L33688 Page 1of 28 Contractor Information |LCD Information | Coding Information |General Information Contractor Information Contractor Name First Coast Service Options, Inc. Contractor Number 09102 Contractor Type MAC -Part B LCD Information [back to top] LCD ID Number L33688 LCD Title Psychological and Neuropsychological Tests Contractor's Determination Number AMA CPT / ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2012 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 Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869 (f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.2 – Psychological Tests and Neuropsychological Tests, and Sections 160-170 –Clinical Psychologists and Clinical Social Worker (CSW) Services CMS Manual System, Pub. 100-08, Medicare Program Integrity, Chapter 3, Section 3.3.2.6 – Psychotherapy Notes CMS Medicare Learning Network, March 2012, Mental Health Services (accessible at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/Mental_Health_Services_ICN903195.pdf) National Correct Coding Initiative Policy Manual for Medicare Services NCCI), Chap 11, section M –Central http://medicare.fcso.com/Fee_lookup/LCDDisplay.asp?id=L33688&submitcode=+Submit+ 8/30/2013 L33688 Page 2of 28 Nervous System Assessments/Tests Primary Geographic Jurisdiction Florida Oversight Region Region IV Original Determination Effective Date 10/14/2013 Original Determination Ending Date Revision Effective Date 10/14/2013 Revision Ending Date Indications and Limitations of Coverage and/or Medical Necessity Neuropsychological tests provide measurements of brain function that are objective, valid, and reliable. Neuropsychological tests are quantifiable in nature and require patients to directly demonstrate their level of cognitive competence in a particular cognitive domain. Neuropsychological tests are administered in the context of a comprehensive assessment that synthesizes data from clinical interview, record review, medical history, and behavioral observations. Information from neuropsychological assessments directly impacts medical management of patients by providing information about diagnosis, prognosis, and treatment of disorders that are known to impact central nervous system (CNS) functioning. In addition, neuropsychological assessments predict functional abilities across a variety of disorders. Indications for neuropsychological assessments include a history of medical or neurological disorder compromising cognitive or behavioral functioning; congenital, genetic, or metabolic disorders known to be associated with impairments in cognitive or brain development; reported impairments in cognitive functioning; and evaluations of cognitive function as a part of the standard of care for treatment selection and treatment outcome evaluations (e.g., deep brain stimulators, epilepsy surgery). Neuropsychological assessments are not limited in relevance to patients with evidence of structural brain damage, and are frequently necessary to document impairments in patients with probable neuropsychological and neurobehavioral disorders, and are the tool of choice whenever objective documentation of subjective cognitive complaints and symptom validity testing are indicated. In children and adolescents, a significant inability to develop expected knowledge, skills or abilities as required to adapt to new or changing cognitive, social, emotional, or physical demands warrants a neuropsychological evaluation. Neuropsychological testing is not supported or excluded from medical necessity based on diagnosis alone. Rather, indications for testing are based on whether there is known or suspected neurocognitive involvement or effects, or where neuropsychological testing will impact the management of the patient by confirmation or delineation of diagnosis, or otherwise providing substantive information regarding diagnosis, treatment planning, prognosis, or quality of life. Neuropsychological testing is useful in persons with documented changes in cognitive function to differentiate neurologic diseases (i.e., one of the types of dementia) or injuries (e.g., traumatic brain injury, stroke) from depressive disorders or other psychiatric conditions (e.g., psychosis, schizophrenia) when the diagnosis is uncertain after complete neurological examination, mental status examination, and other neurodiagnostic studies (e.g., CT scanning, MR imaging). The clinician presented with complaints of memory impairment or slowness in thinking in a patient who is depressed or paranoid may be unsure of the possible contribution