Urinalysis

Local Coverage Determination

CPT Codes: 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020

  Numerical Sort:

  016.00-016.96 038.0-038.9 041.00-041.9 54.10 54.11 54.12 54.13 054.19 070.0-070.59 070.70-070.71 072.0 078.11 078.88 079.81-079.89 079.98 087.0-087.1 095.4 098.0-098.39 098.89 099.3 099.40-099.49 099.53-099.54 100.0 102.0-102.9 112.1 112.2 125.0-125.1 131.00-131.03 135 185 186.0-186.9 187.1-187.8 188.0-188.9 189.0-189.9 198.0-198.1 203.00-203.02 222.2 223.0-223.3 223.81-223.89 233.4 233.7 233.9 236.5 236.7 236.90-236.99 249.00-249.91 250.00-250.93 253.5-253.6 271.4 272.2-272.4 273.0-273.8 274.00-274.03 274.10-274.19 275.01-275.09

Tuberculosis of genitourinary system Septicemia Bacterial infection in condition classified elsewhere and of unspecified site Genital herpes, unspecified Herpetic vulvovaginitis Herpetic ulceration of the vulva Herpetic infection of penis Genital herpes, other Viral hepatitis Hepatitis, viral, Type C, unspecified Mumps orchitis Condyloma acuminatum Other specified diseases due to Chlamydia Other specified viral and chlamydial infection Unspecified chlamydial infection Relapsing fever Syphilis of kidney Gonoccocal infections Gonococcal infection of other specified sites Reiter’s disease Other nongonococcal urethritis (NGU) Venereal diseases, other, due to Chlamydia trachomatis Leptospiral icterohemorrhagia Yaws Candidiasis of vulva and vagina Candidiasis of other urogenital sites Filarial infection and dracontiasis Urogenital trichomoniasis Sarcoidosis Malignant neoplasm of prostate Malignant neoplasm of testis Malignant neoplasm of penis and other male genital organs Malignant neoplasm of bladder Malignant neoplasm of kidney and other and unspecified urinary organs Malignant neoplasm, secondary, of kidney and other urinary organs Multiple myeloma Benign neoplasm of prostate Benign neoplasm of kidney and other urinary organs Benign neoplasm of urethra and other urinary organs Malignant neoplasm, Carcinoma in situ, of prostate Malignant neoplasm, Carcinoma in situ, of bladder Malignant neoplasm, Carcinoma in situ, of other and unspecified urinary organs Neoplasm of uncertain behavior of prostate Neoplasm of uncertain behavior of bladder Neoplasm of uncertain behavior of other and unspecified urinary organs Diabetes mellitus, secondary Diabetes mellitus Diabetes insipidus and other disorders of neurohypophysis Renal glycosuria Hyperlipidemia, mixed and other unspecified Disorders of plasma protein metabolism Gouty arthropathy Gouty nephropathy Iron metabolism, disorders

 

January 2015

Medicare Limited Coverage Tests

 

275.42 Hypercalcemia 276.0-276.9 Disorders of fluid, electrolyte, and acid-base balance 277.00-277.09 Cystic Fibrosis 277.1-277.2 Disorders of porphyrin/purine and pyrimidine metabolism 277.3-277.39 Amyloidosis 277.4 Amyloidosis/disorders of bilirubin excretion 277.5 Mucopolysaccharidosis 277.88 Tumor Iysis Syndrome 282.60-282.69 Sickle-cell anemia 283.11 Hemolytic-uremic syndrome 283.2 Hemoglobinuria due to hemolysis from external causes 287.41 Posttransfusion purpura 287.49 Thrombocytopenia, other secondary 306.53 Psychogenic Dysuria 310.1 Personality change due to conditions classified elsewhere 344.61 Cauda equina syndrome with neurogenic bladder 401.0-401.9 Hypertension, Essential 402.00402.91 Hypertensive heart disease 403.00403.91 Hypertensive chronic kidney disease 404.00-404.93 Hypertensive heart and chronic kidney disease 405.01-405.99 Secondary hypertension 421.0-421.9 Endocarditis, Acute and subacute 428.0 Congestive heart failure 446.0-446.1 Polyarteritis nodosa and allied conditions 446.20-446.29 Hypersensitivity angitis 446.3-446.7 Polyarteritis nodosa and allied conditions 447.3-447.6 Disorders of arteries and arterioles, other 456.4 Scrotal varices (varicocele) 457.0-457.1 Postmastectomy lymphedema and other lymphedema 570 Necrosis of liver, acute and subacute 571.40-571.49 Hepatitis, chronic 571.5-571.8 Cirrhosis of the liver, chronic and other 572.2 Hepatic coma 573.0-573.3 Disorders of liver, other 580.0-580.9 Glomerulonephritis, acute 581.0-581.9 Nephrotic syndrome 582.0-582.9 Glomerulonephritis, chronic 583.0-583.7 Nephritis and nephropathy, not specified as acute or chronic 583.81-583.89 Nephritis and nephropathy, specified and other 583.9 Nephritis and nephropathy with unspecified pathological lesion in kidney 584.5-584.9 Renal failure, acute 585.1-585.9 Disease, kidney, chronic 586 Renal failure, unspecified 587 Renal sclerosis, unspecified 588.1 Renal osteodystrophy 588.2 Nephrogenic diabetes insipidus 588.81-588.89 Disorders resulting from impaired renal function, other specified 589.0-589.9 Small kidney of unknown cause 590.00-590.01 Pyelonephritis, chronic 590.10-590.11 Pyelonephritis, acute 590.2-590.3 Renal and perinephric abscess/pyeloureteritus 590.80-590.81 Pyelonephritis or pyonephrosis, other, not specified as acute or chronic 590.9 Infection of kidney, unspecified 591 Hydronephrosis 592.0-592.9 Calculus of kidney and ureter 593.0-593.6 Disorders of kidney and ureter, other 593.70-593.73 Cesicoureteral reflux 593.81-593.89 Disorders of kidney and ureter, other specified 593.9 Disorder of kidney and ureter, unspecified 594.0-594.9 Calculus of lower urinary tract 595.0-595.4 Cystitis; acute, chronic, other chronic, trigonitis, in diseases classified elsewhere Medicare Limited Coverage Tests January 2015

