General rules which apply to all procedure codes in the Radiology Services Fee Schedule sections of Diagnostic Radiology, Diagnostic Ultrasound, Radiation Oncology and Nuclear Medicine are as follows:

1. Dollar values include usual contrast media, equipment and materials. An additional charge may be warranted when special surgical trays and materials are provided by the physician.

2. Dollar values include consultation and a written report to the referring physician.

3. When multiple X-ray examinations are performed during the same visit, reimbursement shall be limited to the greater fee plus 60% of the lesser fee(s). When more than one part of the body is included in a single X-ray for which reimbursement is claimed, the charge shall be only for a single X-ray. When bilateral X-ray examinations are performed during the same visit, reimbursement shall be limited to 160% of the procedure value (see modifier -50). The above provisions regarding fee reductions for multiple X-rays are applicable to X-rays taken of all parts of the body.

4. When repeat X-ray examinations of the same part and for the same illness are required because of technical or professional error in the original X-rays, such repeat X-rays are not eligible for payment. (See Rule 5 below.)

5. When repeat X-ray examination of the same part and for the same illness is required for reasons other than technical or professional error in the original X-ray. It should be identified by use of modifier -76.

6. RADIOLOGICAL SUPERVISION AND INTERPRETATION CODES: The Maximum fee is applicable when the physician incurs the costs of both the technical /administrative and professional components of the imaging procedure. (For the professional component of radiologic procedures, see modifier -26). When a procedure is performed by two physicians, the radiologic portion of the procedure is designated as "radiological supervision and interpretation." When a physician performs both the procedure and provides imaging supervision and interpretation, a combination of procedure codes outside the 70000 series and imaging supervision and interpretation codes are to be used.

7. BY REPORT: A service that is rarely provided, unusual, variable, or new may require a special report in determining medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort and equipment necessary to provide the service. Additional items which may be included are:

complexity of symptoms, final diagnosis, pertinent physical findings (such as size, locations, and number of lesion(s), if appropriate), diagnostic and therapeutic procedures including major and supplementary surgical procedures, if appropriate), concurrent problems, and follow-up care.

When the value of a procedure is to be determined "By Report" (BR), information concerning the nature, extent and need for the procedure or service must be furnished in addition to the time, skill and equipment necessitated. Appropriate documentation (eg, procedure description, itemized invoices, etc) should accompany all claims submitted.

Itemized invoices must document acquisition cost, the line item cost from a manufacturer or wholesaler net of any rebates, discounts or other valuable considerations.


8. SEPARATE PROCEDURES: Some of the listed procedures are commonly carried out as an integral part of a total service, and as such, do not warrant a separate identification. When, however, such a procedure is performed independently of, and is not immediately related to, other services, it may be listed as a "separate procedure." Thus, when a procedure that is ordinarily a component of a larger procedure is performed alone for a specific purpose, it may be reported as a separate procedure.

9. FEES: The fees are listed in the Physician Radiology Fee Schedule, available at
http://www.emedny.org/ProviderManuals/Physician/index.html
Listed fees are the maximum reimbursable Medicaid fees. Fees for the MOMS Program can be found in the Enhanced Program fee schedule.

Note: NCCI associated modifiers are recognized for NCCI code pairs/related edits. For additional information please refer to the CMS website: http://www.cms.hhs.gov/NationalCorrectCodInitEd/

-26 Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier -26 to the usual procedure number.

-50 Bilateral Procedures (X-ray): Unless otherwise identified in the listing, when bilateral X-ray examinations are performed at the same time, the service will be identified by adding the modifier -50 to the usual procedure code number. (Reimbursement will not exceed 160% of the maximum State Medical Fee Schedule amount. One claim line is to be billed representing the bilateral procedure. Amount billed should reflect total amount due.)

-76 Repeat Procedure by Same Physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. (When a repeat X-ray examination of the same part and for the same illness is required for reasons other than technical or professional error in the original X-ray, it will be identified by adding modifier -76.) (Reimbursement will not exceed 100% of the maximum State Medical Fee Schedule amount.)

-AQ Physician Providing a Service in an Unlisted Health Professional Shortage Area (HPSA)

-FP Service Provided as Part of Family Planning Program: All Family Planning Services will be identified by adding the modifier -FP to the usual procedure code number. (Reimbursement will not exceed 100% of the maximum State Medical Fee Schedule amount.)

-LT Left Side (used to identify procedures performed on the left side of the body): Add modifier –LT to the usual procedure code number. (Reimbursement will not exceed 100% of the Maximum Fee Schedule amount. One claim line should be billed.) (Use modifier –50 when both sides done at same operative session.)

-RT Right Side (used to identify procedures performed on the right side of the body): Add modifier –RT to the usual procedure code number. (Reimbursement will not exceed 100% of the Maximum Fee Schedule amount. One claim line should be billed.) (Use modifier –50 when both sides done at same operative session.)

-TC Technical Component: Under certain circumstances, a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier -TC to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians.

HEART

Cardiac magnetic imaging differs from traditional magnetic resonance imaging (MRI) in its ability to provide a physiologic evaluation of cardiac function. Traditional MRI relies on static images to obtain clinical diagnoses based upon anatomic information. Improvement in spatial and temporal resolution has expanded the application from an anatomic test and includes physiologic evaluation of cardiac function.

 Flow and velocity assessment for valves and intracardiac shunts is performed in addition to a function and morphologic evaluation. Use 75559 with 75565 to report flow with pharmacologic wall motion stress evaluation without contrast. Use 75563 with 75565 to report flow with pharmacologic perfusion stress with contrast.

Listed procedures may be performed independently or in the course of overall medical care. If the physician providing these services is also responsible for diagnostic workup and/ or follow-up care of the patient, see appropriate sections also. Only one procedure in the series 75557-75563 is appropriately reported per session. Cardiac MRI studies may be performed at rest and/or during pharmacologic stress.

Therefore, the appropriate stress testing code from the 93015-93018 series should be reported in addition to 75559 or 75563.

75557 Cardiac magnetic resonance imaging for morphology and function without contrast material;

75559 with stress imaging

75561 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences;

75563 with stress imaging

75565 Cardiac magnetic resonance imaging for velocity flow mapping
(List separately in addition to code)

(Use 75565 in conjunction with 75557, 75559, 75561, 75563)

(Do not report 75557, 75559, 75561, 75563, 75565 in conjunction with 76376, 76377)

Background

Disruption of a vulnerable coronary plaque with subsequent thrombosis is currently recognized as the primary mechanism for acute myocardial infarction. Although such plaques are considered to have a thin (less than 65 microns) fibrous cap overlying a lipid pool, imaging modalities in current clinical practice do not have sufficient resolution to identify thin fibrous caps. Optical coherence tomography (OCT) is a new imaging technology capable of obtaining cross-sectional images of coronary vessels. As an optical analog of ultrasound, OCT uses a high-bandwidth infra-red light source instead of an ultrasound-emitting crystal to create high-resolution cross-sectional images of coronary vessels. The resolution of the current OCT system is 10 to 20 microns, which is approximately 10-fold higher than that of intra-vascular ultrasound (IVUS). Furthermore, OCT can visualize stent mal-apposition and tissue protrusion after stenting and neointimal hyperplasia at follow-up.

While there is extensive research on intra-vascular OCT, this new imaging modality has not been adequately assessed. Thus, its clinical value has yet to be established. Stamper et al (2006) stated that the identification of unstable plaque is central in risk-stratifying patients for acute coronary events; and OCT is a modality that has shown considerable promise for the identification of high-risk plaques. They concluded that OCT is a promising technology for the assessment of vulnerable and unstable plaque. The advantages of OCT include its high-resolution and fast data acquisition rate. They stated that future work will focus on improving plaque risk-stratification, especially the identification of reliable markers within the images. Manfrini et al (2007) stated that intra-vascular OCT's high-resolution (10 to 20 microns) makes it a very interesting method for assessing atherosclerotic plaque microstructure in patients suffering from coronary artery disease (CAD). However, significant limitations still exist, including poor penetration in non-transparent tissue. Kubo and Akasaka (2008) noted that OCT is a specialized research tool that might provide new insights into the diagnosis and treatment of CAD.

Raffel et al (2008) evaluated the in-vivo association between coronary artery remodeling and underlying plaque characteristics identified by OCT. They determined that coronary plaques with positive remodeling exhibit characteristic features of vulnerable plaque. This may explain the link between positive remodeling and unstable clinical presentations. They noted that prospective, longitudinal studies with a larger cohort are needed to confirm these findings and to investigate their clinical significance.

Zafar et al (2014) noted that frequency domain OCT (FD-OCT) provides cross-sectional images of coronary arteries and deployed stents with micron resolution and measures lumen dimensions with good reproducibility.

Yonetsu et al (2013) stated that since its invention in the late 1990s, intra-vascular OCT has been rapidly adopted in clinical research and, more recently, in clinical practice. They determined that although OCT has contributed to cardiovascular research by providing a better understanding of the pathophysiology of CAD, data linking the images and clinical outcomes are lacking.

Indications

Intra-vascular optical coherence tomography (OCT) by any technique for any indication is not safe and effective based on review of available literature using standard strength of evidence guidelines.

Limitations

Cahaba GBA considers intra-vascular optical coherence tomography (OCT) investigational for any indications, including the following because of insufficient evidence of its effectiveness.

Assessment of acute coronary syndrome
Assessment of pulmonary arterial wall fibrosis (as a prognostic marker of pulmonary arterial hypertension)
Assessment of severity of coronary artery lesion (identification and risk stratification of vulnerable plaque)
Guidance of intra-coronary stenting and follow-up evaluation of post-stent placement
Treatment (as an adjunct to percutaneous coronary interventions)



CPT/HCPCS Codes


Group 1 Codes:
0291TIv oct for proc init vessel
0292TIv oct for proc addl vessel



ICD-10 CODEDESCRIPTION

XX000Not Applicable

Indications

Pelvic pain undiagnosed by standard exam;
Dysmenorrhea;
Menorrhagia;
Metrorrhagia;
Menometrorrhagia;
Postmenopausal bleeding;
Abnormal pelvic examination;
Further evaluation of abnormality found on other imaging studies; and
Cancer

76856 is a complete evaluation and must minimally include:

Female: description and measurements of the uterus and adnexal structures, measurement of the endometrium and bladder, and a description of any pelvic pathology.

Male: evaluation and measurement of the bladder, evaluation of the prostate and seminal vesicles and any pelvic pathology.

76857 is a limited study and typically focuses on one or more elements listed under 76856 and/or the reevaluation of one or more pelvic abnormalities.

Limitations

Post voiding residual bladder volume is not reimbursable by CPT codes 76856 and 76857. Measurement of post voiding residual should be billed using CPT code 51798.

The accuracy of ultrasonographic studies depends on the knowledge, skills and experience of the technologist and interpreter. Consequently, the providers of interpretations must be capable of demonstrating documented training and experience and maintain documentation of such for possible audit. Further, ultrasonographic studies must be either (1) performed by persons with appropriate training that have demonstrated minimum entry level competency by being credentialed by a nationally recognized credentialing organization in ultrasound technology (e.g., American Registry of Radiologic Technologists (ARRT) in sonography), (2) performed by or under the direct supervision of a physician, or (3) performed in facilities with laboratories accredited in ultrasonography.