of neurological changes to the clinical picture. Neuropsychological testing may be particularly helpful when the findings of the neurological examination and ancillary procedures are either negative or equivocal. The differential diagnosis of incipient dementia from depression is a case in point, particularly when computed tomography (CT) fails to yield definitive results. Neuropsychological testing may be indicated in persons with epilepsy. Neuropsychological testing is used in these patients to monitor the efficacy and possible cognitive side effects of drug therapy (e.g., new anti- http://medicare.fcso.com/Fee_lookup/LCDDisplay.asp?id=L33688&submitcode=+Submit+ 8/30/2013 L33688 Page 3of 28 convulsant drug therapy) by comparing baseline performance with subsequent testing performance. Neuropsychological testing is also used to assess post-surgical changes in cognitive functioning to guide further treatment services. Preferably, these tests should be administered by a psychiatrist or certified psychologist trained to conceptualize the neuro-anatomical and the neuro-behavioral implications of the diagnostic entities under consideration and who is capable of interpreting patterns of test scores in view of principles of lateralization and localization of cerebral function. Codes 96105, 96111, 96116, 96118, 96119, 96120, 96125, and G0451 are defined by their CPT/HCPCS descriptors. Code 96105 represents the formal evaluation of aphasia using a psychometric instrument such as the Boston Diagnostic Aphasia Examination. This testing is typically performed once during treatment, and the medical necessity for such testing should be documented. Repeat testing should only be done if there is a significant change in the patient’s aphasic condition. Codes 96118, 96119, 96120, 96125 describe testing which is intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. Neuropsychological testing is considered medically necessary for the following indications: (cid:122) When there are deficits on standard mental status testing or clinical interview, and a neuropsychological assessment is needed to establish the presence of abnormalities or distinguish them from other disease processes; or (cid:122) When neuropsychological data could provide clarification of clinical, laboratory, and neuroimaging data to assist in establishing a clinical diagnosis in neurological or systemic conditions known to affect CNS functioning; or (cid:122) When there is a need to quantify cognitive or behavioral deficits related to CNS impairment, and the information will be useful in determining a prognosis or treatment planning by determining the rate of disease progression; or (cid:122) When there is a need for a pre-surgical or treatment-related cognitive evaluation to inform whether one might safely proceed with a medical or surgical procedure that may affect brain function (e.g., deep brain stimulation, resection of brain tumors or arteriovenous malformations, epilepsy surgery) or significantly alter a patient’s functional status; or (cid:122) When there is a need to assess the potential impact of adverse effects of therapeutic substances that may cause cognitive impairment (e.g., radiation, chemotherapy, antiepileptic medications), and this information is utilized in treatment planning; or (cid:122) When there is a need to assess progression, recovery, and response to changing treatments, in patients with CNS disorders, in order to determine the most effective plan of care; or (cid:122) When there is a need for objective measurement of patients' subjective complaints about memory, attention, or other cognitive dysfunction, which directly impacts medical management by differentiating psychogenic from neurogenic syndromes (e.g., dementia vs. depression), and in some cases will result in initial detection of neurological disorders or systemic diseases affecting the brain; or (cid:122) When there is a need for treatment planning purposes of determining functional abilities/impairments in individuals with known or suspected CNS disorders (e.g., capacity for independent living or movement from a family home into an institutional setting); or (cid:122) When there is a need to determine whether a patient can comprehend and participate effectively in complex treatment regimens and to determine functional capacity for health care decision-making, independent living, etc.; or (cid:122) When there is a need to design, administer, and/or assess outcomes of cognitive rehabilitation procedures, often in collaboration with other specialists such as speech