 

595.81-595.89 595.9 596.0-596.4 596.51-596.59 596.6-596.9 597.0 597.80-597.89 598.00-598.01 598.1-598.9 599.0-599.5 599.60-599.69 599.70-599.72 599.81-599.89 599.9 600.01 600.11 600.21 600.91 601.0-601.9 602.0-602.9 603.0-603.9 604.0 604.90-604.91 605 606.1 606.9 607.1 607.81 607.84 607.89 608.1 608.2 608.23-608.24 608.83 608.89 608.9 616.10-616.11 618.00-618.09 619.0-619.9 625.0 625.6 625.7-625.79 625.9 628.9 629.31-629.32 634.00-634.32 635.00-635.32 636.00-636.32 637.00-637.32 638.0-638.3 639.0-639.3 642.00-642.94 646.10-646.14 646.20-646.24 646.50-646.54 646.60-646.64 647.10-647.14 648.00-648.04 January 2015

Cystitis, other specified types Cystitis, unspecified Disorders of bladder, other Disorders of bladder, other functional Rupture of bladder, nontraumatic; hemorrhage into bladder wall; other specified disorders of bladder Abscess, urethral Urethritis, other and unspecified Urethral stricture due to infection Urethral stricture Disorders of urethra and urinary tract, other Urinary obstruction Hematuria Disorders of urethra and urinary tract, other specified Disorders of urethra and urinary tract, unspecified Hypertrophy (benign) of prostate with urinary obstruction Nodular prostate with urinary obstruction Benign localized hyperplasia of prostate with urinary obstruction Hyperplasia of prostate, unspecified with urinary obstruction Inflammatory diseases of prostate Disorders of prostate, other Hydrocele Orchitis and epididymitis Orchitis, epididymitis and epididymo-orchitis, other, without mention of abscess Redundant prepuce and phimosis Oligospermia Infertility, male, unspecified Balanoposthitis Balanitis xerotica obliterans Impotence of organic origin Disorders of penis, other specified Seminal vesiculitis Spermatocele Torsion of appendix Vascular disorders of male genital organs Disorders of male genital organs, other Disorders of male genital organs, unspecified Vaginitis and vulvovaginitis Genital prolapse Fistula involving female genital tract Dyspareunia Stress incontinence, female Vulvodynia Unspecified symptom associated with female genital organs Infertility, female of unspecified origin Vaginal mesh erosion or exposure Abortion, spontaneous Abortion, legally induced Abortion, illegally induced Abortion, unspecified Abortion, failed attempted Abortion, complications following and ectopic and molar pregnancies Pregnancy, complicated by hypertension Pregnancy complications, edema or excessive weight gain, without mention of hypertension Pregnancy complications, unspecified renal disease, without mention of hypertension Pregnancy complications, asymptomatic bacteriuria Pregnancy, infections of genitourinary tract Pregnancy, infections and parasitic conditions in mother, Gonorrhea Pregnancy, diabetes mellitus, other current conditions in mother Medicare Limited Coverage Tests

 

648.80-648.84 654.40-654.44 658.40-658.43 659.20-659.23 659.30-659.33 664.80-664.84 664.90-664.94 665.40-665.44 665.50-665.54 665.80-665.84 669.30-669.34 670.00-670.04 670.20-670.24 670.82-670.84 672.00-672.04 710.0-710.4 710.9 711.00-711.09 714.0-714.9 719.40-719.49 724.2 724.5 752.51 753.0 753.10-753.19 753.20-753.29 753.3-753.9 780.02 780.09 780.20 780.33 780.40 780.60-780.66 780.79 780.91 780.97 780.99 782.3 783.5 785.59 787.01 787.03 787.91 788.0-788.1 788.20-788.29 788.30-788.39 788.41-788.43 788.5 788.61-788.69 788.7-788.8 788.91-788.99 789.00-789.09 789.36 789.51 790.29 790.7 790.93 790.95 791.0-791.9

