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Contractor Information

Contractor Name ^{back to top}

Palmetto GBA
Contractor Number ^{back to top}
00380
Contractor Type ^{back to top}
FI

LCD Information

LCD ID Number ^{back to top}

L921

LCD Title ^{back to top}
Urinalysis

Contractor's Determination Number ^{back to top}
93A-0010-L

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}
Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations. CMS Manual System, Pub 100-08, Medicare Program Integrity, Transmittal 63, dated January 23, 2004, Change Request 3010

Primary Geographic Jurisdiction ^{back to top}
South Carolina

Oversight Region ^{back to top}
Region IV

Original Determination Effective Date ^{back to top}
For services performed on or after 11/15/1997

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 01/23/2009

Revision Ending Date ^{back to top}
09/30/2009

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
A urinalysis is a physical, chemical, and microscopic examination of urine. In order for Medicare coverage to be provided for a urinalysis, the patient must have signs or symptoms of a kidney/urinary tract disorder or a condition, which is known to affect the kidney/urinary tract. The following is a list of conditions in which a urinalysis will be considered medically necessary: · The patient has symptoms suggestive of possible kidney/urinary tract disorder, e.g. dysuria, frequency, hesitancy, nocturia, urgency, flank pain, pelvic pain, abdominal pain, etc. · The patient exhibits signs of kidney/urinary tract disorder such as hematuria, discoloration of urine, malodorous urine, edema, etc. · The patient has been recently treated or is under treatment for a urinary tract disorder, and a repeat urinalysis is necessary to evaluate the patient · The patient has a condition known to affect the kidneys or urinary tract, such as hypertension, diabetes mellitus, collagen vascular disease, etc. · The patient is undergoing treatment with a medication known to potentially adversely affect the kidneys, such as chemotherapy agents · The patient has sustained trauma affecting the genitourinary system · The patient has unexplained fever · The patient is pregnant and a urinalysis is performed as part of the prenatal care · Urine specific gravity determination can be covered as part of the evaluation of a dehydrated patient · The patient is scheduled for a major surgical procedure and a urinalysis is being performed as part of the preoperative evaluation

Coding Information

Bill Type Codes: ^{back to top}

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.

12x	Hospital-inpatient or home health visits (Part B only)
13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
14x	Non-Patient Laboratory Specimens
18x	Hospital-swing beds
21x	SNF-inpatient, Part A
22x	SNF-inpatient or home health visits (Part B only)
23x	SNF-outpatient (HHA-A also)
71x	Clinic-rural health
72x	Clinic-hospital based or independent renal dialysis facility
73x	Clinic-independent provider based FQHC (eff 10/91)
85x	Special facility or ASC surgery-rural primary care hospital (eff 10/94)

Revenue Codes: ^{back to top}

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.

030X	Laboratory-general classification

CPT/HCPCS Codes ^{back to top}

81000	Urinalysis, nonauto w/scope
81001	Urinalysis, auto w/scope
81002	Urinalysis nonauto w/o scope
81003	Urinalysis, auto, w/o scope
81005	Urinalysis
81007	Urine screen for bacteria
81015	Microscopic exam of urine

