Hepatitis Screening: Diagnosis Codes

UnitedHealthcare? Community Plan Policy Appendix: Applicable Code List

Hepatitis Screening: Diagnosis Codes

This list of codes applies to the Medical Policy titled Hepatitis Screening.

Effective Date: December 1, 2021

Applicable Codes

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. The listing of a code does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

Diagnosis Code A50.01 A50.02 A50.03 A50.04 A50.05 A50.06 A50.07 A50.08 A50.09 A50.1 A50.2 A50.30 A50.31 A50.32 A50.39 A50.40 A50.41 A50.42 A50.43 A50.44 A50.45 A50.49 A50.51 A50.52 A50.53 A50.54

Description Early congenital syphilitic oculopathy Early congenital syphilitic osteochondropathy Early congenital syphilitic pharyngitis Early congenital syphilitic pneumonia Early congenital syphilitic rhinitis Early cutaneous congenital syphilis Early mucocutaneous congenital syphilis Early visceral congenital syphilis Other early congenital syphilis, symptomatic Early congenital syphilis, latent Early congenital syphilis, unspecified Late congenital syphilitic oculopathy, unspecified Late congenital syphilitic interstitial keratitis Late congenital syphilitic chorioretinitis Other late congenital syphilitic oculopathy Late congenital neurosyphilis, unspecified Late congenital syphilitic meningitis Late congenital syphilitic encephalitis Late congenital syphilitic polyneuropathy Late congenital syphilitic optic nerve atrophy Juvenile general paresis Other late congenital neurosyphilis Clutton's joints Hutchinson's teeth Hutchinson's triad Late congenital cardiovascular syphilis

Hepatitis Screening: Diagnosis Codes

Page 1 of 82

UnitedHealthcare Community Plan Policy Appendix: Applicable Code List

Effective 12/01/2021

Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code A50.55 A50.56 A50.57 A50.59 A50.6 A50.7 A50.9 A51.0 A51.1 A51.2 A51.31 A51.32 A51.39 A51.41 A51.42 A51.43 A51.44 A51.45 A51.46 A51.49 A51.5 A51.9 A52.00 A52.01 A52.02 A52.03 A52.04 A52.05 A52.06 A52.09 A52.10 A52.11 A52.12 A52.13 A52.14 A52.15 A52.16 A52.17 A52.19 A52.2 A52.3 A52.71

Description Late congenital syphilitic arthropathy Late congenital syphilitic osteochondropathy Syphilitic saddle nose Other late congenital syphilis, symptomatic Late congenital syphilis, latent Late congenital syphilis, unspecified Congenital syphilis, unspecified Primary genital syphilis Primary anal syphilis Primary syphilis of other sites Condyloma latum Syphilitic alopecia Other secondary syphilis of skin Secondary syphilitic meningitis Secondary syphilitic female pelvic disease Secondary syphilitic oculopathy Secondary syphilitic nephritis Secondary syphilitic hepatitis Secondary syphilitic osteopathy Other secondary syphilitic conditions Early syphilis, latent Early syphilis, unspecified Cardiovascular syphilis, unspecified Syphilitic aneurysm of aorta Syphilitic aortitis Syphilitic endocarditis Syphilitic cerebral arteritis Other cerebrovascular syphilis Other syphilitic heart involvement Other cardiovascular syphilis Symptomatic neurosyphilis, unspecified Tabes dorsalis Other cerebrospinal syphilis Late syphilitic meningitis Late syphilitic encephalitis Late syphilitic neuropathy Charcot's arthropathy (tabetic) General paresis Other symptomatic neurosyphilis Asymptomatic neurosyphilis Neurosyphilis, unspecified Late syphilitic oculopathy

Hepatitis Screening: Diagnosis Codes

Page 2 of 82

UnitedHealthcare Community Plan Policy Appendix: Applicable Code List

Effective 12/01/2021

Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code A52.72 A52.73 A52.74 A52.75 A52.76 A52.77 A52.78 A52.79 A52.8 A52.9 A53.0 A53.9 A54.00 A54.01 A54.02 A54.03 A54.09 A54.1 A54.21 A54.22 A54.23 A54.24 A54.29 A54.30 A54.31 A54.32 A54.33 A54.39 A54.40 A54.41 A54.42 A54.43 A54.49 A54.5 A54.6 A54.81 A54.82 A54.83 A54.84 A54.85 A54.86 A54.89