Pregnancy, abnormal glucose tolerance, other current conditions in mother Pregnancy, abnormalities, other, in shape or position of gravid uterus and of neighboring structures Infection of amniotic cavity Maternal pyrexia during labor, unspecified Generalized infection during labor Other specified trauma to perineum and vulva Unspecified trauma to perineum and vulva High vaginal laceration Other injury to pelvic organs Other specified obstetrical trauma Renal failure, acute, following labor and delivery Major puerperal infection, unspecified Puerperal sepsis Other major puerperal infection Pyrexia of unknown origin during the puerperium Diffuse diseases of connective tissue Diffuse connective disease, unspecified Pyogenic arthritis Rheumatoid arthritis Pain in joint Lumbago Backache, unspecified Undescended testis Renal agenesis and dysgenesis Cystic kidney disease Obstructive defects of renal pelvis and ureter Anomalies of urinary system, other Transient alteration of awareness Alteration of consciousness, other Syncope and collapse Post traumatic seizures Dizziness and giddiness Fever, unspecified Other malaise and fatigue Fussy infant (baby) Altered mental state Other general symptoms Edema Polydipsia Shock without mention of trauma, other Nausea with vomiting Vomiting alone Diarrhea Renal colic/dysuria Retention of urine Incontinence of urine Frequency of urination and polyuria Oliguria and anuria Abnormality of urination, other Urethral discharge/extravasation of urine Other symptoms involving urinary system Symptoms involving abdomen and pelvis, other Abdominal or pelvic swelling mass or lump, epigastric Malignant ascites 790.21Abnormal glucose tolerance test Bacteremia Elevated PSA Elevated C-reactive protein (CRP) Nonspecific findings on examination of urine

  Medicare Limited Coverage Tests

January 2015

 

793.5-793.6 794.4 795.79 796.2 799.21-799.24 799.59 806.5 806.70 806.71 808.0-808.3 808.41-808.49 808.51-808.59 808.9 866.00-866.13 867.0-867.3 867.6-867.9 868.0-868.19 869.0 876.1 878.0-878.9 879.3 879.5 879.7 879.8 879.9 922.1-922.33 922.4 926.0 926.11-926.19 926.8 927.0 928.1 928.2 928.1 928.8 929.0 929.9 939.0 939.2 939.3 939.9 941.39 941.49 941.59 942.20 942.22-942.24 942.29 942.30 942.32-942.34 942.39 942.40 January 2015

Abnormal findings on radiological and other examinations of genitourinary organs, abdominal area, including retroperitoneum Non-specific abnormal results of function of kidney study Other and unspecified nonspecific immunological findings Elevated blood pressure reading without diagnosis of hypertension Signs and symptoms involving emotional state – nervousness, irritability, impulsiveness, emotional liability Signs and symptoms involving cognition, other Open fracture of lumbar spine with spinal cord injury Open fracture of sacrum and coccyx with unspecified spinal cord injury Open fracture of sacrum and coccyx with complete cauda equine lesion Fracture of pelvis Fracture of pelvis, other specified part, closed Fracture of pelvis, other specified part, open Open fracture of pelvis, unspecified Injury to kidney Injury to bladder and urethra Injury to other specified/unspecified pelvic organs Injury to other intra-abdominal organ Injury to unspecified or ill-defined organs, without open wound into cavity Open wound of back, complicated Open wound of genital organs (external), including traumatic amputation Open wound of abdominal wall, anterior, complicated Open wound of abdominal wall lateral complicated Open wound of other and unspecified parts of trunk, complicated Open would(s) (multiple) of unspecified site(s) without complication Open would(s) (multiple) of unspecified site(s), complicated Contusion of trunk Contusion to genital organs Crushing injury of external genitalia Crushing injury of other specified sites Crushing injury to multiple sites of trunk Crushing injury of shoulder region Crushing injury of thigh Crushing injury of hip Crushing injury of lower leg Crushing injury of multiple sites of lower limb Crushing injury of multiple sites not elsewhere classified Crushing injury of unspecified site Foreign body in genitourinary tract, bladder and urethra Foreign body in vulva and vagina Foreign body in penis Foreign body in unspecified site in genitourinary tract Skin loss, full-thickness, due to burn (third degree nos) of multiple sites (except eye) of face, head and neck Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites (except eye) of face, head and neck without loss of a body part Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites (except eye) of face, head and neck with loss of a body part Blisters with epidermal loss due to burn (second degree) of unspecified site of trunk Blisters with epidermal loss due to burn (second degree) of chest wall, abdominal wall, or back Blisters with epidermal loss due to burn (second degree) of other and multiple sites of trunk Skin loss, full thickness, due to burn (third degree nos) of unspecified site of trunk Skin loss, full thickness, due to burn (third degree nos) of chest wall excluding breast and nipple; abdominal wall; back (any part) Skin loss, full thickness, due to burn (third degree nos) of other and multiple sites of trunk Deep necrosis of underlying tissues due to burn (deep third degree) of trunk unspecified without loss of body part Medicare Limited Coverage Tests

 

942.42-942.44

942.49 942.50 942.52-942.54

942.59 943.30 943.39 943.40 943.49 943.50 943.59 946.20 946.30 946.40 946.50 947.1-947.4 947.8 948.21-948.99 949.3 949.4-949.5 958.5 959.11-959.19 961.2 963.1 963.3 965.1 992.0-992.8 995.20-995.23 995.27 995.29 996.30-996.39 995.53 995.54 995.59 996.62 996.64-996.65 996.76 996.81 997.5 998.00-998.03 998.2 999.32

