Consolidation of Part A (Fiscal Intermediary) and Part B (Carrier) Local Coverage Determinations (LCDs)

2365

Colonoscopy

Surgery:  Colonoscopy (Diagnostic)

Part A has no ICD-9 additions.
The Indications, HCPCS codes and ICD-9 codes for Screening Colonoscopies have been replaced with a statement referring Providers to the Medicare Benefit Policy Manual. (Pub 100-02), Section 280.2 for coverage of colorectal cancer screening tests and procedures.

20891

Colony Stimulating Factors

Drugs and Biologicals:  Colony Stimulating Factors

For J1440, J1441, J2820 – add ICD-9 238.79, expand range 288.00 – 288.04, 288.09, 288.59
     
For J2505 – expand range 288.00 – 288.04, add ICD-9 288.59    

22653

Computed Tomographic Angiography of the Heart and Coronary Vessels

Radiology:  Computed Tomographic Angiography of the Heart and Coronary Vessels

Add ICD-9 codes 414.2, 427.31, 427.32 and V72.81

1495

Computed Tomography of the Abdomen and Pelvis

Radiology:  Computed Tomography of the Abdomen and Pelvis

Add ICD-9 codes 006.2, 095.2 – 095.4, expand range 233.1 – 233.9, 251.4, 251.5, 251.8, 277.30, 277.31, 277.39, 289.53, 405.01, 446.0, 447.3, 535.61, 536.1, expand range 536.40 – 536.49, expand range 566 – 568.9, expand range  585.1 – 585.6, 629.89, 710.1, 787.01, 793.99, 996.82, 996.86

13071

Computed Tomography of the Head or Brain

Radiology:  Computed Tomography of the Head or Brain

Add ICD-9 codes 052.2, 053.14, 054.74, 200.31, 200.41, expand range 200.50 – 200.58, 200.61, 200.71, expand range 330.0 – 334.9, 388.45, 768.7, expand range 770.81 – 770.89, 780.32, 995.20

22686

Computed Tomography of the Thorax

Radiology: Computed Tomography of the Thorax

Add ICD-9 codes 277.39, 414.12, 415.12, 423.3, 518.7 and 519.19

1090

Infliximab (REMICADE ®)

Drugs and Biologicals:  Infliximab (Remicade)

Correction:  Change current ICD-9 code range 556.0 – 557.0 to 556.0 – 556.9

13118

Magnetic Resonance Imaging of the Brain

Radiology:  Magnetic Resonance Imaging of the Brain

Add ICD-9 codes as follows:  expand range 015.60 – 015.66, 036.2, 053.14, 054.74, 064, 137.1, 139.0, 200.31, 200.38, 200.41, 200.48, expand range 200.50 – 200.58, 200.61, 200.68, 200.71, 200.78, expand range 323.01 – 323.9, expand range 333.0 – 333.91, 376.30, 376.35, expand range 377.32 – 377.34, 377.43, 377.61, 377.63, 377.73, 377.75, 446.5, 446.7

1261

Magnetic Resonance Imaging of the Spine

Radiology:  Magnetic Resonance Imaging of the Spine

Add ICD-9 codes 003.21, expand range 018.01 – 018.06, expand range 018.81 – 018.86, 036.0, 036.2, 053.14, 054.74, 098.53, 237.72, 433.20, 443.24, 876.1, 905.1, 907.2, 907.3, 926.11, 996.63

855

Pamidronate Disodium (Aredia ®)

Drugs and Biologicals:  Pamidronate Disodium (Aredia)

Add ICD-9:  238.6

21027

Ultrasound of the Abdomen and Retroperitoneum

Radiology:  Ultrasound of the Abdomen and Retroperitoneum

For CPT codes 76700 and 76705 -  006.3, 122.0, 150.2, range 150.5 – 154.0, 189.1, 189.2, 197.4, 197.5, 198.0, range 235.0 – 235.3, 443.22, 443.23, range 453.0 – 453.3, 530.0, range 531.00 – 531.91, range 532.00 – 532.91,  range 533.00 – 533.91, range 534.00 – 534.91, 535.01, 535.11, 535.21, 535.31, 535.41, 535.51, range 535.60 – 535.61, range 536.0 – 536.9, range 537.0 – 537.6, range 537.81 – 537.9, range 541 – 543.9, 551.1, range 551.20 – 551.29, 551.3, 552.1, range 552.20 – 552.29, 552.3, 553.1, 553.20, 553.21, 553.9, range 560.1 – 560.9, range 562.00 – 562.13, 564.2, 564.3, 564.7, 564.81, 568.0, range 568.81 – 568.9, 569.5, range 569.60 – 569.69, range 569.82 – 569.89, range 573.0 – 573.4, 573.9, range 579.1 – 579.9, 751.2, range 751.60 – 751.69, 759.0, 771.81, 783.0, 783.21, 787.01, 790.4, 793.4, 793.6, range 863.0 – 863.39, range 863.41 – 863.44, range 863.51 – 863.54, range 864.02 – 864.09, 864.10, range 864.12 – 864.19, range 868.02 – 868.09, 868.10, range 868.12 – 868.19, 869.0, 869.1, 922.2, 959.12, V42.7, V42.83, V42.84, V67.1, V67.2, V71.1

For CPT codes 76770 and 76775 - 183.0, 198.0, 236.91, 567.29, 593.3, 593.5, range 753.10 – 753.29, 753.3, 753.4, 788.1, 788.30, 789.00, 793.5, range 866.00 – 866.13, 868.14, 959.12, V10.52, V10.53, V42.0, V42.7, V42.83, V42.84

21031

X-ray of the Chest

Radiology:  X-Ray of the Chest

Add ICD-9 codes as follows:  expand range 238.0 – 238.9, 277.39, expand range 284.01 – 284.9, expand range 420.0 – 429.9, expand range 440.0 – 448.9, 449, 488, expand range 510.0 – 519.9, 585.9, 731.3, expand range 768.2 – 771.1, 775.81, 775.89, 787.29, expand range 995.0 – 996.2

25722

Zoledronic Acid

Drugs and Biologicals:  Zoledronic Acid

Add ICD-9 range 140.0 – 208.91