Local Coverage Determination (LCD)

Neurophysiology Evoked Potentials (NEPs)

L34975

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34975
Original ICD-9 LCD ID
Not Applicable
LCD Title
Neurophysiology Evoked Potentials (NEPs)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL34975
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/17/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
02/19/2016
Notice Period End Date
04/06/2016

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for neurophysiology evoked potentials. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for neurophysiology evoked potentials and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site.

IOM Citations:

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
  • CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 2, Section 160.10 Evoked Response Tests
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 Reasonable and Necessry Provision in an LCD

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
  • Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claims that lacks the necessary information to process the claim.

Federal Register References:

  • Title 42 Code of Federal Regulations (CFR) section 410.32(d)(3) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. Diagnostic laboratory tests; Claims review

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

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

  1. Somatosensory Evoked Potentials/Responses (SEPs/SERs),
  2. Brainstem Auditory Evoked Potentials/Responses (BAEPs/BAERs), and
  3. 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 have 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.

Covered Indications

Somatosensory Evoked Potentials and Responses (SEPs/SERs) are appropriate for the following indications:

  1. Spinal cord trauma
  2. Degenerative, non-traumatic spinal cord lesions (e.g., cervical spondylosis with myelopathy)
  3. Multiple sclerosis
  4. Spinocerebellar degeneration
  5. Myoclonus
  6. Coma
  7. Intraoperative monitoring
  8. Subacute combined degeneration
  9. Other diseases of myelin (e.g., adrenoleukodystrophy, adrenomyeloneuropathy, metachromatic leukodystrophy, and Pelizaeus-Merzbacher disease)
  10. Syringomyelia
  11. Hereditary spastic paraplegia

 Brainstem Auditory Evoked Potentials and Responses (BAEPs/BAERs) are appropriate:

  1. 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
  2. Preoperative baseline for:
    • Posterior fossa surgery
    • Cochlear implant
  3. Postoperative testing for:
    • Cochlear implant

Note: Please refer to LCD L35007, Vestibular and Audiologic Function Studies for additional information regarding BAEPs/BAERs.

Visual Evoked Potentials or Responses (VEPs/VERs) are appropriate for the following indications:

  1. Confirm diagnosis of multiple sclerosis when clinical criteria are inconclusive.
  2. Detect optic neuritis at an early, subclinical stage.
  3. 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)
  4. Monitor the visual system during optic nerve (or related) surgery (monitoring of short-latency evoked potential studies).

 Limitations

The following are considered not reasonable and necessary and therefore will be denied:

  1. 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.
  2. 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.

Place of Services (POS)

For additional information on services performed in an Independent Diagnostic Testing Facility (IDTF), please refer to Local Coverage Determination (LCD) L35448 Independent Diagnostic Testing Facility (IDTF).

Provider Qualifications

Testing shall be performed by physicians who have evidence of training, and expertise to perform and interpret these tests. Physicians must have knowledge, training, and expertise to perform and interpret these tests, and to assess and train personnel working with them. This Training and expertise must have been acquired within the framework of an accredited school, residency or fellowship program.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payments rules. Refer to Billing and Coding: Neurophysiology Evoked Potentials (NEPs), A56773, for applicable CPT/HCPCS codes and diagnosis codes.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A 

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information


Refer to the Local Coverage Article: Billing and Coding: Neurophysiology Evoked Potentials (NEPs), A56773, for all coding information.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The medical record documentation must support the medical necessity of the services as stated in this policy.
  4. The patient’s medical record must contain documentation that fully supports the medical necessity for NEPs as covered by Medicare (see Indications and Limitations of Coverage 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.
  5. For the BAEPs/BAERs, the patient’s medical record should document the otologic exam describing both ear canals and tympanic membranes, as well as a gross hearing assessment. The medical record should also include the results of air and bone pure tone audiogram and speech audiometry.
  6. The physician’s SEPs/SERs report should note which nerves were tested, latencies at various testing points, and an evaluation of whether the resulting values are normal or abnormal.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Sources of Information

Contractor is not responsible for the continued availability of websites listed.

Consultations with the representative to the Carrier Advisory Committee and other Medicare contractors.