CPT/HCPCS Codes


76856Us exam pelvic complete
76857Us exam pelvic limited



ICD-10 CODEDESCRIPTION

A18.14Tuberculosis of prostate
A56.11Chlamydial female pelvic inflammatory disease
C45.1Mesothelioma of peritoneum
C48.0 - C48.8 - Opens in a new windowMalignant neoplasm of retroperitoneum - Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum
C52 - C57.4 - Opens in a new windowMalignant neoplasm of vagina - Malignant neoplasm of uterine adnexa, unspecified
C57.9 - C58 - Opens in a new windowMalignant neoplasm of female genital organ, unspecified - Malignant neoplasm of placenta
C61 - C62.92 - Opens in a new windowMalignant neoplasm of prostate - Malignant neoplasm of left testis, unspecified whether descended or undescended
C63.9Malignant neoplasm of male genital organ, unspecified
C67.0 - C67.9 - Opens in a new windowMalignant neoplasm of trigone of bladder - Malignant neoplasm of bladder, unspecified
C76.3Malignant neoplasm of pelvis
D06.0 - D07.39 - Opens in a new windowCarcinoma in situ of endocervix - Carcinoma in situ of other female genital organs
D25.0 - D27.9 - Opens in a new windowSubmucous leiomyoma of uterus - Benign neoplasm of unspecified ovary
D28.1 - D28.2 - Opens in a new windowBenign neoplasm of vagina - Benign neoplasm of uterine tubes and ligaments
D28.9 - D29.9 - Opens in a new windowBenign neoplasm of female genital organ, unspecified - Benign neoplasm of male genital organ, unspecified
D39.0 - D39.12 - Opens in a new windowNeoplasm of uncertain behavior of uterus - Neoplasm of uncertain behavior of left ovary
D39.8 - D40.0 - Opens in a new windowNeoplasm of uncertain behavior of other specified female genital organs - Neoplasm of uncertain behavior of prostate
D41.3 - D41.8 - Opens in a new windowNeoplasm of uncertain behavior of urethra - Neoplasm of uncertain behavior of other specified urinary organs
D78.01 - D78.02 - Opens in a new windowIntraoperative hemorrhage and hematoma of the spleen complicating a procedure on the spleen - Intraoperative hemorrhage and hematoma of the spleen complicating other procedure
D78.21 - D78.22 - Opens in a new windowPostprocedural hemorrhage of the spleen following a procedure on the spleen - Postprocedural hemorrhage of the spleen following other procedure
E28.0 - E28.9 - Opens in a new windowEstrogen excess - Ovarian dysfunction, unspecified
E36.01 - E36.02 - Opens in a new windowIntraoperative hemorrhage and hematoma of an endocrine system organ or structure complicating an endocrine system procedure - Intraoperative hemorrhage and hematoma of an endocrine system organ or structure complicating other procedure
E89.40 - E89.41 - Opens in a new windowAsymptomatic postprocedural ovarian failure - Symptomatic postprocedural ovarian failure
G97.31 - G97.32 - Opens in a new windowIntraoperative hemorrhage and hematoma of a nervous system organ or structure complicating a nervous system procedure - Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating other procedure
G97.51 - G97.52 - Opens in a new windowPostprocedural hemorrhage of a nervous system organ or structure following a nervous system procedure - Postprocedural hemorrhage of a nervous system organ or structure following other procedure
I72.3Aneurysm of iliac artery
I72.9Aneurysm of unspecified site
I80.211 - I80.219 - Opens in a new windowPhlebitis and thrombophlebitis of right iliac vein - Phlebitis and thrombophlebitis of unspecified iliac vein
K35.2 - K37 - Opens in a new windowAcute appendicitis with generalized peritonitis - Unspecified appendicitis
K50.00 - K50.919 - Opens in a new windowCrohn's disease of small intestine without complications - Crohn's disease, unspecified, with unspecified complications
K57.20Diverticulitis of large intestine with perforation and abscess without bleeding
K57.32Diverticulitis of large intestine without perforation or abscess without bleeding
K57.40Diverticulitis of both small and large intestine with perforation and abscess without bleeding
K57.52Diverticulitis of both small and large intestine without perforation or abscess without bleeding
K57.80Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding
K57.92Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding
K66.1 - K66.8 - Opens in a new windowHemoperitoneum - Other specified disorders of peritoneum
K68.11Postprocedural retroperitoneal abscess
K68.9Other disorders of retroperitoneum
K91.61 - K91.62 - Opens in a new windowIntraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure - Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating other procedure
K91.840 - K91.841 - Opens in a new windowPostprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure - Postprocedural hemorrhage of a digestive system organ or structure following other procedure
N13.9Obstructive and reflux uropathy, unspecified
N21.0Calculus in bladder
N31.0 - N33 - Opens in a new windowUninhibited neuropathic bladder, not elsewhere classified - Bladder disorders in diseases classified elsewhere
N36.44Muscular disorders of urethra
N41.0 - N41.9 - Opens in a new windowAcute prostatitis - Inflammatory disease of prostate, unspecified
N70.01 - N71.9 - Opens in a new windowAcute salpingitis - Inflammatory disease of uterus, unspecified
N73.0 - N74 - Opens in a new windowAcute parametritis and pelvic cellulitis - Female pelvic inflammatory disorders in diseases classified elsewhere
N80.0 - N80.9 - Opens in a new windowEndometriosis of uterus - Endometriosis, unspecified
N82.8Other female genital tract fistulae
N83.53 - N84.0 - Opens in a new windowTorsion of ovary, ovarian pedicle and fallopian tube - Polyp of corpus uteri
N84.8 - N85.9 - Opens in a new windowPolyp of other parts of female genital tract - Noninflammatory disorder of uterus, unspecified
N89.7Hematocolpos
N91.0 - N94.0 - Opens in a new windowPrimary amenorrhea - Mittelschmerz
N94.4 - N94.89 - Opens in a new windowPrimary dysmenorrhea - Other specified conditions associated with female genital organs and menstrual cycle
N95.0Postmenopausal bleeding
N98.1Hyperstimulation of ovaries
N99.510 - N99.518 - Opens in a new windowCystostomy hemorrhage - Other cystostomy complication
N99.61 - N99.62 - Opens in a new windowIntraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure - Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating other procedure
N99.820 - N99.83 - Opens in a new windowPostprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure - Residual ovary syndrome
Q50.01 - Q56.4 - Opens in a new windowCongenital absence of ovary, unilateral - Indeterminate sex, unspecified
Q64.0Epispadias
Q64.11Supravesical fissure of urinary bladder
Q64.5 - Q64.79 - Opens in a new windowCongenital absence of bladder and urethra - Other congenital malformations of bladder and urethra
R10.0 - R10.9 - Opens in a new windowAcute abdomen - Unspecified abdominal pain
R16.0 - R16.2 - Opens in a new windowHepatomegaly, not elsewhere classified - Hepatomegaly with splenomegaly, not elsewhere classified
R18.0 - R19.09 - Opens in a new windowMalignant ascites - Other intra-abdominal and pelvic swelling, mass and lump
R19.30 - R19.37 - Opens in a new windowAbdominal rigidity, unspecified site - Generalized abdominal rigidity
R19.8Other specified symptoms and signs involving the digestive system and abdomen
R31.0 - R31.9 - Opens in a new windowGross hematuria - Hematuria, unspecified
T81.4XXAInfection following a procedure, initial encounter
T88.8XXAOther specified complications of surgical and medical care, not elsewhere classified, initial encounter
Z48.22Encounter for aftercare following kidney transplant
Z85.40 - Z85.41 - Opens in a new windowPersonal history of malignant neoplasm of unspecified female genital organ - Personal history of malignant neoplasm of cervix uteri
Z85.44Personal history of malignant neoplasm of other female genital organs
Z87.42Personal history of other diseases of the female genital tract
Z87.59Personal history of other complications of pregnancy, childbirth and the puerperium
Z94.0Kidney transplant status

Procedure Codes and Descripiton


Group 1 Codes:

77371RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CRANIAL LESION(S) CONSISTING OF 1 SESSION; MULTI-SOURCE COBALT 60 BASED

77372RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CRANIAL LESION(S) CONSISTING OF 1 SESSION; LINEAR ACCELERATOR BASED

77373STEREOTACTIC BODY RADIATION THERAPY, TREATMENT DELIVERY, PER FRACTION TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS

77432STEREOTACTIC RADIATION TREATMENT MANAGEMENT OF CRANIAL LESION(S) (COMPLETE COURSE OF TREATMENT CONSISTING OF 1 SESSION)

77435STEREOTACTIC BODY RADIATION THERAPY, TREATMENT MANAGEMENT, PER TREATMENT COURSE, TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS

G0339IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPY IN ONE SESSION OR FIRST SESSION OF FRACTIONATED TREATMENT

G0340IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY, DELIVERY INCLUDING COLLIMATOR CHANGES AND CUSTOM PLUGGING, FRACTIONATED TREATMENT, ALL LESIONS, PER SESSION, SECOND THROUGH FIFTH SESSIONS, MAXIMUM FIVE SESSIONS PER COURSE OF TREATMENT

Coverage Indications, Limitations, and/or Medical Necessity

Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiation Therapy (SBRT) (for Cranial Lesions Only) is a method of delivering high doses of ionizing radiation to small intracranial targets. In SRS, highly focused convergent beams are delivered to the target while adjacent structures are spared due to a rapid dose fall-off. SRS relies on stereotactic guidance and many SRS systems use a positioning frame to restrict head movement. Treatments may be delivered between 1-5 sessions. SRS typically is performed in a single session, using a rigidly attached stereotactic guiding device, other immobilization technology and/or a stereotactic-guidance system, but can be performed in a limited number of sessions, up to a maximum of five. (If more than one session is required, the SBRT codes must be used.)

SRS requires computer-assisted, three-dimensional planning and delivery with stereotactic and convergent-beam technologies, including, but not limited to: multiple convergent cobalt sources (e.g. Gamma Knife®); protons; multiple, coplanar or non-coplanar photon arcs or angles (e.g. XKnife®); fixed photon arcs; or image-directed robotic devices (e.g. CyberKnife®) that meet the criteria. To assure quality of patient care, the procedure involves a multidisciplinary team consisting of a neurosurgeon, radiation oncologist, and medical physicist. (For a subset of tumors involving the skull base, the multidisciplinary team may also include a head and neck surgeon with training in stereotactic radiosurgery.)

Regardless of the number of sessions, all SRS procedures include the following components:
1. Planning
2. Position stabilization (attachment of a frame or frameless)
3. Imaging for localization (CT, MRI, angiography, PET, etc.)
4. Computer assisted tumor localization (i.e. “Image Guidance”)
5. Treatment planning – number of isocenters, number, placement and length of arcs or angles, number of beams, beam size and weight, etc.
6. Isodose distributions, dosage prescription and calculation
7. Setup and accuracy verification testing
8. Simulation of prescribed arcs or fixed portals
9. Radiation treatment delivery

Radiation oncologists and neurosurgeons have separate CPT billing codes for SRS. CPT Codes 61781-61783, 61796-61800 and 63620 and 63621 are reported for the work attributed to the neurosurgeon. These codes are mutually exclusive with the radiation oncology CPT codes 77432 and 77435; therefore the same physician should not bill for both of these codes.

A radiation oncologist may bill the SRS management code 77432 stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of one session) for single fraction intracranial SRS and only once per treatment course) when and only when fully participating in the management of the procedure. CPT 77432 will be paid only once per course of treatment for cranial lesions regardless of the number of lesions. When SRS is administered in more than one but not more than five fractions to the brain or in one through five fractions to the spine, the radiation oncologist should instead bill the Stereotactic Body Radiation Therapy (SBRT) code 77435 to cover patient management during the course of therapy. CPT 77435 will be paid only once per course of therapy regardless of the number of sessions, lesions or days of treatment. The radiation oncologist may not bill 77432 and 77435 for the same course of therapy. In addition to the management codes, a radiation oncologist may bill other appropriate radiation oncology (77xxx) codes for services performed prior to the delivery of SRS as indicated by the pattern of care and other Medicare policies.

No one physician may bill both the neurosurgical codes 61781-83, 61796-61800, 63620 or 63621 and the radiation oncology 77xxx codes. The physician(s) billing these codes must be physically present during the entire process of defining the target volume and structures at risk. If either the radiation oncologist or the neurosurgeon does not fully participate in the patient’s care, that physician must take care to indicate this change by using the appropriate – 54 modifier (followed by any appropriate – 55 modifier) on the global procedure(s) submitted. As the services are collegial in nature with different specialties providing individual components of the treatment, surgical assistants will not be reimbursed.

The technical charges used by hospital-based and outpatient facilities for SRS delivery are described by the CPT codes listed below. It is not appropriate to bill more than one treatment delivery code on the same day of service, even though some types of delivery may have elements of several modalities (for example, a stereotactic approach with IMRT). Only one delivery code is to be billed.

Other radiation oncology professional and technical services required prior to the delivery of SRS are coded separately and may be appropriately billed by the radiation oncologist, when necessary.

