Gamma Glutamyltransferase (GGT) 1-11

GAMMA GLUTAMYLTRANSFERASE (GGT)

NCD

Source: Program Memorandum AB-02-110, Effective 11-25-02; Medicare NCD Manual, July 2003 Release; October 2003 Release; October 2004 Release; October 2005 Release; October 2006 Release; Medicare Trans. 1531, Effective 7-1-08, October 2008 Release, January 2008 Release, April 2009 Release, October 2009 Release, October 2010 Release, January 2011 Release

CMS (Medicare) has determined that Gamma Glutamyltransferase (GGT) (CPT Code 82977) is only medically necessary and, therefore, reimbursable by Medicare when ordered for patients with any of the diagnostic conditions listed below in the “ICD-9-CM Codes Covered by Medicare Program.” If you are ordering this test for a diagnostic condition other than those listed below, please have your patient sign and date an Advanced Beneficiary Notice (ABN). All ICD-9-CM codes provided must be consistent with the documentation in the patient’s medical records for the date of service. NOTE: Please be aware that it is not enough to link the procedure code to a correct, payable ICD-9-CM diagnosis code. The diagnosis must be present for the procedure to be paid. In addition, the procedure must be reasonable and necessary for that diagnosis. Documentation within the beneficiary's medical record must support the necessity for the test(s) provided for each date of service. For additional information, see the “Limited Coverage Guidebook Information” provided in this section.

ICD-9-CM Codes Covered by Medicare Program: 003.1 Salmonella septicemia 006.0-006.9 Amebiasis 014.00-014.86 Tuberculosis of intestines, peritoneum, and mesenteric glands 017.90-017.96 Tuberculosis of other specified organs 018.90-018.96 Miliary tuberculosis, unspecified 020.0-020.9 Plague 022.3 Anthrax septicemia 027.0 Listeriosis 027.1 Erysipelothrix infection 030.1 Tuberculoid leprosy [Type T] 032.83 Diphtheritic peritonitis 036.1 Meningococcal encephalitis 036.2 Meningococcemia 038.0 Septicemia, streptococcal 038.10-038.19 Septicemia, staphylococcal 038.2-038.3 Septicemia, pneumococcal, anaerobes 038.40-038.49 Septicemia due to other gram negative organisms 038.8-038.9 Septicemia – other specified, unspecified 039.2 Actinomycotic infections, abdominal 040.0 Gas gangrene 042 Human immunodeficiency virus (HIV) disease 054.0 Eczema herpeticum 054.5 Herpetic septicemia 060.0-060.1 Yellow fever 070.0-070.9 Viral hepatitis 072.71 Mumps hepatitis 073.0 Ornithosis, with pneumonia 074.8 Other specified diseases due to Coxsackie virus 075 Infectious mononucleosis 078.5 Cytomegaloviral disease 079.99 Unspecified viral infection

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Gamma Glutamyltransferase (GGT) 1-11

082.0-082.3 082.40-082.49 082.8-082.9 084.9 086.1 088.81 091.62 095.3 100.0 112.5 115.00 120.9 121.1 121.3 122.0 122.5 122.8 122.9 130.5 135 150.0-159.9 160.0-165.9 170.0-176.9 179 180.0-184.9 185 186.0-189.9 200.00-202.9 203.02 203.12 203.82 204.02 204.12 204.22 204.82 204.92 205.02 205.12 205.22 205.32 205.82 205.92 206.02 206.12 206.22 206.82 206.92 207.02 207.12 207.22