Deep necrosis of underlying tissues due to burn (deep third degree) of chest wall excluding breast and nipple without loss of chest wall; abdominal wall without loss of abdominal wall; back (any part) without loss of back Deep necrosis of underlying tissues due to burn (deep third degree) of other and multiple sites of trunk without loss of body part Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of trunk with loss of body part Deep necrosis of underlying tissues due to burn (deep third degree) of chest wall excluding breast and nipple with loss of chest wall; abdominal wall with loss of abdominal wall; back (any part) with loss of back Deep necrosis of underlying tissues due to burn (deep third degree) of other and multiple sites of trunk with loss of body part Skin loss, full thickness, due to burn (third degree nos) of unspecified site of upper limb Skin loss, full thickness, due to burn (third degree nos) of multiple sites of upper limb except wrist and hand Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of upper limb without loss of a body part Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of upper limb except wrist and hand without loss of upper limb Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of upper limb with loss of a body part Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of upper limb except wrist and hand with loss of upper limb Blisters with epidermal loss due to burn (second degree) of multiple specified sites. Skin loss, full thickness, due to burn (third degree nos) of multiple specified sites Deep necrosis of underlying tissues due to burn (deep third degree) of multiple specified sites without loss of a body part Deep necrosis of underlying tissues due to burn (deep third degree) of multiple specified sites with loss of a body part Burn of internal organs – larynx, trachea and lung; esophagus; gastrointestinal tract; vagina and uterus Burn of other specified sites of internal organs Burns classified according to extent of body surface involved Skin loss, full thickness, due to burn (third degree nos) unspecified site Deep necrosis of underlying tissue due to burn (deep third degree), unspecified site without loss of a body part; with loss of a body part Traumatic anuria Injury, trunk Poisoning by heavy metal anti-infectives Poisoning by anti-neoplastic and immunosuppressive drugs Poisoning by alkalizing agents Poisoning by salicylates Effects of heat and light Adverse effect, unspecified, of drug, medicinal and biological substance, arthus phenomenon, anesthesia, insulin Drug allergy, other Adverse effect, unspecified, of other drug, medicinal and biological substance Complication, Mechanical, of genitourinary devise, implant, and graft Child maltreatment syndrome, sexual abuse Child maltreatment syndrome, physical abuse Child maltreatment syndrome, child abuse and neglect, other Infection and inflammatory reaction, due to other vascular device implant and graft Infection and inflammatory reaction due to internal prosthetic device, implant, and graft Complications, other, due to genitourinary device implant and graft Complications of transplanted kidney Complications, Urinary Postoperative shock Puncture or laceration, Accidental, during a procedure Infection of bloodstream, due to central venous catheter

  Medicare Limited Coverage Tests

January 2015

 

999.33 999.34 999.60-999.69 999.70-999.79 999.80-999.89 V10.46 V10.50-V10.59 V13.00-V13.09 V13.62 V15.51 V15.59 V21.0-V21.2 V21.30-V21.35 V21.8-V21.9 V22.0-V22.2 V23.0-V23.3 V23.41 V23.49 V23.5 V23.7 V23.81-V23.84 V23.89 V23.9 V42.0 V44.50-V44.59 V44.6 V45.11-V45.12 V58.0 V58.63-V58.65 V58.69 V59.4 V67.51 V87.01 V87.09 V87.11 V87.12 V87.19 V87.2 V90.83

Infection, local, due to central venous catheter Infection, acute, following transfusion, infusion, or injection of blood and blood products ABO incompatibility reaction due to transfusion of blood or blood products Rh and other non-ABO incompatibility reaction due to transfusion of blood or blood products Infusion and transfusion, other and unspecified reaction Personal history of malignant neoplasm of prostate Personal history of malignant neoplasm urinary organs Personal history of other diseases urinary system Personal history of other (corrected) congenital malformations of genitourinary system Personal history of traumatic fracture Personal history of other injury Constitutional states in development, Rapid growth; puberty; other adolescence Constitutional states in development, low birth weight status Constitutional states in development, other specified; unspecified Pregnancy, normal Supervision of high risk pregnancy Supervision of high risk pregnancy, with history of labor pre-term Supervision of high risk pregnancy, with other poor obstetric history Supervision of high risk pregnancy, with other poor reproductive history Supervision of high risk pregnancy, with insufficient prenatal care Supervision of high risk pregnancy, Elderly primigravida; elderly multigravida; young primigravida; young multigravida Supervision of high risk pregnancy, other Supervision of high risk pregnancy, unspecified Kidney replaced by transplant Persons with cystostomy Persons with other artificial opening of urinary tract Renal dialysis status Radiotherapy Long-term (current) drug use, Antiplatelets/antithrombotics; Nonsteroidal inflammatories; steroids Long term (current) use of other medications Kidney donors Following completed treatment with high-risk medication, NEC Contact with and (suspected) exposure to arsenic Contact with and (suspected) exposure to other hazardous metals Contact with and (suspected) exposure to aromatic amines Contact with and (suspected) exposure to benzene Contact with and (suspected) exposure to other hazardous aromatic compounds Contact with and (suspected) exposure to other potentially hazardous chemicals Retained stone or crystalline fragments

                             

  Medicare Limited Coverage Tests – Covered Diagnosis Codes Source: National Coverage Determinations, Noridian Administrative Services Effective May 13, 2013 January 2015 Medicare Limited Coverage Tests

 

Urinalysis, Continued Alphabetical Sort:

