NCD Oct 1 2013 final for website and clients updated 10-17 ...

2013 NATIONAL COVERAGE DETERMINATION (NCD)

CPT CODE(S): 84436, 84439, 84443, 84479

THYROID TESTING

366 4710 380

DLS TEST CODES AND NAMES T4, FREE T4, FREE (DIRECT DIALYSIS) TSH

ICD 9 CODE 781.0 783.21 783.1 244.0-244.9 298.3 518.81 255.2 704.00-704.09 780.09 780.97 331.0, 331.11, 331.19, 331.2 285.9 759.2 783.0 300.00-300.09 266.0 427.31 279.49 283.0 279.41 220 227.3

226 275.40-275.49 234.8 427.9 429.3 354.0

DESCRIPTION ABNORMAL INVOLUNTARY MOVEMENTS ABNORMAL LOSS OF WEIGHT ABNORMAL WEIGHT GAIN ACQUIRED HYPOTHYROIDISM ACUTE PARANOID REACTION ACUTE RESPIRATORY FAILURE ADRENOGENITAL DISORDERS ALOPECIA ALTERATION OF CONSCIOUSNESS, OTHER ALTERED MENTAL STATUS

ALZHEIMER'S, PICK'S DISEASE, SENILE DEGENERATION OF BRAIN ANEMIA, UNSPECIFIED ANOMALY OF OTHER ENDOCRINE GLANDS ANOREXIA ANXIETY STATES ARIBOFLAVINOSIS ATRIAL FIBRILLATION AUTOIMMUNE DISEASE, NOT ELSEWHERE CLASSIFIED AUTOIMMUNE HEMOLYTIC ANEMIA AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME BENIGN NEOPLASM OF OVARY BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT BENIGN NEOPLASM OF THYROID GLAND CALCIUM DISORDERS CARCINOMA IN SITU OF OTHER AND UNSPECIFIED SITES CARDIAC DYSRHYTHMIA, UNSPECIFIED CARDIOMEGALY CARPAL TUNNEL SYNDROME

Source: cms.mcd Effective Date: October 1, 2011

Thyroid Testing Page 1 of 8

2013 NATIONAL COVERAGE DETERMINATION (NCD)

CPT CODE(S): 84436, 84439, 84443, 84479

THYROID TESTING

366 4710 380

DLS TEST CODES AND NAMES T4, FREE T4, FREE (DIRECT DIALYSIS) TSH

ICD 9 CODE 782.8 780.64 780.71 780.01 243 428.0 372.73 372.71 564.00-564.09 293.0-293.1 297.1 799.25 311 250.00-250.93 710.0-710.9 368.2 626.0-626.2 782.0 784.51 625.3 787.21 787.22 787.23 787.24 787.20 784.42 780.94 990 799.24

DESCRIPTION

CHANGES IN SKIN TEXTURE CHILLS (WITHOUT FEVER) CHRONIC FATIGUE SYNDROME COMA CONGENITAL HYPOTHYROIDISM CONGESTIVE HEART FAILURE, UNSPECIFIED CONJUNCTIVAL EDEMA CONJUNCTIVAL HYPEREMIA CONSTIPATION DELIRIUM DELUSIONAL DISORDER DEMORALIZATION AND APATHY DEPRESSIVE DISORDER, NEC DIABETES MELLITUS DIFFUSE DISEASE OF CONNECTIVE TISSUE DIPLOPIA DISORDERS OF MENSTRUATION DISTURBANCE OF SKIN SENSATION DYSARTHRIA DYSMENORRHEA DYSPHAGIA, ORAL PHASE DYSPHAGIA, OROPHARYNGEAL PHASE DYSPHAGIA, PHARYNGEAL PHASE DYSPHAGIA, PHARYNGO-ESOPHAGEAL PHASE DYSPHAGIA, UNSPECIFIED DYSPHONIA EARLY SATIETY EFFECTS OF RADIATION, UNSPECIFIED EMOTIONAL LABILITY

Source: cms.mcd Effective Date: October 1, 2011

Thyroid Testing Page 2 of 8

2013 NATIONAL COVERAGE DETERMINATION (NCD)

CPT CODE(S): 84436, 84439, 84443, 84479

THYROID TESTING

366 4710 380

DLS TEST CODES AND NAMES T4, FREE T4, FREE (DIRECT DIALYSIS) TSH

ICD 9 CODE 676.20-676.24

296.00-296.99 333.1 401.0-401.9 376.30-376.31 376.22 374.82 780.61 780.60 V67.00-V67.9 780.72 780.8 780.96 255.41 240.0-240.9 275.5 278.3 784.43 403.00-403.91 404.00-404.93 784.44 252.1 276.0 276.1 780.65