Indications for SRS/SBRT (for Cranial Lesions only):

1. Primary central nervous system malignancies, generally used as a boost or salvage therapy for lesions < 5 cm.
2. Primary and secondary tumors involving the brain or spine parenchyma, meninges/dura, or immediately adjacent bony structures.
3. Benign brain tumors and spinal tumors such as meningiomas, acoustic neuromas, other schwannomas, pituitary adenomas, pineocytomas, craniopharyngiomas, glomus tumors, hemangioblastomas.
4. Cranial arteriovenous malformations, cavernous malformations, and hemangiomas
5. Other cranial non-neoplastic conditions such as trigeminal neuralgia and select cases of medically refractory epilepsy. As a boost treatment for larger cranial or spinal lesions that have been treated initially with external beam radiation therapy or surgery (e.g. sarcomas, chondrosarcomas, chordomas, and nasopharyngeal or paranasal sinus malignancies).
6. Metastatic brain or spine lesions, with stable systemic disease, Karnofsky Performance Status 40 or greater (or expected to return to 70 or greater with treatment), and other wise reasonable survival expectations, OR an Eastern Cooperative Oncology Group (ECOG) Performance Status of 3 or less (or expected to return to 2 or less with treatment).
7. Relapse in a previously irradiated cranial or spinal field where the additional stereotactic precision is required to avoid unacceptable vital tissue radiation.
8. Unilateral thalamotomy using stereotactic radiosurgery may be used to treat limb tremor in Essential Tremor that is refractory to medical management using at least two drugs but is not currently recommended by the Guidelines of the American Academy of Neurology.

Limitations for SRS/SBRT (for Cranial Lesions only):

SRS is not considered medically necessary under the following circumstances:

1. Treatment for anything other than a severe symptom or serious threat to life or critical functions.
2. Treatment unlikely to result in functional improvement or clinically meaningful disease stabilization, not otherwise achievable.
3. Patients with wide-spread cerebral or extra-cranial metastases with limited life expectancy unlikely to gain clinical benefit within their remaining life.
4. Patients with poor performance status (Karnofsky Performance Status less than 40 or an ECOG Performance greater than 3)- see Karnofsky and ECOG Performance Status scales below.
5. Cobalt-60 pallidotomy is non-covered.
6. Basic dosimetry calculations (77300) are limited to one (1) unit for each arc in a linear accelerator system and one (1) unit for each shot in Cobalt-60 system with a maximum of ten (10) units.
7. Treatment devices, complex (77334) is limited to one unit for each collimator in a linear accelerator system or one for each helmet in a cobalt-60 system. If the total number of units exceeds six (6) or the number of isocenters plus three (3) when multiple isocenters are necessary, a detailed explanation of medical necessity must be documented in the medical record. (See Documentation Guidelines.)

Stereotactic Body Radiation Therapy (SBRT)

SBRT is a treatment that couples a high degree of anatomic targeting accuracy and reproducibility with very high doses of extremely precise, externally generated, ionizing radiation, thereby maximizing the cell-killing effect on the target(s) while minimizing radiation-related injury in adjacent normal tissues. SBRT is used to treat extra-cranial sites as opposed to stereotactic radiosurgery (SRS) which is used to treat intra-cranial and spinal targets.

The adjective “stereotactic” describes a procedure during which a target lesion is localized relative to a known three dimensional reference system that allows for a high degree of anatomic accuracy and precision. Examples of devices used in SBRT for stereotactic guidance may include a body frame with external reference markers in which a patient is positioned securely, a system of implanted fiducial markers that can be visualized with low-energy (kV) x-rays, and CT-imaging-based systems used to confirmed the location of a tumor immediately prior to treatment.

Treatment of extra-cranial sites requires accounting for internal organ motion as well as for patient motion. Thus, reliable immobilization or repositioning systems must often be combined with devices capable of decreasing organ motion or accounting for organ motion e.g. respiratory gating. Additionally, all SBRT is performed with at least one form of image guidance to confirm proper patient positioning and tumor localization prior to delivery of each fraction. The ASTRO/ACR Practice Guidelines for SBRT outline the responsibilities and training requirements for personnel involved in the administration of SBRT.

SBRT may be delivered in one to five sessions (fractions). Each fraction requires an identical degree of precision, localization and image guidance. Since the goal of SBRT is to maximize the potency of the radiotherapy by completing an entire course of treatment within an extremely accelerated time frame, any course of radiation treatment extending beyond five fractions is not considered SBRT and is not to be billed using these codes. SBRT is meant to represent a complete course of treatment and not to be used as a boost following a conventionally fractionated course of treatment.

Stereotactic Body Radiation Therapy (SBRT) addresses only the CPT codes for SBRT treatment management - 77435, and SBRT treatment delivery -77373, G0339, and G0340.

When billing for SBRT delivery, it is not appropriate to bill more than one treatment delivery code on the same day of service, even though some types of delivery may have elements of several modalities (for example, a stereotactic approach with intensity-modulated static beams or arcs.) Also, only one, delivery code is to be billed even if multiple lesions are treated on the same day.

Indications for Stereotactic Body Radiation Therapy (SBRT):

SBRT is indicated for primary tumors of and tumors metastatic to the lung, liver, kidney, adrenal gland, or pancreas as well as for pelvic and head and neck tumors that have recurred after primary irradiation when and only when each of the following criteria are met, and each specifically documented in the medical record. Multiple ICD-10 codes fit this description and they are not listed in detail here.

1. The patient’s general medical condition (notably, the performance status) justifies aggressive treatment to a primary cancer or, for the case of metastatic disease, justifies aggressive local therapy to one or more discrete deposits of cancer within the context of efforts to achieve total clearance or clinically beneficial reduction in the patient’s overall burden of systemic disease.
2. Other forms of radiotherapy, including but not limited to external beam and IMRT, cannot be safely or effectively utilized.
3. The tumor burden can be completely targeted with acceptable risk to critical normal structures.
4. If the tumor histology is germ cell or lymphoma, effective chemotherapy regimens have been exhausted and external beam radiation is ineffective or inappropriate for the patient as fully explained in the medical record.

Other Neoplasms:

? For patients with tumors of any type arising in or near previously irradiated regions, SBRT may be appropriate when a high level of precision and accuracy is needed to minimize the risk of injury to surrounding normal tissues. Also, in other cases where a high dose per fraction treatment is indicated SBRT may be appropriate. The necessity should be documented in the medical record.

Coverage may be considered at the Redetermination (Appeal) level on an individual basis for lesions when documentation clearly supports the necessity for high radiation dose per fraction and the necessity to avoid surrounding tissue exposure.

Low or intermediate risk prostate cancer may be covered when the patient is enrolled in an IRB-approved clinical trial and which clinical trial meets the “standards of scientific integrity and relevance to the Medicare population” described in IOM 100-03, National Coverage Determinations Manual, Chap 1, Part 1, section 20.32, B3a-k (with l-m desirable). Similarly, enrollment in a clinical registry compliant with the principles established in AHRQ’s “Registries for Evaluating Patient Outcomes: A User’s Guide”, such as the Registry for Prostate Cancer Radiosurgery (RPCR), may qualify the treatment for coverage.

Limitations for Stereotactic Body Radiation Therapy (SBRT):

? Primary treatment of lesions of bone, breast, uterus, ovary, and other internal organs not listed earlier in this LCD as covered is non-covered. The literature does not support an outcome advantage over other conventional radiation modalities. However, SBRT treatment in the setting of recurrence after conventional radiation modalities have been utilized may be covered.

SBRT is not considered medically necessary under the following circumstances for any condition:

1. Treatment unlikely to result in clinical cancer control and/or functional improvement.
2. The tumor burden cannot be completely targeted with acceptable risk to critical normal structures.
3. Patients with poor performance status (Karnofsky Performance Status less than 40 or Eastern Cooperative Oncology Group (ECOG) Status of 3 or worse).

Karnofsky Performance Status Scale (Perez and Brady, p225)

100 Normal; no complaints, no evidence of disease

90 Able to carry on normal activity; minor signs or symptoms of disease

80 Normal activity with effort; some signs or symptoms of disease

70 Cares for self; unable to carry on normal activity or to do active work

60 Requires occasional assistance but is able to care for most needs

50 Requires considerable assistance and frequent medical care

40 Disabled; requires special care and assistance

30 Severely disabled; hospitalization is indicated although death not imminent

20 Very sick; hospitalization necessary; active supportive treatment is necessary

10 Moribund, fatal processes progressing rapidly

0 Dead

Karnofsky DA, Burchenal JH. (1949). “The Clinical Evaluation of Chemotherapeutic Agents in Cancer.” In: MacLeod CM (Ed), Evaluation of Chemotherapeutic Agents. Columbia Univ Press. Page 196.

ECOG Performance Status Scale

Grade 0: Fully active, able to carry on all pre-disease performance without restriction.

Grade 1: Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g. light house work, office work.

Grade 2: Ambulatory and capable of all self-care but unable to carry out and work activities. Up and about more than 50% of waking hours.

Grade 3: Capable of only limited self-care, confined to bed or chair more than 50% of waking hours.

Grade 4: Completed disabled. Cannot carry on any self-care. Totally confined to bed or chair.

Grade 5: Dead

Eastern Cooperative Oncology Group, Robert Comis M.D., Group Chair.

*As published in Am. J. Clin. Oncol.: Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carone, P.P.; Toxicity And Response Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649-655, 1982.



Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
012xHospital Inpatient (Medicare Part B only)
013xHospital Outpatient
022xSkilled Nursing - Inpatient (Medicare Part B only)
085xCritical Access Hospital

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

033XRadiology - Therapeutic and/or Chemotherapy Administration - General Classification
034XNuclear Medicine - General Classification
040XOther Imaging Services - General Classification



Group 2 Paragraph: Stereotactic Body Radiation Therapy (SBRT) Services.

The CPT 77373, G0339 and G0340 will pay only once per day of treatment regardless of the number of sessions or lesions. CPT 77435 will pay only once per course of therapy

Group 2 Codes:

77373STEREOTACTIC BODY RADIATION THERAPY, TREATMENT DELIVERY, PER FRACTION TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS

77435STEREOTACTIC BODY RADIATION THERAPY, TREATMENT MANAGEMENT, PER TREATMENT COURSE, TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS

G0339IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPY IN ONE SESSION OR FIRST SESSION OF FRACTIONATED TREATMENT

G0340IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY, DELIVERY INCLUDING COLLIMATOR CHANGES AND CUSTOM PLUGGING, FRACTIONATED TREATMENT, ALL LESIONS, PER SESSION, SECOND THROUGH FIFTH SESSIONS, MAXIMUM FIVE SESSIONS PER COURSE OF TREATMENT