  789.36 793.5-793.6 790.21-790.29 788.61-788.69 794.4 999.60-999.69 638.0-638.3 636.00-636.32 635.00-635.32 634.00-634.32 637.00-637.32 639.0-639.3 597.0 995.20-995.23 995.29 995.27 780.97 277.3-277.39 277.3-277.4 282.60-282.69 753.3-753.9 780.02 780.09 724.5 790.7 041.00-041.9 607.81 607.1 223.0-223.3 222.2 223.81-223.89 942.22-942.24 946.20 942.29 942.20 948.21-948.99 947.1-947.4 947.8 592.0-592.9 594.0-594.9 112.2 112.1 344.61 593.70-593.73 995.59 995.54 995.53 571.5-571.8 799.59 997.5 996.30-996.39

Abdominal or pelvic swelling mass or lump, epigastric Abnormal findings on radiological and other examinations of genitourinary organs, abdominal area, including retroperitoneum Abnormal glucose tolerance test Abnormality of urination, other Abnormal results of function of kidney study, non-specific ABO incompatibility reaction due to transfusion of blood or blood products Abortion, failed attempted Abortion, illegally induced Abortion, legally induced Abortion, spontaneous Abortion, unspecified Abortion, complications following and ectopic and molar pregnancies Abscess, urethral Adverse effect, unspecified, of drug, medicinal and biological substance, arthus phenomenon, anesthesia, insulin Adverse effect, unspecified, of other drug, medicinal and biological substance Allergy; drug, other Altered mental state Amyloidosis Amyloidosis/disorders of bilirubin excretion Anemia; sickle-cell Anomalies of urinary system, other Alteration of awareness, transient Alteration of consciousness, other Backache, unspecified Bacteremia Bacterial infection in condition classified elsewhere and of unspecified site Balanitis xerotica obliterans Balanoposthitis Benign neoplasm of kidney and other urinary organs Benign neoplasm of prostate Benign neoplasm of urethra and other urinary organs Blisters with epidermal loss due to burn (second degree) of chest wall, abdominal wall, or back Blisters with epidermal loss due to burn (second degree) of multiple specified sites. Blisters with epidermal loss due to burn (second degree) of other and multiple sites of trunk Blisters with epidermal loss due to burn (second degree) of unspecified site of trunk Burns classified according to extent of body surface involved Burn of internal organs – larynx, trachea and lung; esophagus; gastrointestinal tract; vagina and uterus Burn or other specified sites of internal organs Calculus; kidney and ureter Calculus; lower urinary tract Candidiasis of other urogenital sites Candidasis of vulva and vagina Cauda equina syndrome with neurogenic bladder Cesicoureteral reflux Child maltreatment syndrome, child abuse and neglect, other Child maltreatment syndrome, physical abuse Child maltreatment syndrome, sexual abuse Cirrhosis of the liver, chronic and other Cognition, signs and symptoms involving, other Complications, urinary Complications; mechanical, of genitourinary devise, implant, and graft

 

Medicare Limited Coverage Tests

January 2015

 

996.76 996.81 078.11 428.0 V21.0-V21.2 V21.30-V21.35 V21.8-V21.9 V87.11 V87.01 V87.12 V87.19 V87.09 V87.2 922.4 922.1-922.33 926.0 926.11-926.19 926.8 600.3 277.00-277.09 753.10-753.19 595.0-595.4 595.81-595.89 595.9 942.52-942.54

942.42-942.44

941.59 941.49 943.59 943.49 946.50 946.40 942.59 942.49 942.40 942.50 943.40 943.50 949.4-949.5 253.5-253.6 588.1 249.00-249.91 250.00-250.93

Complications, other, due to genitourinary device implant and graft Complications; transplanted kidney Condyloma acuminatum Congestive heart failure Constitutional states in development, Rapid growth; puberty; other adolescence Constitutional states in development, low birth weight status Constitutional states in development, other specified; unspecified Contact with and (suspected) exposure to aromatic amines Contact with and (suspected) exposure to arsenic Contact with and (suspected) exposure to benzene Contact with and (suspected) exposure to other hazardous aromatic compounds Contact with and (suspected) exposure to other hazardous metals Contact with and (suspected) exposure to other potentially hazardous chemicals Contusion; genital organs Contusion; trunk Crushing; injury of external genitalia Crushing; injury of other specified sites Crushing; injury to multiple sites of trunk Cyst; prostate Cystic Fibrosis Cystic kidney disease Cystitis; acute, chronic, other chronic, trigonitis, in diseases classified elsewhere Cystitis, other specified types Cystitis, unspecified Deep necrosis of underlying tissues due to burn (deep third degree) of chest wall excluding breast and nipple with loss of chest wall; abdominal wall with loss of abdominal wall; back (any part) with loss of back Deep necrosis of underlying tissues due to burn (deep third degree) of chest wall excluding breast and nipple without loss of chest wall; abdominal wall without loss of abdominal wall; back (any part) without loss of back Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites (except eye) of face, head and neck with loss of a body part Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites (except eye) of face, head and neck without loss of a body part Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of upper limb except wrist and hand with loss of upper limb Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of upper limb except wrist and hand without loss of upper limb Deep necrosis of underlying tissues due to burn (deep third degree) of multiple specified sites with loss of a body part Deep necrosis of underlying tissues due to burn (deep third degree) of multiple specified sites without loss of a body part Deep necrosis of underlying tissues due to burn (deep third degree) of other and multiple sites of trunk with loss of body part Deep necrosis of underlying tissues due to burn (deep third degree) of other and multiple sites of trunk without loss of body part Deep necrosis of underlying tissues due to burn (deep third degree) of trunk unspecified without loss of body part Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of trunk with loss of body part Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of upper limb without loss of a body part Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of upper limb with loss of a body part Deep necrosis of underlying tissue due to burn (deep third degree), of unspecified site without loss of a body part; with loss of a body part Diabetes insipidus and other disorders of neurohypophysis Diabetes; Nephrogenic, insipidus Diabetes mellitus, secondary Diabetes mellitus without complication