pathologists, occupational therapists, physiatrists, and rehabilitation psychologists; or (cid:122) When there is a need for treatment planning of identification and assessment of neurocognitive sequelae of disease ; or (cid:122) Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies for certain individuals with neuropsychiatric disorders; or (cid:122) When there is a need to diagnose cognitive or functional deficits in children and adolescents based on an inability to develop expected knowledge, skills or abilities as required to adapt to new or changing cognitive, social, emotional, or physical demands. http://medicare.fcso.com/Fee_lookup/LCDDisplay.asp?id=L33688&submitcode=+Submit+ 8/30/2013 L33688 Page 4of 28 The content of neuropsychological testing procedures (96118, 96119, 96120, 96125) differs from that of psychological testing (96101-96111and G0451) in that neuropsychological testing consists primarily of individually administered ability tests that comprehensively sample cognitive and performance domains that are known to be sensitive to the functional integrity of the brain (e.g., abstraction, memory and learning, attention, language, problem solving, sensorimotor functions, constructional praxis, etc.). Neuropsychological testing does not rely on self-report questionnaires such as the Minnesota Multiphasic Personality Inventory 2 (MMPI-2), rating scales such as the Hamilton Depression Rating Scale, or projective techniques such as the Rorschach or Thematic Apperception Test (TAT). In circumstances when additional time is necessary to integrate other sources of clinical data including previously completed and reported technician-and/or computer-administered tests, the neuropsychological testing may include time spent integrating self-report questionnaires. Psychological testing codes (96101, 96102, and 96103) include the administration, interpretation, and scoring of the tests mentioned in the CPT descriptors and other medically accepted tests for the evaluation of intellectual strengths, psychopathology, psychodynamics, mental health risks, insight, motivation, and other factors influencing treatment and prognosis. Psychological tests are used to address a variety of questions about people’s functioning, diagnostic classification, co-morbidity, and choice of treatment approach. For example, personality tests and inventories evaluate the thoughts, emotions, attitudes, and behavioral traits that contribute to an individual’s interpersonal functioning. The results of these tests determine an individual's personality strengths and weaknesses and may identify certain disturbances in personality or psychopathology. One type of personality test is the projective personality assessment, which asks a subject to interpret some ambiguous stimuli, such as a series of inkblots. The subject's responses can provide insight into his or her thought processes and personality traits. Examples of problems that might require psychological testing include: Assessment of mental functioning for individuals with suspected or known mental disorders for purposes of differential diagnosis and/or treatment planning. Assessment of patient strengths and disabilities for use in treatment planning or management when signs or symptoms of a mental disorder are present. Assessment of patient capacity for decision-making when impairment is suspected that would affect patient care or management. Assessment of mental function in certain chronic pain patients when indicated after psychological screening prior to surgical pain management intervention (e.g., implantable neurostimulator). Assessment of mental function in a chronic pain patient with suspected somatization disorder. Changes in mental illness may require psychological testing to determine new diagnoses or the need for changes in therapeutic measures. Repeat testing not required for diagnosis or continued treatment would be considered medically unnecessary. Nonspecific behaviors that do not indicate the presence of, or change in, a mental illness would not be an acceptable indication for testing. Psychological or psychiatric evaluations that can be accomplished through the clinical interview alone (e.g., response to medication) would not require psychological testing, and such testing might be considered as medically unnecessary. Adjustment reactions or dysphoria associated with moving to a nursing facility do not constitute medical necessity for psychological testing. When a psychiatric condition or the presence of dementia has already been diagnosed, there is