About this policy
The following coding and billing guidance is to be used with its associated Local coverage determination. Documentation supporting medical necessity must be legible, maintained in the patient's record, and made available to the A/B MAC upon request. The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 83880 | HCPCS | Covered |
| I11.0 | ICD10CM | Covered |
| I13.0 | ICD10CM | Covered |
| I13.2 | ICD10CM | Covered |
| I16.0 | ICD10CM | Covered |
| I16.1 | ICD10CM | Covered |
| I20.0 | ICD10CM | Covered |
| I20.2 | ICD10CM | Covered |
| I21.01 | ICD10CM | Covered |
| I21.02 | ICD10CM | Covered |
| I21.09 | ICD10CM | Covered |
| I21.11 | ICD10CM | Covered |
| I21.19 | ICD10CM | Covered |
| I21.21 | ICD10CM | Covered |
| I21.29 | ICD10CM | Covered |