  January 2015

Medicare Limited Coverage Tests

 

787.91 710.9 710.0-710.4 585.1-585.9 447.3-447.6 596.0-596.4 596.51-596.59 276.0-276.6 275.0 593.6 593.81-593.89 593.9 589.0-589.9 573.0-573.3 608.89 608.9 607.89 273.0-273.8 277.1-277.2 588.88-588.89 599.0-599.7 599.81-599.89 599.9 602.0-602.9 780.40 625.0 782.3 992.0-992.8 796.2 790.95 790.93 799.21-799.24 421.0-421.9 780.60-780.66 125.0-125.1 795.79 619.0-619.9 V67.51 939.0 939.3 939.2 939.9 808.0-808.3 808.41-808.49 808.51-808.59 806.5 808.9 806.70 806.71 788.41-788.43 780.91 618.00-618.09 580.0-580.9 582.0-582.9 098.0-098.39 098.89 274.00-274.03 274.10-274.19 599.70-599.72

Diarrhea Diffuse connective disease, unspecified Diffuse diseases of connective tissue Disease, kidney, chronic Disorder; arteries and arterioles, other Disorder; bladder, other Disorder; bladder, other functional Disorder; fluid, electrolyte, and acid-base balance Disorder; iron metabolism 593.0Disorder; kidney and ureter, other Disorder; kidney and ureter, other specified Disorder; kidney and ureter, unspecified Disorder; kidney, small kidney of unknown cause Disorder; liver, other Disorder; male genital organs, other Disorder; male genital organs, unspecified Disorder; penis, other specified Disorder; plasma protein metabolism Disorders of porphyrin/purine and pyrimidine metabolism Disorders resulting from impaired renal function, other specified Disorder; urethra and urinary tract, other Disorder; urethra and urinary tract, other specified Disorder; urethra and urinary tract, unspecified Disorders; prostate, other Dizziness and giddiness Dyspareunia Edema Effects of heat and light Elevated blood pressure reading without diagnosis of hypertension Elevated C-reactive protein (CRP) Elevated PSA Emotional state, signs and symptoms– nervousness, irritability, impulsiveness, emotional liability Endocarditis, acute and subacute Fever, unspecified Filarial infection and dracontiasis Findings, abnormal, without diagnosis; other and unspecified nonspecific immunological findings Fistula involving female genital tract Following completed treatment with high-risk medication, NEC Foreign body in genitourinary tract, bladder and urethra Foreign body in penis Foreign body in vulva and vagina Foreign body in unspecified site in genitourinary tract Fracture of pelvis Fracture of pelvis, other specified part, closed Fracture of pelvis, other specified part, open Fracture, open, of lumbar spine with spinal cord injury Fracture, open, of pelvis, unspecified Fracture, open, of sacrum and coccyx with unspecified spinal cord injury Fracture, open, of sacrum and coccyx with complete cauda equine lesion Frequency of urination and polyuria Fussy infant (baby) Genital prolapse Glomerulonephritis, acute Glomerulonephritis, chronic Gonoccocal infections Gonococcal infection, other specified sites Gouty arthropathy Gouty nephropathy Hematuria

Medicare Limited Coverage Tests

January 2015

 

283.2 283.11 572.2 571.40-571.49 070.0-070.59 070.70-070.71 054.19 054.10 054.13 054.12 054.11 603.0-603.9 591 275.42 272.2-272.4 600.21 600.10-600.11 600.91 446.20-446.29 401.0-401.9 405.01-405.99 402.00-402.91 403.00-403.91 404.00-404.93 600.01 607.84 788.30-788.39 999.34 658.40-658.43 996.64-996.65 996.62 999.32 079.98 659.30-659.33 590.9 999.33 628.9 606.9 601.0-601.9 999.80-999.89 V15.5 928.01 928.1 929.0 928.8 927.0 928.0 929.9 959.11-959.19 867.0-867.3 866.00-866.13 868.0-868.19 665.50-665.54 869.0 867.6-867.9 275.01-275.09 V59.4 V42.0 665.40-665.44 January 2015