value to the testing only if the information derived from the testing would be expected to have significant impact on the understanding and treatment of the patient. Examples include a significant change in the patient’s condition, the need to evaluate a patient’s capacity to function in a given situation or environment, and/or the need to specifically tailor therapeutic and/or compensatory techniques to particular aspects of the patient’s pattern of strengths and disabilities. Limitations Psychological and Neuropsychological testing is not considered reasonable and necessary when: (cid:122) the patient is not neurologically and cognitively able to participate in a meaningful way in the testing http://medicare.fcso.com/Fee_lookup/LCDDisplay.asp?id=L33688&submitcode=+Submit+ 8/30/2013 L33688 Page 5of 28 process; (cid:122) administered for educational or vocational purposes that do not establish medical management; (cid:122) performed when abnormalities of brain or emotional function are not suspected; (cid:122) used for self-administered or self-scored inventories or screening tests of cognitive function (paper-and- pencil or computerized), e.g., AIMS, Folstein Mini-Mental Status Examination; (cid:122) Repeated when not required for medical decision-making. Examples of medical decision making include: whether to start or continue a particular rehabilitative or pharmacologic therapy); (cid:122) Administered when the patient has a substance abuse background, and any of the following apply: the patient has ongoing substance abuse such that test results would be inaccurate, or the patient is currently intoxicated; (cid:122) The patient has been diagnosed previously with brain dysfunction, e.g., Alzheimer’s disease, and there is no expectation that the testing would impact the patient's medical management; (cid:122) The test is being given solely as a screening test for Alzheimer's disease. Medicare does not cover this screening for this diagnosis. Testing conducted when no mental illness/disability is suspected would be considered screening and would not be covered by Medicare. Non-specific behaviors that do not suggest the possibility of mental illness or disability are not an acceptable indication for testing. Evaluations of the mental status that can be performed within the psychiatric diagnostic evaluation (e.g., codes 90791, 90792), (e.g., a list of questions concerning symptoms of depression or organic brain syndrome, corresponding to brief questionnaires or screening measures such as the Folstein Mini Mental Status Examination or the Beck Depression Scale, or use of other mental status exams in isolation ) should not be classified separately as psychological or neuropsychological testing (codes 96101-96125, G0451) since they are typically part of a more general psychiatric/psychological clinical exam or interview. Psychological/neuropsychological testing to evaluate adjustment reactions or dysphoria associated with placement in a nursing home does not constitute medical necessity for testing. Testing of every patient upon entry to a nursing home would be considered a routine service and would not be covered by Medicare. However, some individuals enter a nursing home at a time of physical and cognitive decline and may require psychological/neuropsychological testing to arrive at a diagnosis and plan of care. Decisions to test individuals who have recently entered a nursing home need to be made judiciously, on a case-by-case basis. Each psychological/neuropsychological test administered must be individually medically necessary. A standard battery of tests is only medically necessary if each individual test in the battery is medically necessary. The psychological/neuropsychological testing codes should not be reported by the treating physician for only reading the testing report or explaining the results to the patient or family. Payment for these services is included in the payment for other services rendered to the patient, such as evaluation and management services. Psychological and neuropsychological testing codes should be reported by the performing provider (i.e., clinical psychologist, neuropsychologist, or physician) who administered the test. Coding Information [back to top] Bill Type Codes 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 (Medicare Part B only) 13x Hospital Outpatient 22x Skilled Nursing -Inpatient (Medicare Part B only) http://medicare.fcso.com/Fee_lookup/LCDDisplay.asp?id=L33688&submitcode=+Submit+ 8/30/2013 L33688 Page 6of 28 23x Skilled Nursing -Outpatient 71x Clinic -Rural Health 75x Clinic -Comprehensive Outpatient Rehabilitation Facility (CORF) 76x Clinic -Community Mental Health Center 77x Clinic -Federally Qualified Health Center (FQHC) 85x Critical Access Hospital Revenue Codes 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. 