Description Syphilis of lung and bronchus Symptomatic late syphilis of other respiratory organs Syphilis of liver and other viscera Syphilis of kidney and ureter Other genitourinary symptomatic late syphilis Syphilis of bone and joint Syphilis of other musculoskeletal tissue Other symptomatic late syphilis Late syphilis, latent Late syphilis, unspecified Latent syphilis, unspecified as early or late Syphilis, unspecified Gonococcal infection of lower genitourinary tract, unspecified Gonococcal cystitis and urethritis, unspecified Gonococcal vulvovaginitis, unspecified Gonococcal cervicitis, unspecified Other gonococcal infection of lower genitourinary tract Gonococcal infection of lower genitourinary tract with periurethral and accessory gland abscess Gonococcal infection of kidney and ureter Gonococcal prostatitis Gonococcal infection of other male genital organs Gonococcal female pelvic inflammatory disease Other gonococcal genitourinary infections Gonococcal infection of eye, unspecified Gonococcal conjunctivitis Gonococcal iridocyclitis Gonococcal keratitis Other gonococcal eye infection Gonococcal infection of musculoskeletal system, unspecified Gonococcal spondylopathy Gonococcal arthritis Gonococcal osteomyelitis Gonococcal infection of other musculoskeletal tissue Gonococcal pharyngitis Gonococcal infection of anus and rectum Gonococcal meningitis Gonococcal brain abscess Gonococcal heart infection Gonococcal pneumonia Gonococcal peritonitis Gonococcal sepsis Other gonococcal infections

Hepatitis Screening: Diagnosis Codes

Page 3 of 82

UnitedHealthcare Community Plan Policy Appendix: Applicable Code List

Effective 12/01/2021

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Diagnosis Code A54.9 A55 A56.00 A56.01 A56.02 A56.09 A56.11 A56.19 A56.2 A56.3 A56.4 A56.8 A57 A58 A59.00 A59.01 A59.02 A59.03 A59.09 A59.8 A59.9 A60.00 A60.01 A60.02 A60.03 A60.04 A60.09 A60.1 A60.9 A63.0 A63.8 A64 A74.81 A74.89 A74.9 B00.81 B07.8 B07.9 B17.10 B17.11 B18.2 B19.20

Description Gonococcal infection, unspecified Chlamydial lymphogranuloma (venereum) Chlamydial infection of lower genitourinary tract, unspecified Chlamydial cystitis and urethritis Chlamydial vulvovaginitis Other chlamydial infection of lower genitourinary tract Chlamydial female pelvic inflammatory disease Other chlamydial genitourinary infection Chlamydial infection of genitourinary tract, unspecified Chlamydial infection of anus and rectum Chlamydial infection of pharynx Sexually transmitted chlamydial infection of other sites Chancroid Granuloma inguinale Urogenital trichomoniasis, unspecified Trichomonal vulvovaginitis Trichomonal prostatitis Trichomonal cystitis and urethritis Other urogenital trichomoniasis Trichomoniasis of other sites Trichomoniasis, unspecified Herpesviral infection of urogenital system, unspecified Herpesviral infection of penis Herpesviral infection of other male genital organs Herpesviral cervicitis Herpesviral vulvovaginitis Herpesviral infection of other urogenital tract Herpesviral infection of perianal skin and rectum Anogenital herpesviral infection, unspecified Anogenital (venereal) warts Other specified predominantly sexually transmitted diseases Unspecified sexually transmitted disease Chlamydial peritonitis Other chlamydial diseases Chlamydial infection, unspecified Herpesviral hepatitis Other viral warts Viral wart, unspecified Acute hepatitis C without hepatic coma Acute hepatitis C with hepatic coma Chronic viral hepatitis C Unspecified viral hepatitis C without hepatic coma

Hepatitis Screening: Diagnosis Codes

Page 4 of 82

UnitedHealthcare Community Plan Policy Appendix: Applicable Code List

Effective 12/01/2021

Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code B19.21 B20 B97.35 B97.7 D65 D66 D67 D68.0 D68.1 D68.2 D68.311 D68.312 D68.318 D68.32 D68.4 D68.8 D68.9 F11.10 F11.11 F11.13 F11.120 F11.121 F11.122 F11.129 F11.14 F11.150 F11.151 F11.159 F11.181 F11.182 F11.188 F11.19 F11.20 F11.21 F11.220 F11.23 F11.24 F11.250 F11.251 F11.259 F11.29 F13.10