Hemoglobinuria due to hemolysis from external causes Hemolytic-uremic syndrome Hepatic coma Hepatitis, chronic Viral hepatitis Hepatitis, viral, Type C, unspecified Herpes simplex; genital herpes, other Herpes simplex; genital herpes, unspecified Herpes simplex; herpetic infection of penis Herpes simplex; herpetic ulceration of the vulva Herpes simplex; herpetic vulvovaginitis Hydrocele Hydronephrosis Hypercalcemia Hyperlipidemia, mixed and other unspecified Hyperplasia; prostate, adenofibromatous, benign localized with urinary obstruction Hyperplasia; prostate, nodular Hyperplasia; prostate, unspecified with urinary obstruction Hypersensitivity angitis Hypertension, essential Hypertension, secondary Hypertensive heart disease Hypertensive chronic kidney disease Hypertensive heart and chronic kidney disease Hypertrophy; prostate, benign with urinary obstruction Impotence of organic origin Incontinence of urine Infection; acute, following transfusion, infusion, or injection of blood and blood products Infection, amniotic cavity Infection and inflammatory reaction due to internal prosthetic device, implant, and graft Infection and inflammatory reaction, due to other vascular device implant and graft Infection; bloodstream, due to central venous catheter Infection; chlamydia, unspecified Infection, generalized, during labor Infection; kidney, unspecified Infection; local, due to central venous catheter Infertility, female, unspecified origin Infertility, male, unspecified Inflammatory diseases of prostate Infusion and transfusion, other and unspecified reaction Injury Injury; crushing of hip Injury; crushing of lower leg Injury; crushing of multiple sites not elsewhere classified Injury; crushing of multiple sites of lower limb Injury; crushing of shoulder region Injury; crushing of thigh Injury; crushing of unspecified site Injury, trunk Injury; bladder and urethra Injury; kidney Injury to other intra-abdominal organ Injury; other, to pelvic organs Injury; unspecified or ill-defined organs, without open wound into cavity Injury to other specified/unspecified pelvic organs Iron metabolism, disorders Kidney donors Kidney replaced by transplant Laceration, high vaginal Medicare Limited Coverage Tests

 

100.0 V58.63-V58.65 V58.69 724.2 780.79 789.51 188.0-188.9 189.0-189.9 187.1-187.8 185 186.0-186.9 198.0-198.1 659.20-659.23 277.5 203.00-203.02 072.0 787.01 570 233.7 233.9 233.4 236.7 236.90-236.99 236.5 583.9 583.0-583.7 583.81-583.89 588.1 581.0-581.9 791.0-791.9 665.80-665.84 753.20-753.29 606.1 788.5 604.0 604.90-604.91 780.99 078.88 079.81-079.89 719.40-719.49 V10.46 V10.50-V10.59 V13.62 V13.00-V13.09 V15.59 V15.51 310.1 V44.50-V44.59 V44.6 963.3 963.1 961.2 965.1 446.0-446.1 446.3-446.7 783.5 457.0-457.1 998.00-998.03 287.41

Leptospiral icterohemorrhagia Long-term (current) drug use, Antiplatelets/antithrombotics; Nonsteroidal inflammatories; steroids Long term (current) use of other medications Lumbago Malaise; other malaise and fatigue Malignant ascites Malignant neoplasm of bladder Malignant neoplasm of kidney and other and unspecified urinary organs Malignant neoplasm of penis and other male genital organs Malignant neoplasm of prostate Malignant neoplasm of testis Malignant neoplasm, secondary, of kidney and other urinary organs Maternal pyrexia during labor, unspecified Mucopolysaccharidosis Multiple myeloma Mumps orchitis Nausea with vomiting Necrosis of liver, acute and subacute Neoplasm; malignant, carcinoma in situ of bladder Neoplasm; malignant, carcinoma in situ of other and unspecified urinary organs Neoplasm; malignant, carcinoma in situ of prostate Neoplasm of uncertain behavior of bladder Neoplasm of uncertain behavior of other and unspecified urinary organs Neoplasm of uncertain behavior of prostate Nephritis and nephropathy with unspecified pathological lesion in kidney Nephritis and nephropathy, not specified as acute or chronic Nephritis and nephropathy, specified and other Nephrogenic diabetes insipidus Nephrotic syndrome Nonspecific findings on examination of urine Obstetrical trauma, other, specified Obstructive defects of renal pelvis and ureter Oligospermia Oliguria and anuria Orchitis and epididymitis Orchitis, epididymitis and epididymo-orchitis, other, without mention of abscess Other general symptoms Other specified diseases due to chlamydiae Other specified viral and chlamydial infection Pain in joint Personal history of malignant neoplasm of prostate Personal history of malignant neoplasm urinary organs Personal history of other (corrected) congenital malformations of genitourinary system Personal history of other diseases urinary system Personal history of other injury Personal history of traumatic fracture Personality change due to conditions classified elsewhere Persons with cystostomy Persons with other artificial opening of urinary tract Poisoning by alkalizing agents Poisoning by anti-neoplastic and immunosuppressive drugs Poisoning by heavy metal anti-infectives Poisoning by salicylates Polyarteritis nodosa and allied conditions Polyarteritis nodosa and allied conditions Polydipsia Postmastectomy lymphedema and other lymphedema Postoperative shock Posttransfusion purpura

Medicare Limited Coverage Tests

January 2015

 

780.33 642.00-642.94 648.80-648.84 654.40-654.44 646.10-646.14 646.20-646.24 646.50-646.54 648.00-648.04 647.10-647.14 646.60-646.64 V22.0-V22.2 306.53 670.82-670.84 670.00-670.04 670.20-670.24 998.2 590.80-590.81 590.10-590.11 590.00-590.01 711.00-711.09 672.00-672.04 V58.0 605 099.3 087.0-087.1 753.0 590.2-590.3 788.0-788.1 V45.11-V45.12 584.5-584.9 669.30-669.34 586 271.4 588.0 V90.83 788.20-788.29 999.70-999.79 714.0-714.9 596.6-596.9 135 587 608.0 038.0-038.9 785.59 942.32-942.34 941.39 943.39 946.30 942.39 949.3 942.30