ICD-9 Codes that Support Medical Necessity ^{back to top}

008.04	INTESTINAL INFECTION DUE TO ENTEROHEMORRHAGIC E. COLI
010.00 - 015.96	PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED EXAMINATION - TUBERCULOSIS OF UNSPECIFIED BONES AND JOINTS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
016.00 - 016.96	TUBERCULOSIS OF KIDNEY UNSPECIFIED EXAMINATION - UNSPECIFIED GENITOURINARY TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
017.00 - 018.96	TUBERCULOSIS OF SKIN AND SUBCUTANEOUS CELLULAR TISSUE UNSPECIFIED EXAMINATION - UNSPECIFIED MILIARY TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
034.0 - 034.1	STREPTOCOCCAL SORE THROAT - SCARLET FEVER
035	ERYSIPELAS
036.0 - 036.9	MENINGOCOCCAL MENINGITIS - MENINGOCOCCAL INFECTION UNSPECIFIED
038.9	UNSPECIFIED SEPTICEMIA
040.82	TOXIC SHOCK SYNDROME
042	HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
054.10 - 054.19	GENITAL HERPES UNSPECIFIED - OTHER GENITAL HERPES
054.3	HERPETIC MENINGOENCEPHALITIS
066.40 - 066.49	WEST NILE FEVER, UNSPECIFIED - WEST NILE FEVER WITH OTHER COMPLICATIONS
072.0	MUMPS ORCHITIS
078.5 - 078.6	CYTOMEGALOVIRAL DISEASE - HEMORRHAGIC NEPHROSONEPHRITIS
079.82	SARS-ASSOCIATED CORONAVIRUS INFECTION
079.83	PARVOVIRUSB19
079.88	OTHER SPECIFIED CHLAMYDIAL INFECTION
079.98	UNSPECIFIED CHLAMYDIAL INFECTION
098.0 - 098.19	GONOCOCCAL INFECTION (ACUTE) OF LOWER GENITOURINARY TRACT - OTHER GONOCOCCAL INFECTION (ACUTE) OF UPPER GENITOURINARY TRACT
098.2 - 098.39	GONOCOCCAL INFECTION CHRONIC OF LOWER GENITOURINARY TRACT - OTHER CHRONIC GONOCOCCAL INFECTION OF UPPER GENITOURINARY TRACT
099.3 - 099.49	REITER'S DISEASE - OTHER NONGONOCOCCAL URETHRITIS OTHER SPECIFIED ORGANISM
100.0	LEPTOSPIROSIS ICTEROHEMORRHAGICA
112.1 - 112.2	CANDIDIASIS OF VULVA AND VAGINA - CANDIDIASIS OF OTHER UROGENITAL SITES
112.5	DISSEMINATED CANDIDIASIS
116.0	BLASTOMYCOSIS
117.7	ZYGOMYCOSIS (PHYCOMYCOSIS OR MUCORMYCOSIS)
120.0 - 120.2	SCHISTOSOMIASIS DUE TO SCHISTOSOMA HAEMATOBIUM - SCHISTOSOMIASIS DUE TO SCHISTOSOMA JAPONICUM
131.00 - 131.02	UROGENITAL TRICHOMONIASIS UNSPECIFIED - TRICHOMONAL URETHRITIS
185	MALIGNANT NEOPLASM OF PROSTATE
187.1 - 187.9	MALIGNANT NEOPLASM OF PREPUCE - MALIGNANT NEOPLASM OF MALE GENITAL ORGAN SITE UNSPECIFIED
188.0 - 188.9	MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER - MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED
189.0 - 189.9	MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS - MALIGNANT NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED
198.0	SECONDARY MALIGNANT NEOPLASM OF KIDNEY
198.1	SECONDARY MALIGNANT NEOPLASM OF OTHER URINARY ORGANS
199.0 - 199.1	DISSEMINATED MALIGNANT NEOPLASM - OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE
199.2	MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN
203.00	MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.01	MULTIPLE MYELOMA IN REMISSION
203.02	MULTIPLE MYELOMA, IN RELAPSE
203.10	PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.11	PLASMA CELL LEUKEMIA IN REMISSION
203.12	PLASMA CELL LEUKEMIA, IN RELAPSE
203.80	OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.81	OTHER IMMUNOPROLIFERATIVE NEOPLASMS IN REMISSION
203.82	OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE
222.1	BENIGN NEOPLASM OF PENIS
222.2	BENIGN NEOPLASM OF PROSTATE
222.8	BENIGN NEOPLASM OF OTHER SPECIFIED SITES OF MALE GENITAL ORGANS
223.3	BENIGN NEOPLASM OF BLADDER
223.81	BENIGN NEOPLASM OF URETHRA
223.89	BENIGN NEOPLASM OF OTHER SPECIFIED SITES OF URINARY ORGANS
233.7	CARCINOMA IN SITU OF BLADDER
233.9	CARCINOMA IN SITU OF OTHER AND UNSPECIFIED URINARY ORGANS
236.5	NEOPLASM OF UNCERTAIN BEHAVIOR OF PROSTATE
236.7	NEOPLASM OF UNCERTAIN BEHAVIOR OF BLADDER
236.91	NEOPLASM OF UNCERTAIN BEHAVIOR OF KIDNEY AND URETER
236.99	NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED URINARY ORGANS
239.4	NEOPLASM OF UNSPECIFIED NATURE OF BLADDER
239.5	NEOPLASM OF UNSPECIFIED NATURE OF OTHER GENITOURINARY ORGANS