Tick – borne rickettsioses – spotted fevers, boutonneuse fever, north asian, queensland tick typhus Ehrilichiosis Tick-borne rickettsioses – other specified, unspecified Other pernicious complications of malaria Chagas disease with organ involvement other than heart Lyme disease Secondary syphilitic hepatitis Syphilis of liver Leptospirosis icterohemorrhagica Candidiasis, disseminated Infection by Histoplasma capsulatum without mention of manifestation Schistosomiasis, unspecified Clonorchiasis Fascioliasis Echinococcus granulosus infection of liver Echinococcus multilocularis infection of liver Echinococcosis, unspecified, of liver Echinococcus, other and unspecified Hepatitis due to toxoplasmosis Sarcoidosis Malignant neoplasm of digestive organs and peritoneum Malignant neoplasm of respiratory and intrathoracic organs Malignant neoplasm of bone, connective tissue, skin, and breast Malignant neoplasm of uterus, part unspecified Malignant neoplasm – cervix uteri, body of uterus, ovary and other uterine adnexa, oter and unspecified female genital organs Malignant neoplasm of prostate Malignant neoplasm – testes, penis and other male genital organs, bladder, kidney and other and unspecified urinary organs Malignant neoplasm of lymphatic and hematopoietic tissue Multiple myeloma in relapse Plasma cell leukemia in relapse Other immunoproliferative neoplasms in relapse Acute lymphoid leukemia in relapse Chronic lymphoid leukemia in relapse Subacute lymphoid leukemia in relapse Other lymphoid leukemia in relapse Unspecified lymphoid leukemia in relapse Acute myeloid leukemia in relapse Chronic myeloid leukemia in relapse Subacute myeloid leukemia in relapse Myeloid sarcoma in relapse Other myeloid leukemia in relapse Unspecified myeloid leukemia in relapse Acute monocytic leukemia in relapse Chronic monocytic leukemia in relapse Subacute monocytic leukemia in relapse Other monocytic leukemia in relapse Unspecified monocytic leukemia in relapse Acute erythremia and erythroleukemia in relapse Chronic erythremia in relapse Megakaryocytic leukemia in relapse

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Gamma Glutamyltransferase (GGT) 1-11

207.82 208.02 208.12 208.22 208.82 208.92 209.20-209.29 209.70 209.71 209.72 209.73 208.74 209.75 209.79 211.5 211.6 211.7 228.04 230.7 230.8 230.9 235.0-236.7 236.90-236.91, 236.99 237.0-237.6 237.70-237.72 *237.73-237.79 237.9 238.0-238.6 238.71-238.79 238.8-238.9 239.0 250.00-250.93 252.00 252.01 252.02 252.08 263.1 263.9 268.0 268.2 269.0 270.2 270.9 271.0 272.0 272.1 272.2 272.4 272.7 272.9 273.4 *275.01-275.09

Other specified leukemia in relapse Acute leukemia of unspecified cell type in relapse Chronic leukemia of unspecified cell type in relapse Subacute leukemia of unspecified cell type in relapse Other leukemia of unspecified cell type in relapse Unspecified leukemia of unspecified cell type in relapse Malignant neuroendocrine tumor Secondary neuroendocrine tumor, unspecified site Secondary neuroendocrine tumor of distant lymphnodes Secondary neuroendocrine tumor of liver Secondary neuroendocrine tumor of bone Secondary neuroendocrine tumor of peritoneum Secondary Merkel cell carcinoma Secondary neuroendocrine tumor of other sites Benign neoplasm of liver and biliary passages Benign neoplasm of pancreas, except islets of Langerhans Benign neoplasm of islets of Langerhans Hemangioma of intra-abdominal structures Carcinoma in situ of other and unspecified parts of intestine Carcinoma in situ of liver and biliary system Carcinoma in situ other and unspecified digestive organs Neoplasms of uncertain behavior – digestive and respiratory systems, genitourinary organs Neoplasms of uncertain behavior – other and unspecified urinary organs Neoplasms of uncertain behavior of endocrine glands and nervous system Neurofibromatosis Schwannomatosis, other neurofibromatosis Other and unspecified parts of nervous system Neoplasm of uncertain behavior of other and unspecified sites and tissues Other lymphatic and hematopoetic tissues, (PTLD) Neoplasms of uncertain behavior – other specified sites, unspecified Neoplasm of unspecified nature of digestive system Diabetes mellitus Hyperparathyroidism, unspecified Primary hyperparathyroidism Secondary hyperparathyroidism, non-renal Other hyperparathyroidism Malnutrition of mild degree Unspecified protein-calorie malnutrition Rickets, active Osteomalacia, unspecified Deficiency of vitamin K Other disturbances of aromatic amino acid metabolism Unspecified disorder of amino acid metabolism Glycogenosis Pure hypercholesterolemia Pure hyperglyceridemia Mixed hyperlipidemia Other and unspecified hyperlipidemia Lipidoses Unspecified disorder of lipoid metabolism Alpha-1-antitrypsin deficiency Hereditary hemochromatosis, hemochromatosis due to repeated red blood cell

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Gamma Glutamyltransferase (GGT) 1-11