Post traumatic seizures Pregnancy, complicated by hypertension Pregnancy, abnormal glucose tolerance, other current conditions in mother Pregnancy, abnormalities, other, in shape or position of gravid uterus and of neighboring structures Pregnancy complications, edema or excessive weight gain, without mention of hypertension Pregnancy complications, unspecified renal disease, without mention of hypertension Pregnancy complications, asymptomatic bacteriuria Pregnancy, diabetes mellitus, other current conditions in mother Pregnancy, infections and parasitic conditions in mother, Gonorrhea Pregnancy, infections of genitourinary tract Pregnancy, normal Psychogenic Dysuria Puerperal infection, major, other Puerperal infection, major, unspecified Puerperal sepsis Puncture or laceration, accidental, during a procedure Pyelonephritis or pyonephrosis, other, not specified as acute or chronic Pyelonephritis, acute Pyelonephritis, chronic Pyogenic arthritis Pyrexia of unknown origin during the puerperium Radiotherapy Redundant prepuce and phimosis Reiter’s disease Relapsing fever Renal agenesis and dysgenesis Renal and perinephric abscess/pyeloureteritus Renal colic/dysuria Renal dialysis status Renal failure, acute Renal failure, acute, following labor and delivery Renal failure, unspecified Renal glycosuria Renal osteodystrophy Retained stone or crystalline fragments Retention of urine Rh and other non-ABO incompatibility reaction due to transfusion of blood or blood products Rheumatoid arthritis Rupture of bladder, nontraumatic; hemorrhage into bladder wall; other specified disorders of bladder Sarcoidosis Sclerosis; renal, renal sclerosis, unspecified Seminal vesiculitis Septicemia Shock without mention of trauma, other Skin loss, full thickness, due to burn (third degree nos) of chest wall excluding breast and nipple; abdominal wall; back (any part) Skin loss, full-thickness, due to burn (third degree nos) of multiple sites (except eye) of face, head and neck Skin loss, full thickness, due to burn (third degree nos) of multiple sites of upper limb except wrist and hand Skin loss, full thickness, due to burn (third degree nos) of multiple specified sites Skin loss, full thickness, due to burn (third degree nos) of other and multiple sites of Trunk Skin loss, full thickness, due to burn (third degree nos) unspecified site Skin loss, full thickness, due to burn (third degree nos) of unspecified site of trunk

  January 2015

Medicare Limited Coverage Tests

 

943.30 608.1 625.6 V23.0-V23.3 V23.81-V23.84 V23.89 V23.9 V23.41 V23.7 V23.49 V23.5 789.00-789.09 625.9 780.20 095.4 287.49 608.2 608.23-608.24 664.80-664.84 664.90-664.94 958.5 131.00-131.03 016.00-016.96 277.88 752.51 788.7-788.8 598.1-598.9 598.00-598.01 597.80-597.89 099.40-099.49 599.60-599.69 788.91-788.99 629.31-629.32 616.10-616.11 456.4 608.83 099.53-099.54 787.03 625.7-625.79 879.8 879.9 879.3 879.5 876.1 878.0-878.9 879.7 102.0-102.9

Skin loss, full thickness, due to burn (third degree nos) of unspecified site of upper limb Spermatocele Stress incontinence, female Supervision of high risk pregnancy Supervision of high risk pregnancy, Elderly primigravida; elderly multigravida; young primigravida; young multigravida Supervision of high risk pregnancy, other Supervision of high risk pregnancy, unspecified Supervision of high risk pregnancy, with history of labor pre-term Supervision of high risk pregnancy, with insufficient prenatal care Supervision of high risk pregnancy, with other poor obstetric history Supervision of high risk pregnancy, with other poor reproductive history Symptoms; abdomen and pelvis, other involving Symptoms; genital organs; female, unspecified symptom associated with Syncope and collapse Syphilis of kidney Thrombocytopenia, other secondary Torsion of testis Torsion of appendix Trauma, other specified, to perineum and vulva Trauma to perineum and vulva Traumatic anuria Trichomoniasis; urogenital Tuberculosis of genitourinary system Tumor Iysis Syndrome Undescended testis Urethral discharge/extravasation of urine Urethral stricture Urethral stricture due to infection Urethritis, other and unspecified Urethritis; other nongonococcal urethritis (NGU) Urinary obstruction Urinary system, other symptoms Vaginal mesh erosion or exposure Vaginitis and vulvovaginitis Varicose; scrotum; scrotal varices (varicocele) Vascular disorders of male genital organs Venereal diseases, other, due to Chlamydia trachomatis Vomiting alone Vulvodynia Would(s); open (multiple) of unspecified site(s) without complication Would(s); open (multiple) of unspecified site(s), complicated Wound; open of abdominal wall, anterior, complicated Wound; open of abdominal wall, lateral complicated Wound; open of back, complicated Wound; open of genital organs (external), including traumatic amputation Wound; open of other and unspecified parts of trunk, complicated Yaws

                 

  Medicare Limited Coverage Tests – Covered Diagnosis Codes Source: National Coverage Determinations, Noridian Administrative Services Effective May 13, 2013 Medicare Limited Coverage Tests

January 2015