ICD-10 Codes that Support Medical Necessity


ICD-10 CODEDESCRIPTION

C11.0Malignant neoplasm of superior wall of nasopharynx
C11.1Malignant neoplasm of posterior wall of nasopharynx
C11.2Malignant neoplasm of lateral wall of nasopharynx
C11.3Malignant neoplasm of anterior wall of nasopharynx
C11.8Malignant neoplasm of overlapping sites of nasopharynx
C30.0Malignant neoplasm of nasal cavity
C30.1Malignant neoplasm of middle ear
C31.0Malignant neoplasm of maxillary sinus
C31.1Malignant neoplasm of ethmoidal sinus
C31.2Malignant neoplasm of frontal sinus
C31.3Malignant neoplasm of sphenoid sinus
C31.8Malignant neoplasm of overlapping sites of accessory sinuses
C70.0Malignant neoplasm of cerebral meninges
C71.0Malignant neoplasm of cerebrum, except lobes and ventricles
C71.1Malignant neoplasm of frontal lobe
C71.2Malignant neoplasm of temporal lobe
C71.3Malignant neoplasm of parietal lobe
C71.4Malignant neoplasm of occipital lobe
C71.5Malignant neoplasm of cerebral ventricle
C71.6Malignant neoplasm of cerebellum
C71.7Malignant neoplasm of brain stem
C71.8Malignant neoplasm of overlapping sites of brain
C72.21Malignant neoplasm of right olfactory nerve
C72.22Malignant neoplasm of left olfactory nerve
C72.31Malignant neoplasm of right optic nerve
C72.32Malignant neoplasm of left optic nerve
C72.41Malignant neoplasm of right acoustic nerve
C72.42Malignant neoplasm of left acoustic nerve
C72.59Malignant neoplasm of other cranial nerves
C75.1Malignant neoplasm of pituitary gland
C75.2Malignant neoplasm of craniopharyngeal duct
C75.3Malignant neoplasm of pineal gland
C75.5Malignant neoplasm of aortic body and other paraganglia
C79.31Secondary malignant neoplasm of brain
C79.32*Secondary malignant neoplasm of cerebral meninges
C79.49*Secondary malignant neoplasm of other parts of nervous system
C79.51*Secondary malignant neoplasm of bone
C79.52*Secondary malignant neoplasm of bone marrow
C79.89*Secondary malignant neoplasm of other specified sites
D18.02Hemangioma of intracranial structures
D32.0Benign neoplasm of cerebral meninges
D33.0Benign neoplasm of brain, supratentorial
D33.1Benign neoplasm of brain, infratentorial
D33.3Benign neoplasm of cranial nerves
D35.2Benign neoplasm of pituitary gland
D35.3Benign neoplasm of craniopharyngeal duct
D35.4Benign neoplasm of pineal gland
D35.5Benign neoplasm of carotid body
D35.6*Benign neoplasm of aortic body and other paraganglia
D42.0*Neoplasm of uncertain behavior of cerebral meninges
D42.1*Neoplasm of uncertain behavior of spinal meninges
D43.0*Neoplasm of uncertain behavior of brain, supratentorial
D43.1*Neoplasm of uncertain behavior of brain, infratentorial
D43.4*Neoplasm of uncertain behavior of spinal cord
D44.3Neoplasm of uncertain behavior of pituitary gland
D44.4Neoplasm of uncertain behavior of craniopharyngeal duct
D44.5Neoplasm of uncertain behavior of pineal gland
D44.6*Neoplasm of uncertain behavior of carotid body
D44.7*Neoplasm of uncertain behavior of aortic body and other paraganglia
D49.6*Neoplasm of unspecified behavior of brain
D49.7*Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system
G20*Parkinson's disease
G21.4Vascular parkinsonism
G25.0Essential tremor
G40.301Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus
G40.311Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.319Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.911Epilepsy, unspecified, intractable, with status epilepticus
G40.919Epilepsy, unspecified, intractable, without status epilepticus
G50.0Trigeminal neuralgia
G50.8Other disorders of trigeminal nerve
G51.0Bell's palsy
G51.1Geniculate ganglionitis
G51.2Melkersson's syndrome
G51.3Clonic hemifacial spasm
G51.4Facial myokymia
G51.8Other disorders of facial nerve
G52.0*Disorders of olfactory nerve
G52.1*Disorders of glossopharyngeal nerve
G52.2*Disorders of vagus nerve
G52.3*Disorders of hypoglossal nerve
G52.7*Disorders of multiple cranial nerves
G52.8*Disorders of other specified cranial nerves
G53*Cranial nerve disorders in diseases classified elsewhere
Q28.2*Arteriovenous malformation of cerebral vessels
Q28.3*Other malformations of cerebral vessels
T66.XXXA*Radiation sickness, unspecified, initial encounter
T66.XXXD*Radiation sickness, unspecified, subsequent encounter
T66.XXXS*Radiation sickness, unspecified, sequela
Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: * ICD-10-CM Codes C79.32, C79.49, C79.51, C79.52, C79.89, D35.6, D44.6, D44.7, D43.0, D43.1,D43.4, D42.0, D42.1, D49.6, D49.7, G52.0, G52.1, G52.2, G52.8, G52.7, G52.3, G53 and Q28.2, Q28.3 are all limited to use for lesions occurring either above the neck or in the spine.

* ICD-10-CM Code G20 is limited to the patient who cannot be controlled with medication, has major systemic disease or coagulopathy, and who is unwilling or unsuited for open surgery.

*ICD-10-CM Code T66.XXXA, T66.XXXD, and T66.XXXS may only be used where prior radiation therapy to the site is the governing factor necessitating SRS in lieu of other radiotherapy. An ICD-10-CM code for the anatomic diagnosis must also be used.


Group 2 Paragraph: Stereotactic Body Radiation Therapy (SBRT) Services (CPT 77373, 77435, G0339 and G0340:

Group 2 Codes:


ICD-10 CODEDESCRIPTION
C00.1*Malignant neoplasm of external lower lip
C00.3*Malignant neoplasm of upper lip, inner aspect
C00.4*Malignant neoplasm of lower lip, inner aspect
C00.8*Malignant neoplasm of overlapping sites of lip
C01*Malignant neoplasm of base of tongue
C02.0*Malignant neoplasm of dorsal surface of tongue
C02.1*Malignant neoplasm of border of tongue
C02.2*Malignant neoplasm of ventral surface of tongue
C02.4*Malignant neoplasm of lingual tonsil
C02.8*Malignant neoplasm of overlapping sites of tongue
C03.0*Malignant neoplasm of upper gum
C03.1*Malignant neoplasm of lower gum
C04.0*Malignant neoplasm of anterior floor of mouth
C04.1*Malignant neoplasm of lateral floor of mouth
C04.8*Malignant neoplasm of overlapping sites of floor of mouth
C05.0*Malignant neoplasm of hard palate
C05.1*Malignant neoplasm of soft palate
C05.2Malignant neoplasm of uvula
C05.8*Malignant neoplasm of overlapping sites of palate
C06.0*Malignant neoplasm of cheek mucosa
C06.1*Malignant neoplasm of vestibule of mouth
C06.2*Malignant neoplasm of retromolar area
C06.89*Malignant neoplasm of overlapping sites of other parts of mouth
C07*Malignant neoplasm of parotid gland
C08.0*Malignant neoplasm of submandibular gland
C08.1*Malignant neoplasm of sublingual gland
C09.0*Malignant neoplasm of tonsillar fossa
C09.1*Malignant neoplasm of tonsillar pillar (anterior) (posterior)
C09.8*Malignant neoplasm of overlapping sites of tonsil
C10.0*Malignant neoplasm of vallecula
C10.1*Malignant neoplasm of anterior surface of epiglottis
C10.2*Malignant neoplasm of lateral wall of oropharynx
C10.3*Malignant neoplasm of posterior wall of oropharynx
C10.4*Malignant neoplasm of branchial cleft
C10.8*Malignant neoplasm of overlapping sites of oropharynx
C22.0Liver cell carcinoma
C22.1Intrahepatic bile duct carcinoma
C22.2Hepatoblastoma
C22.3Angiosarcoma of liver
C22.4Other sarcomas of liver
C22.7Other specified carcinomas of liver
C22.8Malignant neoplasm of liver, primary, unspecified as to type
C22.9Malignant neoplasm of liver, not specified as primary or secondary
C25.0Malignant neoplasm of head of pancreas
C25.1Malignant neoplasm of body of pancreas
C25.2Malignant neoplasm of tail of pancreas
C25.3Malignant neoplasm of pancreatic duct
C25.4Malignant neoplasm of endocrine pancreas
C25.7Malignant neoplasm of other parts of pancreas
C25.8Malignant neoplasm of overlapping sites of pancreas
C34.00Malignant neoplasm of unspecified main bronchus
C34.01Malignant neoplasm of right main bronchus
C34.02Malignant neoplasm of left main bronchus
C34.11Malignant neoplasm of upper lobe, right bronchus or lung
C34.12Malignant neoplasm of upper lobe, left bronchus or lung
C34.2Malignant neoplasm of middle lobe, bronchus or lung
C34.31Malignant neoplasm of lower lobe, right bronchus or lung
C34.32Malignant neoplasm of lower lobe, left bronchus or lung
C34.81Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82Malignant neoplasm of overlapping sites of left bronchus and lung
C61Malignant neoplasm of prostate
C64.1Malignant neoplasm of right kidney, except renal pelvis
C64.2Malignant neoplasm of left kidney, except renal pelvis
C65.1Malignant neoplasm of right renal pelvis
C65.2Malignant neoplasm of left renal pelvis
C74.01Malignant neoplasm of cortex of right adrenal gland
C74.02Malignant neoplasm of cortex of left adrenal gland
C74.11Malignant neoplasm of medulla of right adrenal gland
C74.12Malignant neoplasm of medulla of left adrenal gland
C75.5Malignant neoplasm of aortic body and other paraganglia
C77.1Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes
C78.01Secondary malignant neoplasm of right lung
C78.02Secondary malignant neoplasm of left lung
C78.7Secondary malignant neoplasm of liver and intrahepatic bile duct
C79.01Secondary malignant neoplasm of right kidney and renal pelvis
C79.02Secondary malignant neoplasm of left kidney and renal pelvis
C79.71Secondary malignant neoplasm of right adrenal gland
C79.72Secondary malignant neoplasm of left adrenal gland
T66.XXXA*Radiation sickness, unspecified, initial encounter
T66.XXXD*Radiation sickness, unspecified, subsequent encounter
T66.XXXS*Radiation sickness, unspecified, sequela

Procedure code and Description



Group 1 Codes:

51785NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, ANY TECHNIQUE

92265NEEDLE OCULOELECTROMYOGRAPHY, 1 OR MORE EXTRAOCULAR MUSCLES, 1 OR BOTH EYES, WITH INTERPRETATION AND REPORT

95860NEEDLE ELECTROMYOGRAPHY; 1 EXTREMITY WITH OR WITHOUT RELATED PARASPINAL AREAS

95861NEEDLE ELECTROMYOGRAPHY; 2 EXTREMITIES WITH OR WITHOUT RELATED PARASPINAL AREAS

95863NEEDLE ELECTROMYOGRAPHY; 3 EXTREMITIES WITH OR WITHOUT RELATED PARASPINAL AREAS

95864NEEDLE ELECTROMYOGRAPHY; 4 EXTREMITIES WITH OR WITHOUT RELATED PARASPINAL AREAS

95865NEEDLE ELECTROMYOGRAPHY; LARYNX

95866NEEDLE ELECTROMYOGRAPHY; HEMIDIAPHRAGM

95867NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED MUSCLE(S), UNILATERAL

95868NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED MUSCLES, BILATERAL

95869NEEDLE ELECTROMYOGRAPHY; THORACIC PARASPINAL MUSCLES (EXCLUDING T1 OR T12)

95870NEEDLE ELECTROMYOGRAPHY; LIMITED STUDY OF MUSCLES IN 1 EXTREMITY OR NON-LIMB (AXIAL) MUSCLES (UNILATERAL OR BILATERAL), OTHER THAN THORACIC PARASPINAL, CRANIAL NERVE SUPPLIED MUSCLES, OR SPHINCTERS

95872NEEDLE ELECTROMYOGRAPHY USING SINGLE FIBER ELECTRODE, WITH QUANTITATIVE MEASUREMENT OF JITTER, BLOCKING AND/OR FIBER DENSITY, ANY/ALL SITES OF EACH MUSCLE STUDIED

95873ELECTRICAL STIMULATION FOR GUIDANCE IN CONJUNCTION WITH CHEMODENERVATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

95874NEEDLE ELECTROMYOGRAPHY FOR GUIDANCE IN CONJUNCTION WITH CHEMODENERVATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

95885NEEDLE ELECTROMYOGRAPHY, EACH EXTREMITY, WITH RELATED PARASPINAL AREAS, WHEN PERFORMED, DONE WITH NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY; LIMITED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

95886NEEDLE ELECTROMYOGRAPHY, EACH EXTREMITY, WITH RELATED PARASPINAL AREAS, WHEN PERFORMED, DONE WITH NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY; COMPLETE, FIVE OR MORE MUSCLES STUDIED, INNERVATED BY THREE OR MORE NERVES OR FOUR OR MORE SPINAL LEVELS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

95887NEEDLE ELECTROMYOGRAPHY, NON-EXTREMITY (CRANIAL NERVE SUPPLIED OR AXIAL) MUSCLE(S) DONE WITH NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

95905MOTOR AND/OR SENSORY NERVE CONDUCTION, USING PRECONFIGURED ELECTRODE ARRAY(S), AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH LIMB, INCLUDES F-WAVE STUDY WHEN PERFORMED, WITH INTERPRETATION AND REPORT

95907NERVE CONDUCTION STUDIES; 1-2 STUDIES

95908NERVE CONDUCTION STUDIES; 3-4 STUDIES

95909NERVE CONDUCTION STUDIES; 5-6 STUDIES

95910NERVE CONDUCTION STUDIES; 7-8 STUDIES

95911NERVE CONDUCTION STUDIES; 9-10 STUDIES

95912NERVE CONDUCTION STUDIES; 11-12 STUDIES

95913NERVE CONDUCTION STUDIES; 13 OR MORE STUDIES

95933ORBICULARIS OCULI (BLINK) REFLEX, BY ELECTRODIAGNOSTIC TESTING

95937NEUROMUSCULAR JUNCTION TESTING (REPETITIVE STIMULATION, PAIRED STIMULI), EACH NERVE, ANY 1 METHOD

95999UNLISTED NEUROLOGICAL OR NEUROMUSCULAR DIAGNOSTIC PROCEDURE

G0255CURRENT PERCEPTION THRESHOLD/SENSORY NERVE CONDUCTION TEST, (SNCT) PER LIMB, ANY NERVE



Coverage Indications, Limitations, and/or Medical Necessity

This contractor expects healthcare professionals who perform electrodiagnostic (ED) testing will be appropriately trained and/or credentialed, either by a formal residency/fellowship program, certification by a nationally recognized organization, or by an accredited post-graduate training course covering anatomy, neurophysiology and forms of electrodiagnostics (including both NCS and EMG) acceptable to this contractor, in order to provide the proper testing and assessment of the patient's condition, and appropriate safety measures. It would be highly unlikely that this training and/or credentialing is possessed by providers other than Neurologists, or Physical Medicine & Rehabilitation physicians.