250.00 - 250.93	DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH UNSPECIFIED COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED
253.5 - 253.6	DIABETES INSIPIDUS - OTHER DISORDERS OF NEUROHYPOPHYSIS
255.13	BARTTER'S SYNDROME
271.4	RENAL GLYCOSURIA
273.0 - 273.9	POLYCLONAL HYPERGAMMAGLOBULINEMIA - UNSPECIFIED DISORDER OF PLASMA PROTEIN METABOLISM
274.0 - 274.9	GOUTY ARTHROPATHY - GOUT UNSPECIFIED
276.0 - 276.9	HYPEROSMOLALITY AND/OR HYPERNATREMIA - ELECTROLYTE AND FLUID DISORDERS NOT ELSEWHERE CLASSIFIED
277.00 - 277.7	CYSTIC FIBROSIS WITHOUT MECONIUM ILEUS - DYSMETABOLIC SYNDROME X
277.81 - 277.89	PRIMARY CARNITINE DEFICIENCY - OTHER SPECIFIED DISORDERS OF METABOLISM
277.9	UNSPECIFIED DISORDER OF METABOLISM
282.60	SICKLE-CELL DISEASE UNSPECIFIED
282.61	HB-SS DISEASE WITHOUT CRISIS
282.62	HB-SS DISEASE WITH CRISIS
282.63	SICKLE-CELL/HB-C DISEASE WITHOUT CRISIS
282.64	SICKLE-CELL/HB C DISEASE WITH CRISIS
282.68	OTHER SICKLE-CELL DISEASE WITHOUT CRISIS
283.0 - 283.9	AUTOIMMUNE HEMOLYTIC ANEMIAS - ACQUIRED HEMOLYTIC ANEMIA UNSPECIFIED
289.7	METHEMOGLOBINEMIA
294.0 - 294.9	AMNESTIC DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE - UNSPECIFIED PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE
295.00 - 295.95	SIMPLE TYPE SCHIZOPHRENIA UNSPECIFIED STATE - UNSPECIFIED TYPE SCHIZOPHRENIA IN REMISSION
296.20 - 296.25	MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE UNSPECIFIED DEGREE - MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE IN PARTIAL OR UNSPECIFIED REMISSION
296.30 - 296.35	MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE UNSPECIFIED DEGREE - MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN PARTIAL OR UNSPECIFIED REMISSION
296.7	BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) UNSPECIFIED
298.8	OTHER AND UNSPECIFIED REACTIVE PSYCHOSIS
300.00 - 300.09	ANXIETY STATE UNSPECIFIED - OTHER ANXIETY STATES
306.50	PSYCHOGENIC GENITOURINARY MALFUNCTION UNSPECIFIED
306.53	PSYCHOGENIC DYSURIA
307.1	ANOREXIA NERVOSA
307.50	EATING DISORDER UNSPECIFIED
307.51	BULIMIA NERVOSA
357.82	CRITICAL ILLNESS POLYNEUROPATHY
359.81	CRITICAL ILLNESS MYOPATHY
401.0 - 401.9	MALIGNANT ESSENTIAL HYPERTENSION - UNSPECIFIED ESSENTIAL HYPERTENSION
402.00 - 402.91	MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE - UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE
403.00 - 403.91	HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
404.00 - 404.93	HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
405.01 - 405.99	MALIGNANT RENOVASCULAR HYPERTENSION - OTHER UNSPECIFIED SECONDARY HYPERTENSION
428.0	CONGESTIVE HEART FAILURE UNSPECIFIED
428.31	ACUTE DIASTOLIC HEART FAILURE
428.41	ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE
446.0 - 446.7	POLYARTERITIS NODOSA - TAKAYASU'S DISEASE
447.6	ARTERITIS UNSPECIFIED
453.3	EMBOLISM AND THROMBOSIS OF RENAL VEIN
480.3	PNEUMONIA DUE TO SARS-ASSOCIATED CORONAVIRUS
515	POSTINFLAMMATORY PULMONARY FIBROSIS
540.0 - 540.9	ACUTE APPENDICITIS WITH GENERALIZED PERITONITIS - ACUTE APPENDICITIS WITHOUT PERITONITIS
580.0 - 580.9	ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - ACUTE GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
581.0 - 581.9	NEPHROTIC SYNDROME WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
582.0 - 582.9	CHRONIC GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - CHRONIC GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
583.0 - 583.9	NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
584.5 - 584.9	ACUTE RENAL FAILURE WITH LESION OF TUBULAR NECROSIS - ACUTE RENAL FAILURE UNSPECIFIED
585.1 - 585.9	CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED
586	RENAL FAILURE UNSPECIFIED
587	RENAL SCLEROSIS UNSPECIFIED
588.1	NEPHROGENIC DIABETES INSIPIDUS
588.81 - 588.89	SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN) - OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION
590.00 - 590.9	CHRONIC PYELONEPHRITIS WITHOUT LESION OF RENAL MEDULLARY NECROSIS - INFECTION OF KIDNEY UNSPECIFIED
591	HYDRONEPHROSIS
592.0 - 592.9	CALCULUS OF KIDNEY - URINARY CALCULUS UNSPECIFIED
593.0 - 593.9	NEPHROPTOSIS - UNSPECIFIED DISORDER OF KIDNEY AND URETER
594.0 - 594.9	CALCULUS IN DIVERTICULUM OF BLADDER - CALCULUS OF LOWER URINARY TRACT UNSPECIFIED
595.0 - 595.9	ACUTE CYSTITIS - CYSTITIS UNSPECIFIED
596.0 - 596.9	BLADDER NECK OBSTRUCTION - UNSPECIFIED DISORDER OF BLADDER
597.0 - 597.89	URETHRAL ABSCESS - OTHER URETHRITIS
598.00 - 598.9	URETHRAL STRUCTURE DUE TO UNSPECIFIED INFECTION - URETHRAL STRICTURE UNSPECIFIED
599.0	URINARY TRACT INFECTION SITE NOT SPECIFIED
599.1	URETHRAL FISTULA
599.2	URETHRAL DIVERTICULUM
599.3	URETHRAL CARUNCLE
599.4	URETHRAL FALSE PASSAGE
599.5	PROLAPSED URETHRAL MUCOSA
599.60 - 599.69	URINARY OBSTRUCTION, UNSPECIFIED - URINARY OBSTRUCTION, NOT ELSEWHERE CLASSIFIED
599.70	HEMATURIA, UNSPECIFIED
599.71	GROSS HEMATURIA
599.72	MICROSCOPIC HEMATURIA
599.81 - 599.89	URETHRAL HYPERMOBILITY - OTHER SPECIFIED DISORDERS OF URINARY TRACT
599.9	UNSPECIFIED DISORDER OF URETHRA AND URINARY TRACT
600.00	HYPERTROPHY (BENIGN) OF PROSTATE WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT (LUTS)
600.01	HYPERTROPHY (BENIGN) OF PROSTATE WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS (LUTS)
600.10	NODULAR PROSTATE WITHOUT URINARY OBSTRUCTION
600.11	NODULAR PROSTATE WITH URINARY OBSTRUCTION
600.20	BENIGN LOCALIZED HYPERPLASIA OF PROSTATE WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS (LUTS)
600.21	BENIGN LOCALIZED HYPERPLASIA OF PROSTATE WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS (LUTS)
600.3	CYST OF PROSTATE
600.90	HYPERPLASIA OF PROSTATE, UNSPECIFIED, WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY SYMPTOMS (LUTS)
600.91	HYPERPLASIA OF PROSTATE, UNSPECIFIED, WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY SYMPTOMS (LUTS)
601.0 - 601.9	ACUTE PROSTATITIS - PROSTATITIS UNSPECIFIED
602.0 - 602.9	CALCULUS OF PROSTATE - UNSPECIFIED DISORDER OF PROSTATE
603.0 - 603.9	ENCYSTED HYDROCELE - HYDROCELE UNSPECIFIED
604.0	ORCHITIS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS WITH ABSCESS
604.90	ORCHITIS AND EPIDIDYMITIS UNSPECIFIED
604.91	ORCHITIS AND EPIDIDYMITIS IN DISEASES CLASSIFIED ELSEWHERE
607.0 - 607.9	LEUKOPLAKIA OF PENIS - UNSPECIFIED DISORDER OF PENIS
608.0 - 608.9	SEMINAL VESICULITIS - UNSPECIFIED DISORDER OF MALE GENITAL ORGANS
616.10	VAGINITIS AND VULVOVAGINITIS UNSPECIFIED
617.8	ENDOMETRIOSIS OF OTHER SPECIFIED SITES
618.00 - 618.09	UNSPECIFIED PROLAPSE OF VAGINAL WALLS - OTHER PROLAPSE OF VAGINAL WALLS WITHOUT MENTION OF UTERINE PROLAPSE
618.81 - 618.83	INCOMPETENCE OR WEAKENING OF PUBOCERVICAL TISSUE - PELVIC MUSCLE WASTING
618.89	OTHER SPECIFIED GENITAL PROLAPSE
619.0	URINARY-GENITAL TRACT FISTULA FEMALE
625.6	STRESS INCONTINENCE FEMALE
625.9	UNSPECIFIED SYMPTOM ASSOCIATED WITH FEMALE GENITAL ORGANS
642.00 - 642.94	BENIGN ESSENTIAL HYPERTENSION COMPLICATING PREGNANCY CHILDBIRTH AND THE PUERPERIUM UNSPECIFIED AS TO EPISODE OF CARE - UNSPECIFIED POSTPARTUM HYPERTENSION
646.20 - 646.24	UNSPECIFIED RENAL DISEASE IN PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE - UNSPECIFIED POSTPARTUM RENAL DISEASE
646.50 - 646.54	ASYMPTOMATIC BACTERIURIA IN PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE - POSTPARTUM ASYMPTOMATIC BACTERIURIA
669.80 - 669.84	OTHER COMPLICATIONS OF LABOR AND DELIVERY UNSPECIFIED AS TO EPISODE OF CARE - OTHER COMPLICATIONS OF LABOR AND DELIVERY POSTPARTUM CONDITION OR COMPLICATION
710.0 - 710.4	SYSTEMIC LUPUS ERYTHEMATOSUS - POLYMYOSITIS
710.9	UNSPECIFIED DIFFUSE CONNECTIVE TISSUE DISEASE
714.0 - 714.9	RHEUMATOID ARTHRITIS - UNSPECIFIED INFLAMMATORY POLYARTHROPATHY
719.45	PAIN IN JOINT INVOLVING PELVIC REGION AND THIGH
719.49	PAIN IN JOINT INVOLVING MULTIPLE SITES
724.2	LUMBAGO
724.5	BACKACHE UNSPECIFIED
728.88	RHABDOMYOLYSIS
752.61	HYPOSPADIAS