Description Unspecified viral hepatitis C with hepatic coma Human immunodeficiency virus [HIV] disease Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere Papillomavirus as the cause of diseases classified elsewhere Disseminated intravascular coagulation [defibrination syndrome] Hereditary factor VIII deficiency Hereditary factor IX deficiency Von Willebrand's disease Hereditary factor XI deficiency Hereditary deficiency of other clotting factors Acquired hemophilia Antiphospholipid antibody with hemorrhagic disorder Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors Hemorrhagic disorder due to extrinsic circulating anticoagulants Acquired coagulation factor deficiency Other specified coagulation defects Coagulation defect, unspecified Opioid abuse, uncomplicated Opioid abuse, in remission Opioid abuse with withdrawal Opioid abuse with intoxication, uncomplicated Opioid abuse with intoxication delirium Opioid abuse with intoxication with perceptual disturbance Opioid abuse with intoxication, unspecified Opioid abuse with opioid-induced mood disorder Opioid abuse with opioid-induced psychotic disorder with delusions Opioid abuse with opioid-induced psychotic disorder with hallucinations Opioid abuse with opioid-induced psychotic disorder, unspecified Opioid abuse with opioid-induced sexual dysfunction Opioid abuse with opioid-induced sleep disorder Opioid abuse with other opioid-induced disorder Opioid abuse with unspecified opioid-induced disorder Opioid dependence, uncomplicated Opioid dependence, in remission Opioid dependence with intoxication, uncomplicated Opioid dependence with withdrawal Opioid dependence with opioid-induced mood disorder Opioid dependence with opioid-induced psychotic disorder with delusions Opioid dependence with opioid-induced psychotic disorder with hallucinations Opioid dependence with opioid-induced psychotic disorder, unspecified Opioid dependence with unspecified opioid-induced disorder Sedative, hypnotic or anxiolytic abuse, uncomplicated

Hepatitis Screening: Diagnosis Codes

Page 5 of 82

UnitedHealthcare Community Plan Policy Appendix: Applicable Code List

Effective 12/01/2021

Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code F13.11 F13.120 F13.121 F13.129 F13.14 F13.131 F13.132 F13.139 F13.150

F13.151

F13.159

F13.180 F13.181 F13.182 F13.188 F13.19 F13.20 F13.21 F13.220 F13.230 F13.250

F13.251

F13.259

F13.26

F13.29

F14.10 F14.11 F14.13 F14.120 F14.121 F14.122 F14.129 F14.14 F14.150 F14.151 F14.159

Description Sedative, hypnotic or anxiolytic abuse, in remission Sedative, hypnotic or anxiolytic abuse with intoxication, uncomplicated Sedative, hypnotic or anxiolytic abuse with intoxication delirium Sedative, hypnotic or anxiolytic abuse with intoxication, unspecified Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced mood disorder Sedative, hypnotic or anxiolytic abuse with withdrawal delirium Sedative, hypnotic or anxiolytic abuse with withdrawal with perceptual disturbance Sedative, hypnotic or anxiolytic abuse with withdrawal, unspecified Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced anxiety disorder Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sexual dysfunction Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sleep disorder Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or anxiolytic-induced disorder Sedative, hypnotic or anxiolytic abuse with unspecified sedative, hypnotic or anxiolytic-induced disorder Sedative, hypnotic or anxiolytic dependence, uncomplicated Sedative, hypnotic or anxiolytic dependence, in remission Sedative, hypnotic or anxiolytic dependence with intoxication, uncomplicated Sedative, hypnotic or anxiolytic dependence with withdrawal, uncomplicated Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting amnestic disorder Sedative, hypnotic or anxiolytic dependence with unspecified sedative, hypnotic or anxiolytic-induced disorder Cocaine abuse, uncomplicated Cocaine abuse, in remission Cocaine abuse, unspecified with withdrawal Cocaine abuse with intoxication, uncomplicated Cocaine abuse with intoxication with delirium Cocaine abuse with intoxication with perceptual disturbance Cocaine abuse with intoxication, unspecified Cocaine abuse with cocaine-induced mood disorder Cocaine abuse with cocaine-induced psychotic disorder with delusions Cocaine abuse with cocaine-induced psychotic disorder with hallucinations Cocaine abuse with cocaine-induced psychotic disorder, unspecified

Hepatitis Screening: Diagnosis Codes

Page 6 of 82

UnitedHealthcare Community Plan Policy Appendix: Applicable Code List

Effective 12/01/2021

Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code F14.180 F14.181 F14.182 F14.188 F14.19 F14.20 F14.21 F14.220 F14.250 F14.251 F14.259 F14.29 F15.10 F15.11 F15.13 F15.120 F15.121 F15.122 F15.129 F15.14 F15.150 F15.151 F15.159 F15.180 F15.181 F15.182 F15.188 F15.19 F15.20 F15.21 F15.220 F15.250 F15.251 F15.29 F16.10 F16.11 F16.120 F16.121 F16.122 F16.129 F16.14 F16.150