The electrodiagnostic evaluation is an extension of the neurologic portion of the physical examination. Both require a detailed knowledge of a patient and his/her disease. Training in the performance of electrodiagnostic procedures in isolation of knowledge about clinical diagnostic and management aspects of neuromuscular diseases, may not be adequate for proper performance of an electrodiagnostic evaluation and correct interpretation of electrodiagnostic test results. Without awareness of the patterns of abnormality expected in different diseases and knowledge that the results of nerve conduction studies (NCS) and electromyography (EMG) may be similar in different diseases, diagnosis solely by EMG-NCS findings may be both inadequate and ultimately be detrimental to the patient.

Guidelines about proper qualifications for qualified health care professionals performing electrodiagnostic evaluations have been developed and published by AANEM (American Association of Neuromuscular and Electrodiagnostic Medicine) and other medical organizations, including the AMA, the American Academy of Neurology, the American Academy of Physical Medicine and Rehabilitation, American Neurological Association, the American Board of Physical Therapy Specialties (ABPTS) in Clinical Electrophysiology, and the Department of Veterans Affairs.

Both EMGs and NCSs are usually required for a clinical diagnosis of peripheral nervous system disorders. Performance of one type of testing does not eliminate the need for the other. The intensity and extent of testing with EMG and NCS are matters of clinical judgment developed after the initial pre-test evaluation, and later modified during the testing procedure.

Decisions to continue, modify or conclude a testing rely on knowledge of anatomy, physiology and neuromuscular diseases. Ongoing real-time assessment of data is required during the clinical diagnostic evaluation and especially during EMG examination.

Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation which are recordable over the nerve or from an innervated muscle. With this technique, responses are measured between two sites of stimulation, or between a stimulus and a recording site.

Nerve conduction studies are of two general types: sensory and motor. Either surface or needle electrodes can be used to stimulate the nerve or record the response. Axonal damage or dysfunction generally results in loss of nerve or muscle potential response amplitude; whereas, demyelination leads to prolongation of conduction time and slowing of conduction velocity.

Obtaining and interpreting NCS results requires extensive interaction between the performing qualified health care professional and patient, and is most effective when both obtaining raw data and interpretation are performed concurrently on a real-time basis.

Results of the NCS reflect on the integrity and function of:
(I) the myelin sheath (Schwann cell derived insulation covering an axon), and
(II) the axon (an extension of neuronal cell body) of a nerve.

Interruption of axon and dysfunction of myelin will both affect NCS results.

It is often also valuable to test conduction status in proximal segments of peripheral nerves. This assessment can be accomplished by H-reflex, F-wave and blink reflex testing. These proximal segments include the first several centimeters of a compound nerve emerging from the spinal cord or brainstem. H-reflex, F-waves and Blink reflex testing accomplish this task better than distal NCS.

Electromyography (EMG) is the study and recording of intrinsic electrical properties of skeletal muscles. This is carried out with a needle electrode. Generally, the needles are of two types: monopolar or concentric. EMG is undertaken together with NCS. Unlike NCS, however, EMG testing relies on both auditory and visual feedback to the electromyographer. This testing is also invasive in that it requires needle electrode insertion and adjustment at multiple sites, and at times anatomically critical sites. As in NCS during EMG studies the electromyographer depends on ongoing real-time interpretation based knowledge of clinical diagnosis being evaluated to decide whether to continue, modify, or conclude a test. This process requires knowledge of anatomy, physiology, and neuromuscular diseases.

EMG results reflect not only on the integrity of the functioning connection between a nerve and its innervated muscle but also on the integrity of a muscle itself. The axon innervating a muscle is primarily responsible for the muscle’s volitional contraction, survival, and trophic functions. Thus, interruption of the axon will alter the EMG. A few prime examples of conditions in which EMG is potentially helpful are disc disease producing spinal nerve dysfunction, advanced nerve compression in peripheral lesions, Amyotrophic Lateral Sclerosis (ALS), polyneuropathy, etc. After an acute neurogenic lesion, EMG changes may not appear for several days to weeks in the innervated muscles. Primary muscle disease such as polymyositis will also alter a normal EMG pattern. Myotonic disorders may show a pattern of spontaneous repetitive discharges on needle exploration.

In summary, axonal and muscle involvement are most sensitively detected by EMGs, and myelin and axonal involvement are best detected by NCSs.

Physical Therapists Performing EMGs

Program Memorandum Transmittal B-01-28/Change Request 850 sets forth revised levels of physician supervision required for diagnostic tests payable under the Medicare Physician Fee Schedule. Effective July 1, 2001, certain codes in the range of CPT 95860-95937 were assigned new supervision levels (21, 22, 6a, 66, 77 or 77a). This implementation date would make it possible for physical therapists to acquire the certification required to perform these services without supervision. A physical therapist who is presently certified by the American Board of Physical Therapy Specialties can perform procedures assigned level of 21, 22, 66, 6a, 77, or 77a without supervision. These numeric levels assigned to the CPT codes are listed in the Medicare Physician Fee Schedule Database (MFSDB). Physical therapists who do not possess the ABPTS (American Board of Physical Therapy Specialties) certification by July 1, 2001, may continue to furnish those tests that require the certification if they have been furnishing such diagnostic tests prior to May 1, 2001.
Payment will be based on the Medicare Physician Fee Schedule level of supervision designation.
Nerve conduction code 95905 does not have one of the above designations and is therefore not allowed by Physical Therapists.

Nerve conduction codes 95907-95913 had their Physician Supervision of Diagnostic Procedures Indicators adjusted to 7A effective 01/01/2013 (CR 8169). Therefore if authorized by state law Physical Therapists are allowed the technical portion and professional component of the test according to the description of 7A which is included in the Billing and Coding Guideline attached.

The technical component (TC) of the Neuromuscular junction testing code 95937 had its Physician Supervision of Diagnostic Procedures Indicator changed to “7A” This change is effective January 1, 2013.

Needle electromyographic (EMG) codes 95860-95872 and 95885-95887 have the designation of 6A for the technical portion of the test. Therefore if authorized by state law Physical Therapists are allowed the technical portion of the test according to the description of 6A which is included in the Billing and Coding Guideline attached.

A.Nerve Conduction Studies

The dichotomy into axonal and demyelinating neuropathies provides a practical means of correlating electrical abnormalities with major pathophysiologic changes in the nerve. Electrical studies can be of help in localization of an abnormality, and in distinguishing one variety of neuropathy from another: for example, diffuse vs. multifocal; axonal vs. demyelinating. Such distinction has diagnostic value. Specific classification of nerve injuries into neuropraxia and axonotmesis can be made on the basis of conduction studies and electromyography. Such classification has a bearing on prognosis and treatment.
Focal neuropathies or compressive lesions such as carpal tunnel syndrome, ulnar neuropathies or root lesions, for localization.

Traumatic nerve lesions, for diagnosis and prognosis.

Diagnosis or confirmation of suspected generalized neuropathies, such as diabetic, uremic, metabolic or immune.

Repetitive nerve stimulation in diagnosis of neuromuscular junction disorders such as myasthenia gravis, myasthenic syndrome.

There may be other instances, not detailed here, where NCS may be of use. Not all possible or potential indications are addressed here.

The broad diagnostic scope of NCS is recognizable by the foregoing description. There may be instances where questions about an indication, or need for a study, will arise. The clinical history and examination, carried out before the study, must always describe and document clearly and comprehensibly the need for the planned test. A "rule-out" diagnosis is typically not acceptable. The Contractor is cognizant of the fact that patients are not always referred with a definite diagnosis in mind. Often, pain, paresthesia, or weakness in an extremity is the reason for an NCS or EMG. These common symptoms result not only from axonal and myelin dysfunction but also from systemic, non-neurological illnesses. EMG and NCS may help in making this distinction. Therefore, symptom-based diagnoses such as "pain in limb" weakness, disturbance in skin sensation or "paresthesia" are acceptable provided the clinical assessment unequivocally supports the need for a study. To cite but one example of many, an EMG or NCS is irrelevant as a first order diagnostic test for limb pain resulting from immediate antecedent trauma or acute bone injury.

Both EMGs and NCSs are required for a clinical diagnosis of peripheral nervous system disorders. EMG results reflect on the integrity of the functioning connection between a nerve and its innervated muscle and also on the integrity of a muscle itself. Performance of one does not eliminate the need for the other. The intensity and extent of testing with EMG and NCS are matters of clinical judgment developed after the initial pre-test evaluation, and later modified during the testing procedure.

Decisions to continue, modify or conclude a test also rely on a knowledge base of anatomy, physiology and neuromuscular diseases. There is a requirement for ongoing real-time clinical diagnostic evaluation, especially during EMG examination. Also, EMG examination is invasive. Needle placement in the exact muscle of interest is essential. It requires needle exploration near vital structures as the pleura, femoral neurovascular bundle, peritoneum, intraspinal spaces, carotid artery, orbit and brachial plexus. Risk of infection from AIDS, Hepatitis B-E, Creutzfeldt-Jakob encephalopathy, and hemorrhage from anticoagulation can be managed by proper techniques.

The electrodiagnostic evaluation is actually an extension of the neurologic portion of the physical examination. Both require a detailed knowledge of a patient and his/her disease. Training in the performance of electrodiagnostic procedures, in isolation without awareness and ability to diagnose and manage neuromuscular diseases, is not always adequate for electrodiagnostic consultation. Recognition and experience in the management of disparate diseases that produce common electrodiagnostic findings may be necessary. For example, EMG-NCS findings may overlap in the following pairs of disorders: inflammatory myopathies and ALS, ALS and multi-level radiculopathies, myotonia of channelopathies (periodic paralyses) and myotonic dystrophies, focal neuropathies as Carpal Tunnel Syndrome and proximal plexopathies. Other instances where knowledge of disease behavior is crucial are Chronic Inflammatory Demyelinating Neuropathy (CIDP) and Multifocal Motor Neuropathy. These entities display electrodiagnostic features that resemble generalized polyneuropathies. Neuromuscular transmission disorders require separation based on clinical presentation and electrical features. Treatment will depend on differentiating among them. Without awareness of the disease spectrum, diagnosis solely by EMG-NCS findings may be either wrong or detrimental to the patient.

The following definitions are from the American Association of Neuromuscular & Electrodiagnostic Medicine Recommended Policy for Electrodiagnostic Medicine.