753.0 - 753.9	RENAL AGENESIS AND DYSGENESIS - UNSPECIFIED CONGENITAL ANOMALY OF URINARY SYSTEM
760.1	MATERNAL RENAL AND URINARY TRACT DISEASES AFFECTING FETUS OR NEWBORN
780.09	ALTERATION OF CONSCIOUSNESS OTHER
780.32	COMPLEX FEBRILE CONVULSIONS
780.60	FEVER, UNSPECIFIED
780.61	FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE
780.62	POSTPROCEDURAL FEVER
780.64	CHILLS (WITHOUT FEVER)
780.97	ALTERED MENTAL STATUS
780.99	OTHER GENERAL SYMPTOMS
782.3	EDEMA
783.21	LOSS OF WEIGHT
783.22	UNDERWEIGHT
785.52	SEPTIC SHOCK
785.59	OTHER SHOCK WITHOUT TRAUMA
787.01 - 787.03	NAUSEA WITH VOMITING - VOMITING ALONE
788.0 - 788.62	RENAL COLIC - SLOWING OF URINARY STREAM
788.63	URGENCY OF URINATION
788.64	URINARY HESITANCY
788.65	STRAINING ON URINATION
788.69	OTHER ABNORMALITY OF URINARY STREAM
788.7	URETHRAL DISCHARGE
788.8	EXTRAVASATION OF URINE
788.91	FUNCTIONAL URINARY INCONTINENCE
788.99	OTHER SYMPTOMS INVOLVING URINARY SYSTEM
789.00 - 789.49	ABDOMINAL PAIN UNSPECIFIED SITE - ABDOMINAL RIGIDITY OTHER SPECIFIED SITE
789.51	MALIGNANT ASCITES
789.59	OTHER ASCITES
789.60 - 789.69	ABDOMINAL TENDERNESS UNSPECIFIED SITE - ABDOMINAL TENDERNESS OTHER SPECIFIED SITE
789.9	OTHER SYMPTOMS INVOLVING ABDOMEN AND PELVIS
790.6	OTHER ABNORMAL BLOOD CHEMISTRY
790.7	BACTEREMIA
790.93	ELEVATED PROSTATE SPECIFIC ANTIGEN [PSA]
791.0 - 791.9	PROTEINURIA - OTHER NONSPECIFIC FINDINGS ON EXAMINATION OF URINE
793.5 - 793.6	NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF GENITOURINARY ORGANS - NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF ABDOMINAL AREA INCLUDING RETROPERITONEUM
794.4	NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF KIDNEY
796.2	ELEVATED BLOOD PRESSURE READING WITHOUT DIAGNOSIS OF HYPERTENSION
805.2 - 805.9	CLOSED FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY
806.30 - 806.9	OPEN FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY
866.00 - 866.13	UNSPECIFIED INJURY TO KIDNEY WITHOUT OPEN WOUND INTO CAVITY - COMPLETE DISRUPTION OF KIDNEY PARENCHYMA WITH OPEN WOUND INTO CAVITY
867.0 - 867.1	INJURY TO BLADDER AND URETHRA WITHOUT OPEN WOUND INTO CAVITY - INJURY TO BLADDER AND URETHRA WITH OPEN WOUND INTO CAVITY
867.2 - 867.3	INJURY TO URETER WITHOUT OPEN WOUND INTO CAVITY - INJURY TO URETER WITH OPEN WOUND INTO CAVITY
867.6	INJURY TO OTHER SPECIFIED PELVIC ORGANS WITHOUT OPEN WOUND INTO CAVITY
959.11	OTHER INJURY OF CHEST WALL
959.12	OTHER INJURY OF ABDOMEN
959.13	FRACTURE OF CORPUS CAVERNOSUM PENIS
959.14	OTHER INJURY OF EXTERNAL GENITALS
982.2	TOXIC EFFECT OF CARBON DISULFIDE
985.0	TOXIC EFFECT OF MERCURY AND ITS COMPOUNDS
996.81	COMPLICATIONS OF TRANSPLANTED KIDNEY
V10.46	PERSONAL HISTORY OF MALIGNANT NEOPLASM OF PROSTATE
V10.50 - V10.59	PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED URINARY ORGAN - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER URINARY ORGANS
V13.00 - V13.09	PERSONAL HISTORY OF UNSPECIFIED URINARY DISORDER - PERSONAL HISTORY OF OTHER SPECIFIED URINARY SYSTEM DISORDERS
V23.2	SUPERVISION OF HIGH-RISK PREGNANCY WITH HISTORY OF ABORTION
V23.41	SUPERVISION OF HIGH-RISK PREGNANCY WITH HISTORY OF PRE-TERM LABOR
V23.49	SUPERVISION OF HIGH-RISK PREGNANCY WITH OTHER POOR OBSTETRIC HISTORY
V23.5	SUPERVISION OF HIGH-RISK PREGNANCY WITH OTHER POOR REPRODUCTIVE HISTORY
V23.7	SUPERVISION OF HIGH-RISK PREGNANCY WITH INSUFFICIENT PRENATAL CARE
V42.0	KIDNEY REPLACED BY TRANSPLANT
V44.50 - V44.59	CYSTOSTOMY UNSPECIFIED - OTHER CYSTOSTOMY
V44.6	STATUS OF OTHER ARTIFICIAL OPENING OF URINARY TRACT
V45.11	RENAL DIALYSIS STATUS
V45.12	NONCOMPLIANCE WITH RENAL DIALYSIS
V58.69	LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS
V67.51	FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED
V72.83*	OTHER SPECIFIED PRE-OPERATIVE EXAMINATION
V81.6	SCREENING FOR OTHER AND UNSPECIFIED GENITOURINARY CONDITIONS
*Note: ICD-9-CM code (V72.83) may be used only when a medically necessary urinalysis is performed prior to a major surgical procedure.

