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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