275.1 275.2 275.3 275.40-275.49 275.5 277.1 277.30-277.39 277.4 277.6 282.60-282.69 286.6 286.7 289.4 289.52 291.0-291.5 291.81-291.89 291.9 303.00-303.03 303.90-303.93 304.00-304.93 305.00-305.93 357.5 359.21 359.22 359.23 359.24 359.29 452 453.0-453.3 453.40-453.42 453.6 453.71 453.72 453.73 453.74 453.75 453.76 453.77 453.79 453.81-453.89 453.9 456.0-456.1 456.20-456.21 555.0-555.9 556.0-556.9 557.0 558.1 -558.3 558.41-558.42 558.9 560.0-560.2

transfusions, other hemochromatosis, other disorders of iron metablolism Disorders of copper metabolism ‘Disorders of magnesium metabolism Disorders of phosphorus metabolism Disorders of calcium metabolism Hungry bone syndrome Disorders of porphyrin metabolism Amyloidosis Disorders of bilirubin excretion Other deficiencies of circulating enzymes Sickle cell disease Defibrination syndrome Acquired coagulation factor deficiency Hypersplenism Splenic sequestration Alcohol induced mental disorders Other specified alcohol induced mental disorders – withdrawal, sleep disorders, anxiety, mood, sexual dysfunction Unspecified alcohol induced mental disorders Acute alcoholic intoxication Other and unspecified alcohol dependence Drug dependence Non-dependent abuse of drugs Alcoholic polyneuropathy Myotonic muscular dystrophy Myotonia congenita Myotonic chondrodystrophy Drug induced myotonia Other specified myotonic disorder Portal vein thrombosis Other venous embolism and thrombosis – budd chiari, thrombophlebitis migans, of vena cava, of renal vein Venous embolism and thrombosis of deep vessels of lower extremity Venous embolism and thrombosis of superficial vessels of lower extremity Chronic venous embolism and thrombosis of superficial veins upper extremity Chronic venous embolism and thrombosis of deep veins upper extremity Chronic venous embolism and thrombosis of upper extremity unspecified Chronic venous embolism and thrombosis of axillary veins Chronic venous embolism and thrombosis of subclavian veins Chronic venous embolism and thrombosis of internal jugular veins Chronic venous embolism and thrombosis of other thoracic veins Chronic venous embolism and thrombosis of other specified veins Venous embolism and thrombosis of other specified veins Other venous and embolism thrombosis of unspecified site Esophageal varices – varicose veins of other sites Esophageal varices in diseases classified elsewhere Regional enteritis Ulcerative colitis Acute vascular insufficiency of intestine Other noninfectious gastroenteritis and colitis Eosinophilic gastroenteritis and colitis Other and unspecified noninfectious gastroenteritis and colitis Intestinal obstruction without mention of hernia- intussusception, paralytic ileus, volvulus

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Gamma Glutamyltransferase (GGT) 1-11

560.30-560.89 560.9 562.01 562.03 562.11 562.13 567.0-567.1 567.21-567.89 567.9 569.83 569.87 570 571.0-571.3 571.40-571.49 571.5-571.9

572.0-572.8 573.0-573.9 574.00-574.91 575.0 575.10-575.12 575.2-575.9 576.0-576.9 581.0-581.3

581.81-581.89 581.9 582.0-582.4

582.81-582.89 582.9 583.0-583.7

583.81-583.89 583.9 584.5-584.9 585.6 586 587 588.0-588.1 588.81-588.89 588.9 590.00-590.11 590.2-590.3 590.80-590.81