Diagnoses that Support Medical Necessity ^{back to top}

N/A

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

N/A

General Information

Documentation Requirements ^{back to top}

1. Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim. Claims submitted without such evidence will be denied as being not reasonable and necessary.

2. Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the Intermediary upon request.

Appendices ^{back to top}

N/A

Utilization Guidelines ^{back to top}

N/A

Sources of Information and Basis for Decision ^{back to top}

N/A

Advisory Committee Meeting Notes ^{back to top}

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the Intermediary, this policy was developed in cooperation with advisory groups, which include representatives from the affected provider community. Advisory Committee Meeting date: N/A

Start Date of Comment Period ^{back to top}

06/28/1997

End Date of Comment Period ^{back to top}

08/12/1997

Start Date of Notice Period ^{back to top}

10/15/1997

Revision History Number ^{back to top}

Revision #20, 01/23/2009
Revision #19, 10/01/2008
Revision #18, 09/05/2008
Revision #17, 10/01/2007
Revision #16, 10/01/2006
Revision #15, 03/22/2006
Revision #14, 10/01/2005
Revision #13, 10/08/2005
Revision #12, 11/22/2004
Revision #11 10/01/2004
Revision #10 05/29/2004
Revision #9 11/28/2003
Revision #8 10/01/2003
Revision #7 07/04/2003
Revision #6 10/01/2002
Revision #5 10/15/2000
Revision #4 06/25/2000
Revison #3 01/01/2000
Revision #2 08/15/1999
Revision #1 01/13/1999

Revision History Explanation ^{back to top}

Revision #20, 01/23/2009
Under ICD-9 Codes That Support Medical Necessity section 780.6 was deleted as it was invalid. Added ICD-9 codes 780.60, 780.61, 780.62 and 780.64. These changes become effective on 01/23/2009.