Other Medicare Contractor's Local Coverage Determinations

Contractor Medical Directors

Bibliography
  1. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Somatosensory Evoked Potentials: Clinical Uses. Chapter 5. Muscle Nerve 22: Supplement 8: S111-S118, 1999. Accessed January 14, 2011 at AANEM website. www.aanem.org
  2. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Position Statement - Recommended Policy for Electrodiagnostic Medicine. Accessed January 14, 2011 at AANEM website. www.aanem.org
  3. American Clinical Neurophysiology Society website. Various Guidelines. February 2006. Acessed January 14, 2011 at ACN website. www.acns.org
  4. Bose B, et al. Neurophysiological detection of iatrogenic C-5 nerve deficit during anterior cervical spinal surgery. J Neurosurg Spine. 2007: 6:381-385.
  5. Devlin VJ, et al. Intraoperative Neurophysiologic Monitoring During Spinal Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2007; 15 (9): 549-560.
  6. Duckworth E, Modern Management of Brainstem Cavernous Malformations, Neurology Clinics. Neurology Clinics, 2010; 28: 887-898.
  7. Houlden DA, et al. Early somatosensory evoked potential grades in comatose traumatic brain injury patients predict cognitive and functional outcome. Crit Care Med. 2010; 38(1).
  8. Isley MR, et al. Current Trends in Pedicle Screw Stimulation Techniques: Lumbosacral, Thoracic, and Cervical Levels. Neurodiagn J. 2012; 52: 100-175.
  9. Krassioukov A, et al. Multimodality intraoperative monitoring during complex lumbosacral procedures: indications, techniques, and long-term follow-up review of 61 consecutive cases. J Neurosurg (spine 1). 2004; 3:243-253.
  10. Naismith RT, et al. Optical coherence tomography is less sensitive than visual evoked potentials in optic neuritis. Neurology 2009; 73: 46-52.
  11. Nuwer MR, et al. Evidence-based guideline update: Intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials. American Academy of Neurology. 2012; 78: 585-589.
  12. Sala F, et al. Cost effectiveness of multimodal intraoperative monitoring during spine surgery. Eur Spine J. 2007; 16 (suppl 2): S229-S231.
  13. Schwartz DM, et al. Neurophysiological Identification of Position-induced Neurologic Injury During Anterior Cervical Spine Surgery. Journal of Clinical Monitoring and Computing. 2006; 20: 437-444.
  14. Thurtell MJ, et al. Evaluation of optic neuropathy in multiple sclerosis using low-contrast visual evoked potentials. Neurology 2009; 73: 1849-1857.
  15. Uribe JS, et al. Brachial plexus injury following spinal surgery. J Neurosurg Spine. 2010: 13: 552-558.
  16. Uribe JS, et al. Electromyographic Monitoring and Its Anatomical Implications in Minimally Invasive Spine Surgery. SPINE. 2010; 35(26S): S368-S374.
  17. Xu R, et al. A role for motor and somatosensory evoked potentials during anterior cervical discectomy and fusion for patients without myelopathy: Analysis of 57 consecutive cases. Surgical Neurology International. 2011; 2:133.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/17/2019 R12

LCD revised and published on 10/17/2019. Consistent with CMS Change Request 10901, the entire coding section has been removed from the LCD and placed into the related Billing and Coding Article, A56773. All CPT codes and coding information within the text of the LCD has been placed in the Billing and Coding Article.

  • Other (CMS Change Request 10901)
08/08/2019 R11

LCD revised and published on 08/08/2019. Consistent with Change Request (CR) 10901 CMS IOM language has been removed from the LCD and replaced with appropriate reference. IOM citations have been updated. All CPT/HCPCS codes, ICD-10 codes and coding guidance have been removed from the LCD and placed in the related Billing and Coding Article, A56773. References have been moved to the Bibliography section and link to the related billing and coding article has been added as a related document. There has been no change in coverage with this LCD revision.

  • Other (Changes in response to CMS Change Request)
10/01/2018 R10

LCD revised and published on 10/25/2018 effective for dates of service on and after 10/01/2018 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code(s) have been deleted and therefore removed from the LCD: G51.3. The following ICD-10-CM code(s) have been added to the LCD Group 2 codes: G51.31, G51.32, and G51.33.