Intestinal obstruction without mention of hernia – impaction , other specified Unspecified intestinal obstruction Diverticulitis of small intestine (without mention of hemorrhage) Diverticulitis of small intestine with hemorrhage Diverticulitis of colon (without mention of hemorrhage) Diverticulitis of colon with hemorrhage Peritonitis and retroperitoneal infections – diseases classified elsewhere, pneumococcal Other suppurative peritonitis, retropertoneal, other specified Other disorders of peritoneum Perforation of intestine Vomiting of fecal matter Acute and subacute necrosis of liver Chronic liver disease and cirrhosis- alcoholic Chronic liver disease and cirrhosis – chronic hepatitis Chronic liver disease and cirrhosis – cirrhosis of liver without mention of alcohol, biliary, other chronic non-alcoholic, unspecified chronic liver disease without mention of alcohol Liver abscess and sequelae of chronic liver disease Other disorders of liver Cholelithiasis Other disorders of gallbladder-acute cholecystitis Other cholecysitis Other disorders of gallbladder – obstruction, hydrops, perforation, fistula, cholesterolosis, other specified, unspecified Other disorders of biliary tract Nephrotic syndrome- with lesion of proliferative glomerulonephritis, with lesion of membranous glomerulonephritis, with lesion of membranoproliferative glomerulonephritis, with lesion of minimal change glomerulonephritis Nephrotic syndrome – with other specified pathological lesion in kidney Nephrotic syndrome with unspecified pathological lesion in kidney Chronic glomerulonephritis- with lesion of: priliferative glomerulonephritis, membraneous glomerulonephritis, membranoproliferative glomerulonephritis, rapidly progressive glomerulonephritis Chronic glomerulonephritis – with other specified pathological lesion in kidney Chronic glomerulonephritis – with unspecified pathological lesion in kidney Nephritis and nephropathy, not specified as acute or chronic – with lesion of: proleiferative glomerulonephritis, membranous glomerulonephritis, membranoproliferative glomerulonephritis, rapidly progressive glomeulonephritis, renal cortical necrosis, renal medullary necrosis Nephritis and nephropathy, not specified as acute or chronic – with other specified pathological lesion in kidney Nephritis and nephropathy, not specified as acute or chronic – with unspecified pathological lesion in kidney Acute renal failure End stage renal disease Renal failure, unspecified Renal sclerosis, unspecified Disorders resulting from impaired renal function – renal ostiodystrophy, nephrogenic diabetes insipidus Other specified disorders resulting from impaired renal function Unspecified disorder resulting from impaired renal function Infections of kidney- chronic pyelonephritis, acute pyelonephritis Infections of kidney – renal and perinephric abscess, pyeloureteritis cystica Other pyelonehritis or pyonephrosis, not specified as acute or chronic 5 of 6

Gamma Glutamyltransferase (GGT) 1-11

590.9 642.50-642.54

Infections of kidney, unspecified Severe pre-eclampsia

646.70, 646.71, 646.73 782.4 789.1 790.4 790.5 960.0-964.9

Liver disorders in pregnancy

965.00-965.09 965.1-965.5 965.61-965.69 965.7-968.9 969.00-969.09 969.1-969.6 969.70-969.79 969.8-969.9 *970.81-970.89 971.0-979.9

980.0-989.7

989.81-989.89 989.9 V42.7 V58.61-V58.69 V67.1 V67.2 V67.51

Jaundice, unspecified, not of newborn Hepatomegaly Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase Other nonspecific abnormal serum enzyme levels Poisoning by drugs, medicinal and biological substances – antibiotics, anti-infectives, hormones and synthetic substitutes, primarily systemic agents, by agents primarily affecting blood constituents Poisoning by opiates and related narcotics Poisoning by salicylates, aromatic analgesics (not elsewhere classified), pyrazole derivatives Poisoning by antirheumatics Poisoning by non-narcotic analgesics, other specified analgesics, unspecified, anticonvulsants, sedatives, central nervous system depressants Poisoning by antidepressants; unsp, MAOI, SSNRI,SSRI, Tetracyclic, Tricyclic, other Poisoning by tranquilizers Poisoning by psychostimulants; unsp.,caffeine, amphetamines, methylphenidate, other Poisoning by other specified and or unspecified psychotropes Other specified central nervous system stimulants, cocaine Poisoning by central nervous system stimulants; by agents affecting autonomic nervous, cardiovascular, gastrointestinal. By water, mineral and uric acid metabolism, agents affecting smooth and skeletal muscle and respiratory, agents affecting skin and mucosal membrane, other and uspecified, bacterial vaccines, by other vaccines and biological substances. Toxic effects of substances chiefly nonmedicinal as to source- alcohol, petroleum products, solvents (other than petroleum based), corrosive aromatics, acids, alkalis, lead, other metals, gases, fumes, vapors, noxious substances eaten as food, other Toxic effects of other substances- asbestos, latex, silicone, tobacco, other Unspecified substance, chiefly non-medicinal as to source Organ replaced by transplant, liver Long term (current) drug use Follow-up examination, radiotherapy Follow-up examination, chemotherapy Follow-up examination after completed treatment with high-risk medications, not elsewhere classified

ICD-9-CM Codes That May Be Denied or Do Not Support Medical Necessity Generally, ICD-9-CM codes that are not listed in the “ICD-9-CM Codes Covered by Medicare Program” section will not be covered because they indicate that the tests are performed for screening purposes or because they do not support medical necessity.

Frequency Limitations: When used to assess liver dysfunction secondary to existing non-hepatobiliary disease with no change in signs, symptoms, or treatment, it is generally not necessary to repeat a GGT determination after a normal result has been obtained unless new indications are present. When used to determine if other abnormal enzyme tests reflect liver abnormality rather than other tissue, it generally is not necessary to repeat a GGT more than one time per week.

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