About this policy
The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD. Documentation Requirements The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See “Coverage Indications, Limitations, and/or Medical Necessity") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to the MAC upon request.
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 |
|---|---|---|
| 0509T | HCPCS | Covered |
| 92273 | HCPCS | Covered |
| 92274 | HCPCS | Covered |
| 95930 | HCPCS | Covered |
| A18.53 | ICD10CM | Covered |
| B50.0 | ICD10CM | Covered |
| B50.8 | ICD10CM | Covered |
| B50.9 | ICD10CM | Covered |
| D18.09 | ICD10CM | Covered |
| E08.311 | ICD10CM | Covered |
| E08.319 | ICD10CM | Covered |
| E08.3211 | ICD10CM | Covered |
| E08.3212 | ICD10CM | Covered |
| E08.3213 |