Revision #19, 10/01/2008
Under AMA/CPT & ADA/CDT Copyright Statement the copyright date was changed from 2007 to 2008. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes 203.02, 203.12. ICD-9 code 599.7 expanded to 599.70, 599.71 and 599.72. Correction: 788.9 expanded to 788.91 and 788.99, not 788.92. This revision becomes effective on 10/01/2008.

Revision #18, 09/05/2008
Under AMA/CPT & ADA/CDT Copyright Statement the copyright date was changed from 2007 to 2008. Under ICD-9 Codes That Support Medical Necessity added ICD-9 code 199.2 and 203.82, ICD-9 codes 788.9 expanded to 788.91 and 788.92, V45.1 expanded to V45.11 and V45.12. This LCD has had its annual validation. This revision becomes effective on 09/05/2008.

Revision #17, 10/01/2007
Under AMA/CPT and ADA/CDT Copyright Statement changed the copyright date from 2006 to 2007. Under CMS National Coverage Policy revised the publication number for the cited manual from “100-8” to now read “100-08”. Under ICD-9 Codes That Support Medical Necessity added ICD-9 code 079.83. ICD-9 code 789.5 was extended to a 5th digit to now read 789.51 and 789.59. This policy was reviewed for annual validation. This revision becomes effective 10/01/2007.

Revision #16, 10/01/2006
Under AMA/CPT and ADA/CDT Copyright Statement changed the copyright date to 2006. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes 780.32, 780.97, 788.64, and 788.65 and revised the verbiage for the following ICD-9 codes 403.00-403.91, 404.00-404.93, 600.00, 600.01, 600.20, 600.21, 600.90, 600.91, 618.81-618.83, and 618.89. This policy was reviewed for annual validation. This revision becomes effective 10/01/2006.

Revision #15, 03/22/2006
Under ICD-9 Codes That Support Medical Necessity section of the policy the verbiage for ICD-9 code 010-00-015.96 was changed from Tuberculosis to Primary tuberculosis infection and ICD-9 codes V23.2, V23.41, V23.49, V23.5, and V23.7 were added. Under Sources of Information and Basis for Decision section the Palmetto GBA Part B Policy #93-0010-L is being deleted as that LCD was retired on 05/25/05.These changes become effective on 03/22/2006.

Revision #14, 10/01/2005
Under AMA/CPT and ADA/CDT Copyright Statement changed the copyright date to 2005. Under ICD-9 Codes That Support Medical Necessity ICD-9 code 585 (effective 11/15/97) extended to a 5th digit to include: 585.1, 585.2, 585.3, 585.4, 585.5, 585.6, and 585.9. This revision is for ICD-9 codes (new and revised) that become effective 10/01/2005. Therefore, this revision, even though completed after revision #13, will have an effective date that is prior to the effective date of revision #13. This revision becomes effective 10/01/2005.

Revision #13, 10/08/2005
Under CMS National Coverage Policy added verbiage for Title XVIII of the Social Security Act, sections 1862 (a)(1)(A) and 1862 (a)(7). Under Indications and Limitations of Coverage and/or Medical Necessity added the word “major” to the last bullet. Under Bill Type Codes added 23x and 73x. Under Revenue Codes added 030x. Under Does The “CPT 30% Coding Rule” Apply? changed the verbiage to “Yes”. Under ICD-9 Codes That Support Medical Necessity added multiple ICD-9 codes. Under Note added the word “major”. Under Documentation Requirements changed the verbiage for statement #2. Under Sources of Information and Basis for Decision deleted “Policies from other Medicare Carriers”. Under Advisory Committee Meeting Notes the verbiage was changed. This revision becomes effective 10/08/2005.

Revision #12, 11/22/2004
Under AMA/ CPT and ADA/CDT Copyright Statement section of the policy, deleted the reference to CDT-4 copyright language, as this policy does not contain CDT-4 codes or descriptions. Under ICD-9 Codes That Do Not Support Medical Necessity section of the policy, deleted the verbiage related to Appeal rights, as this information will appear on the Palmetto GBA web site under Appeals information. These changes become effective 11/22/2004.