"The stimulation of nerves is similar across all NCSs; the characteristics of motor, sensory, and mixed NCSs are different and are discussed separately below. In each case, an appropriate nerve is stimulated and recording is made either from the appropriate nerves or from muscle supplied by the motor nerve.
Motor. Motor NCSs are performed by applying electrical stimulation at various points along the course of a motor nerve while recording the electrical response from an appropriate muscle. Response parameters include amplitude, latency, configuration, and motor conduction velocity.

Sensory. Sensory NCSs are performed by applying electrical stimulation near a nerve and recording the response from a distant site along the nerve. Response parameters include amplitude, latency, and configuration.

Mixed NCSs are performed by applying electrical stimulation near a nerve containing both motor and sensory fibers (a mixed nerve) and recording from a different location along that nerve that also contains both motor and sensory nerve fibers. Response parameters include amplitude, latency, configuration, and motor conduction velocity."

CPT code 95905 -Nerve conduction studies performed using automated devices (for example devices such as NC-stat® System) cannot support testing of other locations and other nerves as needed depending on the concurrent results of testing.

When the beneficiary has a high pre-test or a prior probability for having the diagnosis of Carpal Tunnel Syndrome, the NC-stat® System (alone) will be allowed, one service per arm, using CPT code 95905. The diagnosis codes G56.01, G56.02 or G56.03 should be used. All other diagnosis codes will be denied as not medically necessary.

Nerve conduction studies performed independent of needle electromyography (EMG) may only provide a portion of the information needed to diagnose muscle, nerve root, and most nerve disorders. When the nerve conduction study (NCS) is used on its' own without integrating needle EMG findings or when an individual relies solely on a review of NCS data, the results can be misleading, and important diagnoses may be missed.

In most instances, both NCS and usually EMG are necessary to perform diagnostic testing. While a provider may choose to perform just an NCS, when performed alone it is usually considered not medically necessary. The only exception to this is a situation when a provider may consider it appropriate to perform an NCS without doing an EMG for the diagnosis of carpal tunnel syndrome with a high pre-test probability.

B.Electromyography

Neurogenic disorders can be distinguishable from myopathic disorders by a carefully performed EMG. For example, both polymyositis and ALS (Amyotrophic Lateral Sclerosis) produce manifest weakness. The former carries a very different prognosis and treatment than the latter. An EMG is very valuable in making this distinction. Similarly, classification of nerve trauma into axonal vs. demyelinating categories, with corresponding differences in prognoses, are possible with EMG. Below is a list of common disorders where an EMG, in tandem with properly conducted NCS, will be helpful in diagnosis:
Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions.

Radiculopathy - cervical, lumbosacral.

Mono/polyneuropathy - metabolic, degenerative, hereditary.

Myopathy - including poly-and dermatomyositis, myotonic and congenital myopathies.

Plexopathy - idiopathic, trauma, infiltration.

Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG is of special value here.

At times, immediately prior to botulinum toxin injection, for localization.

At times, immediately prior to injection of phenol or other substances for nerve blocking or chemodenervation.

There may be other instances, not detailed here, where EMG may be of use.

Use of EMG with Botulinum Toxin Injection
EMG may be used to optimize the anatomic location of botulinum toxin injection. It is expected there will be one study performed per anatomic location of injection, if needed.





Limitations:

Nerve Conduction Studies

Each descriptor (code) from codes 95907, 95908, 95909, 95910, 95911, 95912, and 95913, can be reimbursed only once per nerve, or named branch of a nerve, regardless of the number of sites tested or the number of methods used on that nerve. For instance, testing the ulnar nerve at wrist, forearm, below elbow, above elbow, axilla and supraclavicular regions will all be considered as a single nerve. Motor and sensory nerve testing are considered separate tests. CPT code 95905 is payable only once per limb studied and cannot be used in conjunction with any other nerve conduction codes.

Routine testing for polyneuropathy of diabetes or endstage renal disease (ESRD) is not considered medically necessary and is not covered. Testing for the sole purpose of monitoring disease intensity or treatment efficacy in these two conditions is also not covered.

Psychophysical measurements (current, vibration, thermal perceptions), even though they may involve delivery of a stimulus, are considered to be part of the physical exam and may not be billed as a separate service.

Current Perception Threshold/Sensory Nerve Conduction Threshold Test (sNCT) – is not covered by Medicare. This procedure is different and distinct from assessment of nerve conduction velocity, amplitude and latency. It is also different from short-latency somatosensory evoked potentials. Codes designated for eliciting nerve conduction velocity, latency or amplitude, and those designed for short latency evoked potentials are not to be used for sNCT. The sNCT has a unique code G0255: Effective October 1, 2002, CMS initially concluded that there was insufficient scientific or clinical evidence to consider the sNCT test and the device used in performing this test reasonable and necessary within the meaning of section 1862(a)(1)(A) of the law. Therefore, sNCT was noncovered. Based on a reconsideration [in March, 2004] of current Medicare policy for sNCT, CMS concludes that there continues to be insufficient scientific or clinical evidence to consider the sNCT test and the device used in performing this test as reasonable and necessary within the meaning of section 1862(a)(1)(A) of the law. CMS Publication 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 160.23

Examination using portable hand-held devices, or devices which are incapable of real-time wave-form display and analysis, and incapable of both NCS and EMG testing; will be included in the E/M service. They will not be paid separately. Examples include; The Axon II or delta fiber analysis testing and/or machines with other names.

Nerve conduction studies must provide a number of response parameters in a real-time fashion to facilitate provider interpretation. Those parameters include amplitude, latency, configuration and conduction velocity. Medicare does not accept diagnostic studies that do not provide this information or those that provide delayed interpretation as substitutes for Nerve conduction studies. Raw measurement data obtained and transmitted trans-telephonically or over the Internet, therefore, does not qualify for the payment of the electrodiagnostic service codes included in this LCD.

Medicare does not expect to receive claims for nerve conduction testing accomplished with discriminatory devices that use fixed anatomic templates and computer-generated reports used as an adjunct to physical examination routinely on all patients.

Electromyography

It is expected that providers will use CPT code 95870 for sampling muscles other than the paraspinals associated with the extremities, which have been tested. Medicare would not expect to see this code billed when the paraspinal muscles corresponding to an extremity are tested and when the extremity EMG code 95860, 95861, 95863 or 95864 is also billed. The necessity and reasonableness of the following uses of EMG studies have not been established:
exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions

definitive diagnostic conclusions based on paraspinal EMG in regions bearing scar of past surgeries (e.g., previous laminectomies)

pattern-setting limited limb muscle examinations, without paraspinal muscle testing for a diagnosis of radiculopathy

EMG testing shortly after trauma, before EMG abnormalities would have reasonably had time to develop

surface and macro EMG’s

multiple uses of EMG in the same patient at the same location of the same limb for the purpose of optimizing botulinum toxin injections.

For outpatient settings other than Comprehensive Outpatient Rehabilitation Facility (CORF)s, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.) Each practitioner must provide only those services within the scope of practice for each state.

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

22510PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; CERVICOTHORACIC

22511PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL

22512PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL CERVICOTHORACIC OR LUMBOSACRAL VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

22513PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC

22514PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR

22515PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

CPT/HCPCS Codes  Group 1 Codes:

75572Ct hrt w/3d image
75573Ct hrt w/3d image congen
75574Ct angio hrt w/3d image


Group 2 Codes:

75571Ct hrt w/o dye w/ca test


Coverage Indications, Limitations, and/or Medical Necessity

Indications

As an alternative to invasive coronary angiography following a stress test that is equivocal or suspected to be inaccurate.

Instead of myocardial perfusion imaging in the evaluation of coronary artery disease in those patients who have moderate pre-test probability of disease based on clinical risk factors and abnormal diagnostic studies, not symptoms alone.

To evaluate the cause of symptoms in patients with known coronary artery disease.

Assessment of suspected congenital anomalies of coronary circulation or great vessels.

Assessment of coronary or pulmonary venous anatomy for the procedures described below:

CTA of the coronary veins is indicated when imaging of the coronary venous anatomy is necessary for biventricular pacemaker lead insertion.

CTA of the pulmonary veins is indicated when imaging of the pulmonary vasculature is necessary for pulmonary vein catheter ablation procedures for atrial fibrillation.
Limitations

Since the majority of the clinical research utilized a 64-slice CT scanner it is the recommended equipment. However, the intent of this LCD is not to monitor equipment utilization.

The procedure must be performed under the direct supervision of and interpreted by a cardiologist or radiologist who meets the competency guidelines outlined by the published guidelines, ACCF/AHA Clinical Competence Statement on Cardiac Imaging with Computed Tomography and Magnetic Resonance, or American College of Radiology Clinical Statement on Noninvasive Cardiac Imaging.

NOT COVERED:

CPT 75571
Using 71275 or 76497
Screening tests are defined as those tests done in the absence of signs, symptoms, or presence of disease. The use of these procedures (75572, 75573, 75574 for coronary CT angiography) in patients without signs, symptoms or presence of disease is considered to be screening by this Contractor.

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999xNot Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999Not Applicable

ICD-10 Codes that Support Medical Necessity


ICD-10 CODEDESCRIPTION

I20.1 - I20.9 - Opens in a new windowAngina pectoris with documented spasm - Angina pectoris, unspecified
I25.10 - I25.119 - Opens in a new windowAtherosclerotic heart disease of native coronary artery without angina pectoris - Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I25.41 - I25.739 - Opens in a new windowCoronary artery aneurysm - Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris
I25.751 - I25.759 - Opens in a new windowAtherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm - Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris
I25.761 - I25.810 - Opens in a new windowAtherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm - Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
I25.82 - I25.9 - Opens in a new windowChronic total occlusion of coronary artery - Chronic ischemic heart disease, unspecified
I48.0 - I48.92 - Opens in a new windowParoxysmal atrial fibrillation - Unspecified atrial flutter
Q20.0 - Q25.0 - Opens in a new windowCommon arterial trunk - Patent ductus arteriosus
Q25.3 - Q26.4 - Opens in a new windowSupravalvular aortic stenosis - Anomalous pulmonary venous connection, unspecified
Q26.8Other congenital malformations of great veins
R06.02Shortness of breath
R07.2Precordial pain
R94.30 - R94.39 - Opens in a new windowAbnormal result of cardiovascular function study, unspecified - Abnormal result of other cardiovascular function study
Z01.810Encounter for preprocedural cardiovascular examination

CPT/HCPCS Codes

Group 1 Codes:

78451Ht muscle image spect sing

78452Ht muscle image spect mult

78453Ht muscle image planar sing

78454Ht musc image planar mult

78466Heart infarct image

78468Heart infarct image (ef)

78469Heart infarct image (3D)


Coverage Indications, Limitations, and/or Medical Necessity



Indications

The usual indications for performing myocardial perfusion imaging (MPI) procedures are:
New onset of symptoms in patients having probability of coronary artery disease (CAD);

A significant change in symptoms in an individual with known coronary artery disease;

Suspicion of chest pain of cardiac origin;

Probability of coronary artery disease (multiple risk factors and strongly suggestive symptoms) with an abnormal exercise ECG;

Abnormal cardiovascular diagnostic studies in asymptomatic patients with significant cardiac risk factors, e.g. diabetes mellitus;

Risk of a subsequent cardiac event following acute myocardial infarction;

Preoperative evaluation prior to increased risk noncardiac surgical procedures in the moderate cardiac risk patient with recent cardiac history, symptoms, or findings. Cardiac catheterization should be considered in the high risk cardiac patient’;

Postoperative assessment following myocardial revascularization procedures (e.g.,CABG, PTCA) in symptomatic patients;

Assessing postoperative asymptomatic patients after PTCA or CABG, such as in patients with an abnormal ECG response to exercise or those with rest ECG changes precluding identification of ischemia during exercise;

Assessing the patient with angiographic proven disease when it is necessary to identify the "culprit" lesion for revascularization with surgery or angioplasty;

Differentiating ischemic and non-ischemic cardiomyopathy;

Evaluating right ventricular function in patients with pulmonary hypertension; or

Evaluation following cardiac transplantation.


Limitations

Myocardial perfusion imaging is not indicated:
In the absence of symptoms following normal coronary angiography.