0918 Behavioral Health Treatment/Services -Testing CPT/HCPCS Codes PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF EMOTIONALITY, INTELLECTUAL ABILITIES, PERSONALITY AND PSYCHOPATHOLOGY, EG, MMPI, RORSCHACH, 96101 WAIS), PER HOUR OF THE PSYCHOLOGIST’S OR PHYSICIAN’S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF EMOTIONALITY, INTELLECTUAL ABILITIES, PERSONALITY AND PSYCHOPATHOLOGY, EG, MMPI AND WAIS), WITH 96102 QUALIFIED HEALTH CARE PROFESSIONAL INTERPRETATION AND REPORT, ADMINISTERED BY TECHNICIAN, PER HOUR OF TECHNICIAN TIME, FACE-TO-FACE PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF EMOTIONALITY, INTELLECTUAL ABILITIES, PERSONALITY AND PSYCHOPATHOLOGY, EG, MMPI), ADMINISTERED 96103 BY A COMPUTER, WITH QUALIFIED HEALTH CARE PROFESSIONAL INTERPRETATION AND REPORT ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, 96105 READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR DEVELOPMENTAL TESTING, (INCLUDES ASSESSMENT OF MOTOR, LANGUAGE, SOCIAL, 96111 ADAPTIVE, AND/OR COGNITIVE FUNCTIONING BY STANDARDIZED DEVELOPMENTAL INSTRUMENTS) WITH INTERPRETATION AND REPORT NEUROBEHAVIORAL STATUS EXAM (CLINICAL ASSESSMENT OF THINKING, REASONING AND JUDGMENT, EG, ACQUIRED KNOWLEDGE, ATTENTION, LANGUAGE, MEMORY, PLANNING AND 96116 PROBLEM SOLVING, AND VISUAL SPATIAL ABILITIES), PER HOUR OF THE PSYCHOLOGIST’S OR PHYSICIAN’S TIME, BOTH FACE-TO-FACE TIME WITH THE PATIENT AND TIME INTERPRETING TEST RESULTS AND PREPARING THE REPORT NEUROPSYCHOLOGICAL TESTING (EG, HALSTEAD-REITAN NEUROPSYCHOLOGICAL BATTERY, WECHSLER MEMORY SCALES AND WISCONSIN CARD SORTING TEST), PER HOUR OF THE 96118 PSYCHOLOGIST’S OR PHYSICIAN’S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT NEUROPSYCHOLOGICAL TESTING (EG, HALSTEAD-REITAN NEUROPSYCHOLOGICAL BATTERY, WECHSLER MEMORY SCALES AND WISCONSIN CARD SORTING TEST), WITH QUALIFIED HEALTH 96119 CARE PROFESSIONAL INTERPRETATION AND REPORT, ADMINISTERED BY TECHNICIAN, PER HOUR OF TECHNICIAN TIME, FACE-TO-FACE NEUROPSYCHOLOGICAL TESTING (EG, WISCONSIN CARD SORTING TEST), ADMINISTERED BY A 96120 COMPUTER, WITH QUALIFIED HEALTH CARE PROFESSIONAL INTERPRETATION AND REPORT STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL’S TIME, BOTH FACE- 96125 TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT DEVELOPMENT TESTING, WITH INTERPRETATION AND REPORT, PER STANDARDIZED G0451 INSTRUMENT FORM http://medicare.fcso.com/Fee_lookup/LCDDisplay.asp?id=L33688&submitcode=+Submit+ 8/30/2013 L33688 Page 7of 28 ICD-9 Codes that Support Medical Necessity For CPT/HCPCS codes 96101, 96102, 96103, 96118, 96119, 96120, 96125, and G0451 only: 290.0 SENILE DEMENTIA UNCOMPLICATED 290.10 PRESENILE DEMENTIA UNCOMPLICATED 290.11 PRESENILE DEMENTIA WITH DELIRIUM 290.12 PRESENILE DEMENTIA WITH DELUSIONAL FEATURES 290.13 PRESENILE DEMENTIA WITH DEPRESSIVE FEATURES 290.20 SENILE DEMENTIA WITH DELUSIONAL FEATURES 290.21 SENILE DEMENTIA WITH DEPRESSIVE FEATURES 290.3 SENILE DEMENTIA WITH DELIRIUM 290.40 VASCULAR DEMENTIA, UNCOMPLICATED 290.41 VASCULAR DEMENTIA, WITH DELIRIUM 290.42 VASCULAR DEMENTIA, WITH DELUSIONS 290.43 VASCULAR DEMENTIA, WITH DEPRESSED MOOD 290.8 OTHER SPECIFIED SENILE PSYCHOTIC CONDITIONS 290.9 UNSPECIFIED SENILE PSYCHOTIC CONDITION 291.0 ALCOHOL WITHDRAWAL DELIRIUM 291.1 ALCOHOL-INDUCED PERSISTING AMNESTIC DISORDER 291.2 ALCOHOL-INDUCED PERSISTING DEMENTIA 291.3 ALCOHOL-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS 291.4 IDIOSYNCRATIC ALCOHOL INTOXICATION 291.5 ALCOHOL-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS 291.81 ALCOHOL WITHDRAWAL 291.82 ALCOHOL INDUCED SLEEP DISORDERS 291.89 OTHER SPECIFIED ALCOHOL-INDUCED MENTAL DISORDERS 291.9 UNSPECIFIED ALCOHOL-INDUCED MENTAL DISORDERS 292.0 DRUG WITHDRAWAL 292.11 DRUG-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS 292.12 DRUG-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS 292.2 PATHOLOGICAL DRUG INTOXICATION 292.81 DRUG-INDUCED DELIRIUM 292.82 DRUG-INDUCED PERSISTING DEMENTIA 292.83 DRUG-INDUCED PERSISTING AMNESTIC DISORDER 292.84 DRUG-INDUCED MOOD DISORDER 292.85 DRUG INDUCED SLEEP DISORDERS 292.89 OTHER SPECIFIED DRUG-INDUCED MENTAL DISORDERS 292.9 UNSPECIFIED DRUG-INDUCED MENTAL DISORDER 293.0 DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE 293.1 SUBACUTE DELIRIUM 293.81 PSYCHOTIC DISORDER WITH