253.7 733.02

DESCRIPTION

ENGORGEMENT OF BREAST ASSOCIATED W/ CHILDBIRTH & DISORDERS OF LACTATION EPISODIC MOOD DISORDERS ESSENTIAL AND OTHER SPECIFIED FORMS OF TREMOR ESSENTIAL HYPERTENSION EXOPHTHALMIC CONDITIONS, UNSPECIFIED AND CONSTANT EXOPHTHALMIC OPHTHALMOPLEGIA EYELID EDEMA FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE FEVER, UNSPECIFIED FOLLOW-UP EXAMINATION FUNCTIONAL QUADRIPLEGIA GENERALIZED HYPERHIDROSIS GENERALIZED PAIN GLUCOCORTICOID DEFICIENCY GOITER SPECIFIED AND UNSPECIFIED HUNGRY BONE SYNDROME HYPERCAROTENEMIA HYPERNASALITY HYPERTENSIVE CHRONIC KIDNEY DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE HYPONASALITY HYPOPARATHYROIDISM HYPOSMOLALITY AND/OR HYPERNATREMIA HYPOSMOLALITY AND/OR HYPONATREMIA HYPOTHERMIA NOT ASSOCIATED WITH LOW ENVIRONMENTAL TEMPERATURE IATROGENIC PITUITARY DISORDERS IDIOPATHIC OSTEOPOROSIS

Source: cms.mcd Effective Date: October 1, 2011

Thyroid Testing Page 3 of 8

2013 NATIONAL COVERAGE DETERMINATION (NCD)

CPT CODE(S): 84436, 84439, 84443, 84479

THYROID TESTING

366 4710 380

DLS TEST CODES AND NAMES T4, FREE T4, FREE (DIRECT DIALYSIS) TSH

ICD 9 CODE 356.9

799.23 780.50 327.01 780.51 780.52 626.4 799.22 701.1 781.3 428.1 374.41 782.3 V58.69 750.15 789.51 194.8

183.0 193 263.0-263.9 262 564.7 780.93 331.83 255.42 272.2 728.2 728.87

DESCRIPTION

IDIOPATHIC PERIPHERAL NEUROPATHY, UNSPECIFIED POLYNEUROPATHY IMPULSIVENESS INSOMNIA INSOMNIA DUE TO MEDICAL CONDITION CLASSIFIED ELSEWHERE INSOMNIA WITH SLEEP APNEA, UNSPECIFIED INSOMNIA, UNSPECIFIED IRREGULAR MENSTRUAL CYCLE IRRITABILITY KERATODERMA, ACQUIRED (DRY SKIN) LACK OF COORDINATION, ATAXIA LEFT HEART FAILURE LID RETRACTION OR LAG LOCALIZED EDEMA LONG TERM (CURRENT) USE OF OTHER MEDICATIONS MACROGLOSSIA, CONGENITAL MALIGNANT ASCITES MALIGNANT NEOPLASM OF OTHER ENDOCRINE GLANDS AND RELATED STRUCTURES MALIGNANT NEOPLASM OF OVARY MALIGNANT NEOPLASM OF THYROID GLAND MALNUTRITION, OTHER AND UNSPECIFIED MALNUTRITION, SEVERE MEGACOLON, OTHER THAN HIRSCHSPRUNG'S MEMORY LOSS MILD COGNITIVE IMPAIRMENT, SO STATED MINERALOCORTICOID DEFICIENCY MIXED HYPERLIPIDEMIA MUSCLE WASTING MUSCLE WEAKNESS (GENERALIZED)

Source: cms.mcd Effective Date: October 1, 2011

Thyroid Testing Page 4 of 8

2013 NATIONAL COVERAGE DETERMINATION (NCD)

CPT CODE(S): 84436, 84439, 84443, 84479

THYROID TESTING

366 4710 380

DLS TEST CODES AND NAMES T4, FREE T4, FREE (DIRECT DIALYSIS) TSH

ICD 9 CODE 729.82 729.1 358.1 359.5 359.9 237.4

239.7 799.21 241.0-241.9 425.7 376.33-376.34 327.00 733.09 253.1 272.4

DESCRIPTION

MUSCULOSKELETAL CRAMP MYALGIA AND MYOSITIS, UNSPECIFIED MYASTHENIC SYNDROMES IN DISEASES CLASSIFIED ELSEWHERE MYOPATHY IN ENDOCRINE DISEASES CLASSIFIED ELSEWHERE MYOPATHY, UNSPECIFIED NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED ENDOCRINE GLANDS NEOPLASM OF UNSPECIFIED NATURE, THYROID GLAND NERVOUSNESS NONTOXIC NODULAR GOITER NUTRITIONAL AND METABOLIC CARDIOMYOPATHY ORBITAL EDEMA OR CONGESTION, INTERMITTENT EXOPHTHALMOS ORGANIC INSOMNIA, UNSPECIFIED OSTEOPOROSIS, DRUG INDUCED OTHER AND UNSPECIFIED ANTERIOR PITUITARY HYPER FUNCTION OTHER AND UNSPECIFIED HYPERLIPIDEMIA

307.9 253.4 789.59 648.10-648.14

246.0-246.9 787.29 333.99

780.99 780.79

OTHER AND UNSPECIFIED SPECIAL SYMPTOMS OR SYNDROMES NEC OTHER ANTERIOR PITUITARY DISORDERS OTHER ASCITES OTHER CURRENT CONDITIONS IN MOTHER, CLASSIFIABLE ELSEWHERE, BUT COMPLICATING PREGNANCY, CHILDBIRTH, OR PUERPERIUM, THYROID DYSFUNCTION OTHER DISORDERS OF THYROID OTHER DYSPHAGIA OTHER EXTRAPYRAMIDAL DISEASES AND ABNORMAL MOVEMENT DISORDERS OTHER GENERAL SYMPTOMS OTHER MALAISE AND FATIGUE

Source: cms.mcd Effective Date: October 1, 2011

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