Description Cocaine abuse with cocaine-induced anxiety disorder Cocaine abuse with cocaine-induced sexual dysfunction Cocaine abuse with cocaine-induced sleep disorder Cocaine abuse with other cocaine-induced disorder Cocaine abuse with unspecified cocaine-induced disorder Cocaine dependence, uncomplicated Cocaine dependence, in remission Cocaine dependence with intoxication, uncomplicated Cocaine dependence with cocaine-induced psychotic disorder with delusions Cocaine dependence with cocaine-induced psychotic disorder with hallucinations Cocaine dependence with cocaine-induced psychotic disorder, unspecified Cocaine dependence with unspecified cocaine-induced disorder Other stimulant abuse, uncomplicated Other stimulant abuse, in remission Other stimulant abuse with withdrawal Other stimulant abuse with intoxication, uncomplicated Other stimulant abuse with intoxication delirium Other stimulant abuse with intoxication with perceptual disturbance Other stimulant abuse with intoxication, unspecified Other stimulant abuse with stimulant-induced mood disorder Other stimulant abuse with stimulant-induced psychotic disorder with delusions Other stimulant abuse with stimulant-induced psychotic disorder with hallucinations Other stimulant abuse with stimulant-induced psychotic disorder, unspecified Other stimulant abuse with stimulant-induced anxiety disorder Other stimulant abuse with stimulant-induced sexual dysfunction Other stimulant abuse with stimulant-induced sleep disorder Other stimulant abuse with other stimulant-induced disorder Other stimulant abuse with unspecified stimulant-induced disorder Other stimulant dependence, uncomplicated Other stimulant dependence, in remission Other stimulant dependence with intoxication, uncomplicated Other stimulant dependence with stimulant-induced psychotic disorder with delusions Other stimulant dependence with stimulant-induced psychotic disorder with hallucinations Other stimulant dependence with unspecified stimulant-induced disorder Hallucinogen abuse, uncomplicated Hallucinogen abuse, in remission Hallucinogen abuse with intoxication, uncomplicated Hallucinogen abuse with intoxication with delirium Hallucinogen abuse with intoxication with perceptual disturbance Hallucinogen abuse with intoxication, unspecified Hallucinogen abuse with hallucinogen-induced mood disorder Hallucinogen abuse with hallucinogen-induced psychotic disorder with delusions

Hepatitis Screening: Diagnosis Codes

Page 7 of 82

UnitedHealthcare Community Plan Policy Appendix: Applicable Code List

Effective 12/01/2021

Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code F16.151 F16.159 F16.180 F16.183 F16.188 F16.19 F16.20 F16.21 F16.220 F16.250 F16.251 F16.259 F16.283 F16.288 F16.29 F19.10 F19.11 F19.120 F19.121 F19.122 F19.129 F19.14 F19.130 F19.131 F19.132 F19.139 F19.150

F19.151

F19.159

F19.16 F19.17 F19.180 F19.181 F19.182 F19.188 F19.19 F19.20 F19.21 F19.220 F19.222

Description Hallucinogen abuse with hallucinogen-induced psychotic disorder with hallucinations Hallucinogen abuse with hallucinogen-induced psychotic disorder, unspecified Hallucinogen abuse with hallucinogen-induced anxiety disorder Hallucinogen abuse with hallucinogen persisting perception disorder (flashbacks) Hallucinogen abuse with other hallucinogen-induced disorder Hallucinogen abuse with unspecified hallucinogen-induced disorder Hallucinogen dependence, uncomplicated Hallucinogen dependence, in remission Hallucinogen dependence with intoxication, uncomplicated Hallucinogen dependence with hallucinogen-induced psychotic disorder with delusions Hallucinogen dependence with hallucinogen-induced psychotic disorder with hallucinations Hallucinogen dependence with hallucinogen-induced psychotic disorder, unspecified Hallucinogen dependence with hallucinogen persisting perception disorder (flashbacks) Hallucinogen dependence with other hallucinogen-induced disorder Hallucinogen dependence with unspecified hallucinogen-induced disorder Other psychoactive substance abuse, uncomplicated Other psychoactive substance abuse, in remission Other psychoactive substance abuse with intoxication, uncomplicated Other psychoactive substance abuse with intoxication delirium Other psychoactive substance abuse with intoxication with perceptual disturbances Other psychoactive substance abuse with intoxication, unspecified Other psychoactive substance abuse with psychoactive substance-induced mood disorder Other psychoactive substance abuse with withdrawal, uncomplicated Other psychoactive substance abuse with withdrawal delirium Other psychoactive substance abuse with withdrawal with perceptual disturbance Other psychoactive substance abuse with withdrawal, unspecified Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delusions Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with hallucinations Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder, unspecified Other psychoactive substance abuse with psychoactive substance-induced persisting amnestic disorder Other psychoactive substance abuse with psychoactive substance-induced persisting dementia Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction Other psychoactive substance abuse with psychoactive substance-induced sleep disorder Other psychoactive substance abuse with other psychoactive substance-induced disorder Other psychoactive substance abuse with unspecified psychoactive substance-induced disorder Other psychoactive substance dependence, uncomplicated Other psychoactive substance dependence, in remission Other psychoactive substance dependence with intoxication, uncomplicated Other psychoactive substance dependence with intoxication with perceptual disturbance

Hepatitis Screening: Diagnosis Codes

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UnitedHealthcare Community Plan Policy Appendix: Applicable Code List

Effective 12/01/2021

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