In addition, the following diagnoses have been added to the Group 2 codes to reflect “bilateral” coverage for diagnoses that were identified as having “right” and “left” included in coverage: G56.43, G57.03, G57.13, G57.23, G57.33, G57.43, G57.53, G57.63, G57.73, G57.83, I63.013, I63.033, I63.113, I63.133, I63.313, I63.323
I63.333, I63.343, I63.413, I63.423, I63.433, and I63.443.

Per LCD annual review, updated references in the “CMS National Coverage Policy” section, formatting changes were made and headers added throughout the LCD without a change in coverage content, expanded the following diagnosis code ranges in Group 2 that were previously listed in a ranged format (without a change in coverage content): M43.01-M43.09, M43.11-M43.19, M47.21-M47.28, M47.811-M47.813, M47.816-M47.818, M54.11-M54.18, M96.1-M96.5, M99.20-M99.24, M99.30-M99.34, M99.40-M99.44, M99.50-M99.54, M99.60-M99.64, M99.70-M99.74, and added hyperlink to related NCD 160.10 in the section for related national coverage documents.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; therefore, not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
  • Other (LCD Annual Review)
01/01/2018 R9

LCD revised and published on 01/25/2018 effective for dates of service on and after 01/01/2018 to reflect the annual CPT/HCPCS code updates. For the following CPT/HCPCS code(s) either the short description and/or the long description has been changed.  Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: 95930.

Per annual review of this LCD, updated the IOM references in the “CMS National Coverage Policy” section, added POS header with reference to LCD L35448 Independent Diagnostic Testing Facility (IDTF), reformatted the CPT Group 1 Codes into 3 separate CPT groups to align with their respective ICD-10 code groups, and added hyperlinks in the “Related Local Coverage Documents” section to LCD L35007 Vestibular and Audiologic Function Studies and LCD L35448 IDTF.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; therefore, not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To CPT/HCPCS Code Changes
  • Other (Clarification)
10/01/2017 R8

LCD revised and published on 10/05/2017 effective for dates of service on and after 10/01/2017 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM codes have been deleted and therefore removed from the LCD: Group 2 Code Deletions: M48.06, S06.317D, S06.317S, S06.318D, S06.318S, S06.327D, S06.327S, S06.328D, S06.328S, S06.347D, S06.347S, S06.348D, S06.348S, S06.357D, S06.357S, S06.358D, S06.358S, S06.377D, S06.377S, S06.378D, S06.378S, S06.387D, S06.387S, S06.388D, S06.388S, S06.4X7D, S06.4X7S, S06.4X8D, S06.4X8S, S06.5X7D, S06.5X7S, S06.5X8D, S06.5X8S, S06.6X7D, S06.6X7S, S06.6X8D, and S06.6X8S. Group 3 Code Deletions: S06.317D, S06.317S, S06.318D, S06.318S, S06.327D, S06.327S, S06.328D, S06.328S, S06.347D, S06.347S, S06.348D, S06.348S, S06.357D, S06.357S, S06.358D, S06.358S, S06.377D, S06.377S, S06.378D, S06.378S, S06.387D, S06.387S, S06.388D, S06.388S, S06.4X7D, S06.4X7S, S06.4X8D, S06.4X8S, S06.5X7D, S06.5X7S, S06.5X8D, S06.5X8S, S06.6X7D, S06.6X7S, S06.6X8D, and S06.6X8S. The following ICD-10-CM code has been added to the LCD: Group 2 Code Addition: M48.062. The following ICD-10-CM codes have undergone a descriptor change: Group 2 Code Descriptor Revisions: S04.031A, S04.031D, S04.031S, S04.032A, S04032D, S04.032S, S04.041A, S04.041D, S04.041S, S04.042A, S04.042D, and S04.042S. Group 3 Code Descriptor Revisions: S04.031A, S04.031D, S04.031S, S04.032A, S04032D, S04.032S, S04.041A, S04.041D, S04.041S, S04.042A, S04.042D, and S04.042S.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; therefore, not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R7 LCD revised and published on 09/29/2016 effective for dates of service on and after 10/01/2016 to reflect the ICD-10 Annual Code Updates. The following ICD-10 code(s) have been deleted and therefore removed from the LCD: Group 2 codes I60.21, I60.22, M50.02, M50.12, M50.22, M50.32, S06.0X6A, S06.0X6D, S06.0X6S, S06.0X7A, S06.0X7D, S06.0X7S, S06.0X8A, S06.0X8D, and S06.0X8S; Group 3 codes S06.0X6A, S06.0X6D, S06.0X6S, S06.0X7A, S06.0X7D, S06.0X7S, S06.0X8A, S06.0X8D, and S06.0X8S. The following ICD-10 code(s) have been added to the LCD: Group 1 codes H90.A11, H90.A12, H90.A21, H90.A22, H90.A31, and H90.A32; Group 2 codes I60.2, M50.021, M50.022, M50.023, M50.121, M50.122, M50.123, M50.221, M50.222, M50.223, M50.321, M50.322, and M50.323.
  • Revisions Due To ICD-10-CM Code Changes
04/07/2016 R6 LCD revised and published on 04/21/2016 for dates of service on and after 04/07/2016 to remove Limitation #4 pertaining to VEP study requirements from this LCD. The following changes were made to Limitation #3: removed MDs and Dos and added accredited “school”.
  • Other (Inquiry)
04/07/2016 R5 Spelling correction within the sources, added the following ICD-10 codes as covered diagnoses to the Group 1 codes: H81.09; H81.49; H83.3x9; and H94.00.
  • Typographical Error
04/07/2016 R4 LCD posted for notice on 02/19/2016 to become effective 04/07/2016.