DELUSIONS IN CONDITIONS CLASSIFIED ELSEWHERE 293.82 PSYCHOTIC DISORDER WITH HALLUCINATIONS IN CONDITIONS CLASSIFIED ELSEWHERE 293.83 MOOD DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE http://medicare.fcso.com/Fee_lookup/LCDDisplay.asp?id=L33688&submitcode=+Submit+ 8/30/2013 L33688 Page 8of 28 293.84 ANXIETY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE OTHER SPECIFIED TRANSIENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED 293.89 ELSEWHERE, OTHER 293.9 UNSPECIFIED TRANSIENT MENTAL DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE 294.0 AMNESTIC DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE 294.10 DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE 294.11 DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE 294.20 DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE 294.21 DEMENTIA, UNSPECIFIED, WITH BEHAVIORAL DISTURBANCE 294.8 OTHER PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE 294.9 UNSPECIFIED PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE 295.00 SIMPLE TYPE SCHIZOPHRENIA UNSPECIFIED STATE 295.01 SIMPLE TYPE SCHIZOPHRENIA SUBCHRONIC STATE 295.02 SIMPLE TYPE SCHIZOPHRENIA CHRONIC STATE 295.03 SIMPLE TYPE SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE EXACERBATION 295.04 SIMPLE TYPE SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION 295.05 SIMPLE TYPE SCHIZOPHRENIA IN REMISSION 295.10 DISORGANIZED TYPE SCHIZOPHRENIA UNSPECIFIED STATE 295.11 DISORGANIZED TYPE SCHIZOPHRENIA SUBCHRONIC STATE 295.12 DISORGANIZED TYPE SCHIZOPHRENIA CHRONIC STATE 295.13 DISORGANIZED TYPE SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE EXACERBATION 295.14 DISORGANIZED TYPE SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION 295.15 DISORGANIZED TYPE SCHIZOPHRENIA IN REMISSION 295.20 CATATONIC TYPE SCHIZOPHRENIA UNSPECIFIED STATE 295.21 CATATONIC TYPE SCHIZOPHRENIA SUBCHRONIC STATE 295.22 CATATONIC TYPE SCHIZOPHRENIA CHRONIC STATE 295.23 CATATONIC TYPE SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE EXACERBATION 295.24 CATATONIC TYPE SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION 295.25 CATATONIC TYPE SCHIZOPHRENIA IN REMISSION 295.30 PARANOID TYPE SCHIZOPHRENIA UNSPECIFIED STATE 295.31 PARANOID TYPE SCHIZOPHRENIA SUBCHRONIC STATE 295.32 PARANOID TYPE SCHIZOPHRENIA CHRONIC STATE 295.33 PARANOID TYPE SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE EXACERBATION 295.34 PARANOID TYPE SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION 295.35 PARANOID TYPE SCHIZOPHRENIA IN REMISSION 295.40 SCHIZOPHRENIFORM DISORDER, UNSPECIFIED 295.41 SCHIZOPHRENIFORM DISORDER, SUBCHRONIC 295.42 SCHIZOPHRENIFORM DISORDER, CHRONIC 295.43 SCHIZOPHRENIFORM DISORDER, SUBCHRONIC WITH ACUTE EXACERBATION 295.44 SCHIZOPHRENIFORM DISORDER, CHRONIC WITH ACUTE EXACERBATION 295.45 SCHIZOPHRENIFORM DISORDER, IN REMISSION 295.50 LATENT SCHIZOPHRENIA UNSPECIFIED STATE 295.51 LATENT SCHIZOPHRENIA SUBCHRONIC STATE 295.52 LATENT SCHIZOPHRENIA CHRONIC STATE http://medicare.fcso.com/Fee_lookup/LCDDisplay.asp?id=L33688&submitcode=+Submit+ 8/30/2013 L33688 Page 9of 28 295.53 LATENT SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE EXACERBATION 295.54 LATENT SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION 295.55 LATENT SCHIZOPHRENIA IN REMISSION 295.60 SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, UNSPECIFIED 295.61 SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, SUBCHRONIC 295.62 SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, CHRONIC 295.63 SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, SUBCHRONIC WITH ACUTE EXACERBATION 295.64 SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, CHRONIC WITH ACUTE EXACERBATION 295.65 SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, IN REMISSION 295.70 SCHIZOAFFECTIVE DISORDER, UNSPECIFIED 295.71 SCHIZOAFFECTIVE DISORDER, SUBCHRONIC 295.72 SCHIZOAFFECTIVE DISORDER, CHRONIC 295.73 SCHIZOAFFECTIVE DISORDER, SUBCHRONIC WITH ACUTE EXACERBATION 295.74 SCHIZOAFFECTIVE DISORDER, CHRONIC WITH ACUTE EXACERBATION 295.75 SCHIZOAFFECTIVE DISORDER, IN REMISSION 295.80 OTHER SPECIFIED TYPES OF SCHIZOPHRENIA UNSPECIFIED STATE 295.81 OTHER SPECIFIED TYPES OF SCHIZOPHRENIA SUBCHRONIC STATE 295.82 OTHER SPECIFIED TYPES OF SCHIZOPHRENIA CHRONIC STATE OTHER SPECIFIED TYPES OF SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE 295.83 EXACERBATION 295.84 OTHER SPECIFIED TYPES OF SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION 295.85 OTHER SPECIFIED TYPES OF SCHIZOPHRENIA IN REMISSION 295.90 UNSPECIFIED TYPE SCHIZOPHRENIA UNSPECIFIED STATE 295.91 UNSPECIFIED