When there is no probability of intervention:
risk too high;
patient refuses to consider; or
unacceptable comorbidities.

As repetitive, frequent testing in the absence of changing clinical parameters, especially in individuals with known CAD.

Screening for coronary disease is not a Medicare covered indication.



Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999xNot Applicable



Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999Not Applicable

CPT/HCPCS Codes

G0151SERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

G0152SERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

G0299DIRECT SKILLED NURSING SERVICES OF A REGISTERED NURSE (RN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

G0300DIRECT SKILLED NURSING SERVICES OF A LICENSE PRACTICAL NURSE (LPN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity

The process of falls evaluation and intervention is a complex task for which there exists evidence-based procedures. The translation of these evidence-based procedures into clinical care, however, has been limited by an incomplete understanding of Medicare coverage rules. While no Medicare benefit category exists for a specific suite of “falls evaluation and intervention” services, some evidence-based falls evaluation and intervention procedures utilize home-based components that may be covered by Medicare with the appropriate documentation. The goal of this policy is to provide the framework for covered skilled nursing, physical therapy, and occupational therapy evaluations and interventions in the population of Medicare beneficiaries with a history of falls.

The complexity of both the evidence-based fall evaluations and interventions and the applicable Medicare coverage instructions, require that documentation be as patient-centered as possible (i.e., reflect the unique needs and circumstances of the patient and the available therapeutic options). The coverage of component, skilled services requires that beneficiaries first be eligible for an existing Medicare defined benefit and then under a physician’s order receive covered services that are “reasonable and necessary” with regard to amount, type, frequency and duration.

Home Health Benefit (Bill type 32X): 

Once eligibility for the Medicare Home Health Benefit has been established, physicians may request that Medicare-certified Home Health Agency (HHA) evaluate the circumstances of fall events and establish a plan of care to intervene by identifying and modifying known risk factors for fall events. The skilled nursing service and/or a therapist must be reasonable and necessary to the diagnosis and treatment of the patient's illness or injury within the context of the patient's unique medical condition. To be considered reasonable and necessary for the diagnosis or treatment of the patient's illness or injury, the services must be consistent with the nature and severity of the illness or injury, the patient's particular medical needs, and accepted standards of medical and nursing practice. The determination of whether the services are reasonable and necessary should be made in consideration that a physician has determined that the services ordered are reasonable and necessary. The services must, therefore, be viewed from the perspective of the condition of the patient when the services were ordered and what was, at that time, reasonably expected to be appropriate treatment for the illness or injury throughout the certification period. A patient's overall medical condition, without regard to whether the illness or injury is acute, chronic, terminal, or expected to extend over a long period of time, should be considered in deciding whether skilled services are needed. A patient's diagnosis should never be the sole factor in deciding that a service the patient needs is either skilled or not skilled. Skilled care may, depending on the unique condition of the patient, continue to be necessary for patients whose condition is stable. The documentation of each component service must substantiate the need for the skilled services, be specified in the care plan and not be duplicative. Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded in order that all concerned can follow the results of the applied services. Beneficiary-appropriate goals and objectives, with measurable outcomes must be included in the documentation. Documentation must also show that the skills of a nurse or therapists are required. Where it becomes apparent after a reasonable period of time that the patient, family, or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary. The reason why the training was unsuccessful should be documented in the record. If the measurement results do not reveal progress toward therapy goals and/or do not indicate that therapy is effective, but therapy continues, the qualified therapist(s) must document why the physician and therapist have determined therapy should be continued.

Coverage of skilled nursing care does not turn on the presence or absence of a patient’s potential for improvement from the nursing care, but rather on the patient’s need for skilled care.

Skilled nursing and/or therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.

To be considered a skilled service, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel.

In determining the reasonable and necessary number of teaching and training visits, consideration must be given to whether the teaching and training provided constitutes reinforcement of teaching provided previously in an institutional setting or in the home or whether it represents initial instruction. Where the teaching represents initial instruction, the complexity of the activity to be taught and the unique abilities of the patient are to be considered. Where the teaching constitutes reinforcement, an analysis of the patient's retained knowledge and anticipated learning progress is necessary to determine the appropriate number of visits. Skills taught in a controlled institutional setting often need to be reinforced when the patient returns home. Where the patient needs reinforcement of the institutional teaching, additional teaching visits in the home are covered.

Re-teaching or retraining for an appropriate period may be considered reasonable and necessary where there is a change in the procedure or the patient's condition that requires re-teaching, or where the patient, family, or caregiver is not properly carrying out the task. The medical record should document the reason that the re-teaching or retraining is required and the patient/caregiver response to the education.

Part B Outpatient Therapy Benefit (Bill type 34X):

Medicare beneficiaries not meeting the eligibility criteria for the Home Health Benefit, but otherwise in need of Medicare-covered, home-based therapy services for the evaluation and intervention of falls, may be eligible for the component physical and occupational therapy services available through the Part B outpatient Medicare benefit. Assuming all other eligibility and coverage criteria have been met, the skilled therapy services must be reasonable and necessary to the treatment of the patient's illness or injury within the context of the patient's unique medical condition.

To be considered reasonable and necessary for the treatment of the illness or injury:
a. The services must be consistent with the nature and severity of the illness or injury, the patient's particular medical needs, including the requirement that the amount, frequency, and duration of the services must be reasonable; and

b. The services must be considered, under accepted standards of medical practice, to be specific, safe, and effective treatment for the patient's condition, meeting the standards" listed in Publication 100-02, Chapter 7, Section 40.2.1. The home health record must specify the purpose of the skilled service provided.

if it becomes apparent at some point that the goal set for the patient is no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of skilled services.

Maintenance Program

Coverage of therapy services (not an assistant) to perform a maintenance program is not determined solely on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care. Assuming all other eligibility and coverage requirements are met, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program. When, however, the individualized assessment does not demonstrate such a necessity for skilled care, including when the performance of a maintenance program does not require the skills of a therapist because it could safely and effectively be accomplished by the patient or with the assistance of non-therapists, including unskilled caregivers, such maintenance services will not be covered.

Palmetto GBA recommends use of the concepts contained within the World Health Organization’s (WHO’s) International Classification of Functioning, Disability, and Health (ICF) to organize the necessary data and communicate the patient-centered information describing the unique health status of each beneficiary. Such communication is critical to both documenting and delivering reasonable and necessary home-based Medicare services to the heterogeneous population of Medicare beneficiaries experiencing fall events.

The component Home Health skilled nursing services (e.g., “observation and assessment”) and the corresponding skilled therapy services must adhere to the coverage criteria outlined in the CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7 – Home Health Services, Sections 40.1 and 40.2 respectively. The component Outpatient skilled physical and occupational therapy services must adhere to the CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §§220-230.2. For unsuccessful interventions the reason(s) why the intervention(s) were unsuccessful should be documented in the record.

CPT/HCPCS Codes

Group 1 Codes:

92585Auditor evoke potent compre
92586Auditor evoke potent limit

Group 2 Paragraph: N/A

Group 2 Codes:
95925Somatosensory testing
95926Somatosensory testing
95927Somatosensory testing
95928C motor evoked uppr limbs
95929C motor evoked lwr limbs
95938Somatosensory testing
95939C motor evoked upr&lwr limbs

Group 3 Paragraph: N/A

Group 3 Codes:
95930Visual evoked potential test


Coverage Indications, Limitations, and/or Medical Necessity

Background

Neurophysiology Evoked Potentials (NEPs) for the purpose of this LCD include:

Somatosensory Evoked Potentials/Responses (SEPs/SERs),
Brainstem Auditory Evoked Potentials/Responses (BAEPs/BAERs), and
Visual Evoked Potentials/Responses (VEPs/VERs)
Evoked potential studies are recorded electrical responses to stimulation of a sensory system. When a sensory impulse reaches the brain, a specific Electroencephalographic (EEG) response is produced (evoked) in the cortical area appropriate to the modality and site of the stimulus. By computer averaging techniques, the evoked responses of repetitive stimuli can be separated from the spontaneous EEG activity. Evoked potentials are clinically useful in evaluating the functional integrity of the somatosensory or special sensory pathways. Different latencies and wave patterns help to localize lesions ranging from the end organ through the nervous system to the cerebral cortex. Often defects in these pathways are not otherwise evident. Evoked potentials are also used to monitor neural pathways when patients are anesthetized during surgery and to document brain death. The following are tests that evaluate potentials evoked by stimulation of the peripheral or cranial nerves:

SEPs/SERs evaluate the pathways from nerves in the extremities through the spinal cord, to the brainstem or cerebral cortex upon stimulation of peripheral axon.

SEPs has an advantage in that it evaluates the entire somatosensory pathway and it is possible to distinguish between lesions located in the peripheral nerve, in the dorsal column pathway, or both.

VEPs/VERs evaluate the visual nervous system pathways from the eyes to the occipital cortex of the brain. VEP or VER involves stimulation of the retina and optic nerve with a shifting checkerboard pattern or flash method. This external visual stimulus causes measurable electrical activity in neurons within the visual pathways. This is called the Visual Evoked Response (VER) and is recorded by electroencephalography electrodes located over the occiput. Using special computer techniques, the evoked responses measured over multiple trials are amplified and averaged. A characteristic waveform is produced. With pattern-shift VER, the waveform normally appears as a straight line with a single positive peak (100 msec after stimulus presentation). Abnormalities in this characteristic waveform may be seen in a variety of pathologic processes involving the optic nerve and its radiations. Pattern-shift VER is a highly sensitive means of documenting lesions in the visual system. It is especially useful when the disease process is subclinical, e.g., ophthalmologic exam is normal and patient lacks visual symptoms.

BAEPs/BAERs evaluate the auditory nerve pathways from the ears through the brain stem. A clicking sound is presented to one ear at a time. The electrical activity of this signal is recorded by electrodes on the scalp. The averaged response is displayed as a waveform that contains peaks and troughs, which correspond to various points along the hearing pathway. The time between these peaks is measured and compared to normal data. A delay in a component of the response might indicate an abnormality at specific anatomic sites in the acoustic nerve or brainstem.


Indications

Somatosensory Evoked Potentials and Responses (SEPs/SERs) (CPT codes 95925, 95926, 95927, 95928, 95929, 95938, 95939) are appropriate for the following indications:

Spinal cord trauma
Degenerative, non-traumatic spinal cord lesions (e.g., cervical spondylosis with myelopathy)
Multiple sclerosis
Spinocerebellar degeneration
Myoclonus
Coma
Intraoperative monitoring
Subacute combined degeneration
Other diseases of myelin (e.g., adrenoleukodystrophy, adrenomyeloneuropathy, metachromatic leukodystrophy, and Pelizaeus-Merzbacher disease
Syringomyelia
Hereditary spastic paraplegia
Brainstem Auditory Evoked Potentials and Responses (BAEPs/BAERs) (CPT codes 92585 and 92586) are appropriate:

For one or more of the following conditions:

Asymmetric hearing loss
Unilateral tinnitus
Sudden hearing loss
Cerebellopontine angle tumor
Demyelinating disorder
Functional hearing loss
Ototoxic drug therapy monitoring including chemotherapy or antibiotics
Auditory neuropathy
Acoustic neuroma

Preoperative baseline for:

Posterior fossa surgery
Cochlear implant

Postoperative testing for:

Cochlear implant
Visual Evoked Potentials or Responses (VEPs/VERs) (CPT code 95930) are appropriate for the following indications:

Confirm diagnosis of multiple sclerosis when clinical criteria are inconclusive.

Detect optic neuritis at an early, subclinical stage.

Evaluate diseases of the optic nerve, such as:

Ischemic optic neuropathy
Pseudotumor cerebri
Toxic amblyopias
Nutritional amblyopias
Neoplasms compressing the anterior visual pathways
Optic nerve injury or atrophy
Hysterical blindness (to rule out)

Monitor the visual system during optic nerve (or related) surgery (monitoring of short-latency evoked potential studies).

Limitations

SEP studies are appropriate only when a detailed clinical history and neurologic examination and appropriate diagnostic tests such as imaging studies, electromyogram, and nerve conduction studies make a lesion (or lesions) of the central somatosensory pathways a likely and reasonable differential diagnostic possibility.

