION
lAlbumin
Bilirubin, Total & Direct
Phosphatase Alkaline
SGOT/AST
SGPT/ALT

*Q 12 months
NOS       No other specification
NEC        Not elsewhere classified

 

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