TYPE SCHIZOPHRENIA SUBCHRONIC STATE 295.92 UNSPECIFIED TYPE SCHIZOPHRENIA CHRONIC STATE 295.93 UNSPECIFIED TYPE SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE EXACERBATION 295.94 UNSPECIFIED TYPE SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION 295.95 UNSPECIFIED TYPE SCHIZOPHRENIA IN REMISSION 296.00 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, UNSPECIFIED 296.01 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MILD 296.02 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MODERATE BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, WITHOUT MENTION OF PSYCHOTIC 296.03 BEHAVIOR BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, SPECIFIED AS WITH PSYCHOTIC 296.04 BEHAVIOR 296.05 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN PARTIAL OR UNSPECIFIED REMISSION 296.06 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN FULL REMISSION 296.10 MANIC AFFECTIVE DISORDER RECURRENT EPISODE UNSPECIFIED DEGREE 296.11 MANIC AFFECTIVE DISORDER RECURRENT EPISODE MILD DEGREE 296.12 MANIC AFFECTIVE DISORDER RECURRENT EPISODE MODERATE DEGREE MANIC AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE WITHOUT PSYCHOTIC 296.13 BEHAVIOR MANIC AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE SPECIFIED AS WITH 296.14 PSYCHOTIC BEHAVIOR 296.15 MANIC AFFECTIVE DISORDER RECURRENT EPISODE IN PARTIAL OR UNSPECIFIED REMISSION 296.16 MANIC AFFECTIVE DISORDER RECURRENT EPISODE IN FULL REMISSION http://medicare.fcso.com/Fee_lookup/LCDDisplay.asp?id=L33688&submitcode=+Submit+ 8/30/2013 L33688 Page 10of 28 296.20 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE UNSPECIFIED DEGREE 296.21 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE MILD DEGREE 296.22 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE MODERATE DEGREE MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE SEVERE DEGREE WITHOUT 296.23 PSYCHOTIC BEHAVIOR MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE SEVERE DEGREE SPECIFIED AS 296.24 WITH PSYCHOTIC BEHAVIOR MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE IN PARTIAL OR UNSPECIFIED 296.25 REMISSION 296.26 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE IN FULL REMISSION 296.30 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE UNSPECIFIED DEGREE 296.31 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE MILD DEGREE 296.32 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE MODERATE DEGREE MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE WITHOUT 296.33 PSYCHOTIC BEHAVIOR MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE SPECIFIED 296.34 AS WITH PSYCHOTIC BEHAVIOR MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN PARTIAL OR UNSPECIFIED 296.35 REMISSION 296.36 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN FULL REMISSION 296.40 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, UNSPECIFIED 296.41 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, MILD 296.42 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, MODERATE BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, SEVERE, WITHOUT 296.43 MENTION OF PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, SEVERE, SPECIFIED AS 296.44 WITH PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, IN PARTIAL OR 296.45 UNSPECIFIED REMISSION 296.46 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, IN FULL REMISSION 296.50 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, UNSPECIFIED 296.51 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, MILD 296.52 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, MODERATE BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, SEVERE, WITHOUT 296.53 MENTION OF PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, SEVERE, SPECIFIED 296.54 AS WITH PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, IN PARTIAL OR 296.55 UNSPECIFIED REMISSION 296.56 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, IN FULL REMISSION 296.60 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, UNSPECIFIED 296.61 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, MILD 296.62 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, MODERATE BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, SEVERE, WITHOUT 296.63 MENTION OF PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, SEVERE, SPECIFIED AS 296.64 WITH PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN PARTIAL OR 296.65 UNSPECIFIED REMISSION 296.66 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN FULL REMISSION http://medicare.fcso.com/Fee_lookup/LCDDisplay.asp?id=L33688&submitcode=+Submit+ 8/30/2013