There is no need for SEPs in the diagnosis of most neuropathies because the conventional nerve conduction study can identify them and no added information is obtained from SEPs.






ICD-10 Codes that Support Medical Necessity


ICD-10 CODEDESCRIPTION

D33.3Benign neoplasm of cranial nerves
G10Huntington's disease
G21.0Malignant neuroleptic syndrome
G23.0 - G26 - Opens in a new windowHallervorden-Spatz disease - Extrapyramidal and movement disorders in diseases classified elsewhere
G35 - G36.8 - Opens in a new windowMultiple sclerosis - Other specified acute disseminated demyelination
G37.0 - G37.8 - Opens in a new windowDiffuse sclerosis of central nervous system - Other specified demyelinating diseases of central nervous system
G80.3Athetoid cerebral palsy
G90.3Multi-system degeneration of the autonomic nervous system
H46.00 - H46.9 - Opens in a new windowOptic papillitis, unspecified eye - Unspecified optic neuritis
H81.01 - H81.09 - Opens in a new windowMeniere's disease, right ear - Meniere's disease, unspecified ear
H81.41 - H81.49 - Opens in a new windowVertigo of central origin, right ear - Vertigo of central origin, unspecified ear
H83.3X1 - H83.3X9 - Opens in a new windowNoise effects on right inner ear - Noise effects on inner ear, unspecified ear
H90.3 - H90.8 - Opens in a new windowSensorineural hearing loss, bilateral - Mixed conductive and sensorineural hearing loss, unspecified
H91.20 - H91.23 - Opens in a new windowSudden idiopathic hearing loss, unspecified ear - Sudden idiopathic hearing loss, bilateral
H93.11 - H93.19 - Opens in a new windowTinnitus, right ear - Tinnitus, unspecified ear
H93.3X1 - H93.3X9 - Opens in a new windowDisorders of right acoustic nerve - Disorders of unspecified acoustic nerve
H94.00 - H94.03 - Opens in a new windowAcoustic neuritis in infectious and parasitic diseases classified elsewhere, unspecified ear - Acoustic neuritis in infectious and parasitic diseases classified elsewhere, bilateral
R25.0 - R25.9 - Opens in a new windowAbnormal head movements - Unspecified abnormal involuntary movements
R42Dizziness and giddiness

ICD-10 CODEDESCRIPTION

A18.01Tuberculosis of spine
A52.11Tabes dorsalis
A52.13 - A52.15 - Opens in a new windowLate syphilitic meningitis - Late syphilitic neuropathy
A52.17 - A52.19 - Opens in a new windowGeneral paresis - Other symptomatic neurosyphilis
A69.20 - A69.22 - Opens in a new windowLyme disease, unspecified - Other neurologic disorders in Lyme disease
A69.29Other conditions associated with Lyme disease
A83.0 - A83.8 - Opens in a new windowJapanese encephalitis - Other mosquito-borne viral encephalitis
A84.0 - A84.8 - Opens in a new windowFar Eastern tick-borne encephalitis [Russian spring-summer encephalitis] - Other tick-borne viral encephalitis
A85.2Arthropod-borne viral encephalitis, unspecified
B00.4Herpesviral encephalitis
B00.82Herpes simplex myelitis
B02.24Postherpetic myelitis
B05.0Measles complicated by encephalitis
B06.01Rubella encephalitis
C41.2Malignant neoplasm of vertebral column
C70.0 - C70.9 - Opens in a new windowMalignant neoplasm of cerebral meninges - Malignant neoplasm of meninges, unspecified
C72.0 - C72.9 - Opens in a new windowMalignant neoplasm of spinal cord - Malignant neoplasm of central nervous system, unspecified
C79.31 - C79.49 - Opens in a new windowSecondary malignant neoplasm of brain - Secondary malignant neoplasm of other parts of nervous system
D32.0 - D33.7 - Opens in a new windowBenign neoplasm of cerebral meninges - Benign neoplasm of other specified parts of central nervous system
D42.0 - D43.2 - Opens in a new windowNeoplasm of uncertain behavior of cerebral meninges - Neoplasm of uncertain behavior of brain, unspecified
D43.4Neoplasm of uncertain behavior of spinal cord
D44.3 - D44.5 - Opens in a new windowNeoplasm of uncertain behavior of pituitary gland - Neoplasm of uncertain behavior of pineal gland
D49.6Neoplasm of unspecified behavior of brain
E03.5Myxedema coma
E08.40Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified
E08.42Diabetes mellitus due to underlying condition with diabetic polyneuropathy
E08.44Diabetes mellitus due to underlying condition with diabetic amyotrophy
E09.40Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified
E09.42Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy
E09.44Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy
E10.40Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.42Type 1 diabetes mellitus with diabetic polyneuropathy
E10.44Type 1 diabetes mellitus with diabetic amyotrophy
E11.40Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.42Type 2 diabetes mellitus with diabetic polyneuropathy
E11.44Type 2 diabetes mellitus with diabetic amyotrophy
E13.40Other specified diabetes mellitus with diabetic neuropathy, unspecified
E13.42Other specified diabetes mellitus with diabetic polyneuropathy
E13.44Other specified diabetes mellitus with diabetic amyotrophy
E71.50 - E71.548 - Opens in a new windowPeroxisomal disorder, unspecified - Other peroxisomal disorders
E75.23Krabbe disease
E75.25 - E75.29 - Opens in a new windowMetachromatic leukodystrophy - Other sphingolipidosis
F44.4 - F44.7 - Opens in a new windowConversion disorder with motor symptom or deficit - Conversion disorder with mixed symptom presentation
G05.4Myelitis in diseases classified elsewhere
G06.1Intraspinal abscess and granuloma
G11.0 - G11.8 - Opens in a new windowCongenital nonprogressive ataxia - Other hereditary ataxias
G13.0 - G13.1 - Opens in a new windowParaneoplastic neuromyopathy and neuropathy - Other systemic atrophy primarily affecting central nervous system in neoplastic disease
G23.0 - G23.9 - Opens in a new windowHallervorden-Spatz disease - Degenerative disease of basal ganglia, unspecified
G32.0 - G32.81 - Opens in a new windowSubacute combined degeneration of spinal cord in diseases classified elsewhere - Cerebellar ataxia in diseases classified elsewhere
G35 - G36.8 - Opens in a new windowMultiple sclerosis - Other specified acute disseminated demyelination
G37.0 - G37.8 - Opens in a new windowDiffuse sclerosis of central nervous system - Other specified demyelinating diseases of central nervous system
G45.0 - G45.2 - Opens in a new windowVertebro-basilar artery syndrome - Multiple and bilateral precerebral artery syndromes
G45.8Other transient cerebral ischemic attacks and related syndromes
G46.0 - G46.2 - Opens in a new windowMiddle cerebral artery syndrome - Posterior cerebral artery syndrome
G54.0 - G54.8 - Opens in a new windowBrachial plexus disorders - Other nerve root and plexus disorders
G55Nerve root and plexus compressions in diseases classified elsewhere
G56.40 - G56.42 - Opens in a new windowCausalgia of unspecified upper limb - Causalgia of left upper limb
G57.00 - G57.92 - Opens in a new windowLesion of sciatic nerve, unspecified lower limb - Unspecified mononeuropathy of left lower limb
G58.7Mononeuritis multiplex
G60.0 - G60.8 - Opens in a new windowHereditary motor and sensory neuropathy - Other hereditary and idiopathic neuropathies
G61.0 - G61.89 - Opens in a new windowGuillain-Barre syndrome - Other inflammatory polyneuropathies
G62.0 - G62.89 - Opens in a new windowDrug-induced polyneuropathy - Other specified polyneuropathies
G63Polyneuropathy in diseases classified elsewhere
G65.0 - G70.89 - Opens in a new windowSequelae of Guillain-Barre syndrome - Other specified myoneural disorders
G73.1 - G73.3 - Opens in a new windowLambert-Eaton syndrome in neoplastic disease - Myasthenic syndromes in other diseases classified elsewhere
G80.0 - G80.2 - Opens in a new windowSpastic quadriplegic cerebral palsy - Spastic hemiplegic cerebral palsy
G80.4 - G80.8 - Opens in a new windowAtaxic cerebral palsy - Other cerebral palsy
G81.00 - G81.94 - Opens in a new windowFlaccid hemiplegia affecting unspecified side - Hemiplegia, unspecified affecting left nondominant side
G90.3Multi-system degeneration of the autonomic nervous system
G93.2Benign intracranial hypertension
G95.0 - G95.19 - Opens in a new windowSyringomyelia and syringobulbia - Other vascular myelopathies
G95.81 - G95.89 - Opens in a new windowConus medullaris syndrome - Other specified diseases of spinal cord
G99.2Myelopathy in diseases classified elsewhere
I60.00 - I62.1 - Opens in a new windowNontraumatic subarachnoid hemorrhage from unspecified carotid siphon and bifurcation - Nontraumatic extradural hemorrhage
I63.011 - I63.09 - Opens in a new windowCerebral infarction due to thrombosis of right vertebral artery - Cerebral infarction due to thrombosis of other precerebral artery
I63.111 - I63.19 - Opens in a new windowCerebral infarction due to embolism of right vertebral artery - Cerebral infarction due to embolism of other precerebral artery
I63.211 - I63.239 - Opens in a new windowCerebral infarction due to unspecified occlusion or stenosis of right vertebral arteries - Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid arteries
I63.30 - I63.49 - Opens in a new windowCerebral infarction due to thrombosis of unspecified cerebral artery - Cerebral infarction due to embolism of other cerebral artery
I63.59 - I63.6 - Opens in a new windowCerebral infarction due to unspecified occlusion or stenosis of other cerebral artery - Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
I65.01 - I65.8 - Opens in a new windowOcclusion and stenosis of right vertebral artery - Occlusion and stenosis of other precerebral arteries
I66.01 - I66.3 - Opens in a new windowOcclusion and stenosis of right middle cerebral artery - Occlusion and stenosis of cerebellar arteries
I66.9Occlusion and stenosis of unspecified cerebral artery
I67.1Cerebral aneurysm, nonruptured
M05.50 - M05.59 - Opens in a new windowRheumatoid polyneuropathy with rheumatoid arthritis of unspecified site - Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
M34.83Systemic sclerosis with polyneuropathy
M40.00 - M41.9 - Opens in a new windowPostural kyphosis, site unspecified - Scoliosis, unspecified
M43.8X1 - M43.9 - Opens in a new windowOther specified deforming dorsopathies, occipito-atlanto-axial region - Deforming dorsopathy, unspecified
M47.011 - M47.029 - Opens in a new windowAnterior spinal artery compression syndromes, occipito-atlanto-axial region - Vertebral artery compression syndromes, site unspecified
M47.11 - M47.16 - Opens in a new windowOther spondylosis with myelopathy, occipito-atlanto-axial region - Other spondylosis with myelopathy, lumbar region
M50.00 - M50.03 - Opens in a new windowCervical disc disorder with myelopathy, unspecified cervical region - Cervical disc disorder with myelopathy, cervicothoracic region
M51.04 - M51.06 - Opens in a new windowIntervertebral disc disorders with myelopathy, thoracic region - Intervertebral disc disorders with myelopathy, lumbar region
M51.9 - M53.1 - Opens in a new windowUnspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder - Cervicobrachial syndrome
M96.2 - M96.5 - Opens in a new windowPostradiation kyphosis - Postradiation scoliosis
Q05.0 - Q05.9 - Opens in a new windowCervical spina bifida with hydrocephalus - Spina bifida, unspecified
Q07.00 - Q07.03 - Opens in a new windowArnold-Chiari syndrome without spina bifida or hydrocephalus - Arnold-Chiari syndrome with spina bifida and hydrocephalus
R20.0 - R20.9 - Opens in a new windowAnesthesia of skin - Unspecified disturbances of skin sensation
R26.0 - R26.1 - Opens in a new windowAtaxic gait - Paralytic gait
R26.81 - R27.9 - Opens in a new windowUnsteadiness on feet - Unspecified lack of coordination
R29.5Transient paralysis
R40.20 - R40.2124 - Opens in a new windowUnspecified coma - Coma scale, eyes open, to pain, 24 hours or more after hospital admission