Revision #11, 10/01/2004
Under AMA/ CPT and ADA/CDT Copyright Statement changed copyright dates from 2003 to 2004. Under CMS National Coverage Policy deleted Change Request 2592. Under ICD-9 Codes That Support Medical Necessity changed verbiage for ICD-9 codes 294.0-294.9, 296.7 and 307.51 to reflect revised annual diagnosis code titles. Extended ICD-9 codes 588.8 to 588.81-588.89 and 618.0 to 618.00-618.09. Added ICD-9 codes 066.40-066.49, 618.81-618.89, and 959.11. These changes become effective 10/01/2004.

Revision #10, 05/29/2004
Converted Local Medical Review Policy (LMRP) to Local Coverage Determination (LCD). Under CMS National Coverage Policy section of the policy added Change Request 3010. Deleted IOM citation CMS Manual System, Pub 100-4, Medicare Claims Processing, Chapter 3, Section 40.3. Under ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY section of the policy deleted ICD-9 code 600.0 as this was expanded to a 5th digit. ICD-9 codes 600.00 and 600.01 currently exist in policy at this time per revision history #8. Added ICD-9 code V81.6 (screening for other and unspecified genitourinary conditions). Extended ICD-9 code 277.0 to 5th digit 277.00, ICD-9 code 590.0 to 5th digit 590.00 and ICD-9 code 788.6 extended to 788.62. Under Documentation Requirements section of the policy added verbiage statement #1.These changes become effective May 29, 2004.
Note: The 1/01/01 revision history was inadvertently not included in the policy. Under ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY section of the policy, ICD-9 code 783.2 was updated to the 5th digit to read 783.21 and ICD-9 code 600 was updated to the 4th digit to read 600.0.
Note: Revision history #2 verbiage inadvertently left off. Verbiage added.

Revision #9, 11/28/2003
Under CMS National Coverage Policy section of this policy the manual citation has been changed to reflect the Internet Only Manual (IOM). This change becomes effective 11/28/2003.

Revision #8, 10/01/2003
ICD-9-CM codes 079.82, 255.13, 282.64, 282.68, 480.3, 600.00, 600.01, 600.10, 600.11, 600.20, 600.21, 600.90, 600.91, 601.0-601.9, 728.88, 785.52, 788.63, 788.7, 788.8, 788.9, 959.12, 959.13, 959.14, have been added to the list of ICD-9-CM Codes That Support Medical Necessity section of this policy. ICD-9-CM codes 277.8, 600.1, 600.2, 600.9, 959.1 have been deleted. ICD-9-CM code titles have been revised to read, 282.60, Sickle-cell disease, unspecified, 282.61, Hb-SS disease without crisis, 282.62, Hb-SS disease with crisis, 282.63, Sickle-cell/Hb-C disease without crisis. These changes will become effective 10/01/2003.

Revision #7, 07/04/2003
Under Indications and Limitations of Coverage and/or Medical Necessity section #8 has been changed to read, "The patient is scheduled for a surgical procedure and a urinalysis is being performed as part of the preoperative evaluation." Note under ICD-9-CM code has been changed to read, "This ICD-9-CM code (V72.83) may be used only when a medically necessary urinalysis is performed prior to a surgical procedure." These changes become effective 07/04/2003.

Revision #6 10/01/02
ICD-9-CM code was updated to the 5th digit 780.99. Under ICD-9-CM Codes That Support Medical Necessity section of this policy. Under Type of Bill Code section, Critical Access Hospital (85x) has been added to the policy. Verbiage change to CPT/HCPCS code 81007. These changes become effective 10/01/2002.

Revision #5 10/15/00
ICD-9-CM Codes 582.0, 582.9 were added to the policy.

Revsion #4 06/25/00
ICD-CM Codes 780.09, 780.9, 300.00, 300.09 were added to the policy.

Revision #3: 01/01/2000
ICD-9-CM codes 789.00, 789.9 were added to the policy

Revision #2: 08/15/1999
CPT codes updated to include 81000, 81001, 81002, and 81003.

Revision #1: 01/13/1999
ICD-9-CM code V72.83 was added to the policy.

This LCD was converted from an LMRP on 5/12/2004

Reason for Change ^{back to top}

ICD9 Addition/Deletion
Maintenance (annual review with new changes, formatting, etc.)

Last Reviewed On Date ^{back to top}

01/12/2009

Medicare Coverage Database

LCD for Urinalysis (L921)