09/17/2015 Draft LCD posted for comment.
  • Creation of Uniform LCDs With Other MAC Jurisdiction
10/01/2015 R3 LCD revised and published on 02/11/2016 for dates of service on and after 10/01/2015 to add several ICD-10 codes to the Group codes 1 and 2 as covered diagnoses. The following diagnosis codes were added to Group 1 codes: C71.6; D33.1; D43.1; G37.9; H90.0; H90.11; H90.12; H90.2; H91.01; H91.02; H91.03; H91.09; H91.10; H91.11; H91.12; H91.13; H91.3; H91.8X1; H91.8X2; H91.8X3; H91.8X9; H91.90; H91.91; H91.92; H91.93; H93.011; H93.012; H93.013; H93.019; H93.091; H93.092; H93.093; H93.099; H93.211; H93.212; H93.213; H93.219; H93.221; H93.222; H93.223; H93.229; H93.231; H93.232; H93.233; H93.239;H93.241; H93.242; H93.243; H93.249; H93.25; H93.291; H93.292; H93.293; H93.299; Z01.12; Z01.818; Z45.321.
The following diagnosis codes were added to Group 2 codes:G83.4; M43.01; M43.02; M43.03; M43.04; M43.05; M43.06; M43.07; M43.08; M43.09; M43.11; M43.12; M43.13; M43.14; M43.15; M43.16; M43.17; M43.18; M43.19; M47.21; M47.22; M47.23; M47.26; M47.27; M47.28; M47.811; M47.812; M47.813; M47.816; M47.817; M47.818; M47.891; M47.892; M47.893; M47.896; M47.897; M47.898; M48.01; M48.02; M48.03; M48.06; M48.07; M50.11; M50.12; M50.21; M50.22; M50.23; M50.31; M50.32; M50.33; M51.24; M51.25; M51.26; M51.27; M51.36; M51.37; M54.11; M54.12; M54.13; M54.14; M54.15; M54.16; M54.17; M96.1; M99.20; M99.21; M99.23; M99.30; M99.31; M99.33; M99.40; M99.41; M99.43; M99.50; M99.51; M99.53; M99.60; M99.61; M99.63; M99.70; M99.71; M99.73.
  • Other (Clarification)
10/01/2015 R2 LCD updated to correct typographical errors. No other content was revised.
  • Typographical Error
10/01/2015 R1 LCD revised and published on 08/14/2014 to reflect changes to the annual ICD-10-CM updates. ICD-10-CM codes M47.17, M47.18, and M51.07 were removed from the policy. ICD-10-CM code M50.01 has undergone a descriptor change which has been reflected in the policy.
  • Revisions Due To ICD-10-CM Code Changes
N/A

Associated Documents

Attachments
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Related National Coverage Documents
NCDs
160.10 - Evoked Response Tests
Public Versions
Updated On Effective Dates Status
10/11/2019 10/17/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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