L29416-LCD

Automated World Health

Local Coverage Determination (LCD) for Syphilis Test (L29416)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type

MAC - Part B

LCD Information

Document Information

LCD ID Number L29416

LCD Title Syphilis Test

Contractor's Determination Number 86592

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. 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. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 01/01/2010

Revision Ending Date

CMS National Coverage Policy

- Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

- Title XVIII of the Social Security Act, section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Indications and Limitations of Coverage and/or Medical Necessity

Medicare does not pay for routine screening tests. ICD-9-CM code V82.9, (special screening of other conditions, unspecified condition), or comparable narratives should be used to indicate screening tests performed in the absence of a specific sign, symptom, or complaint. Inappropriate use of V82.9 or lack of comparable narrative will result in the denial of claims as non covered screening services.

Reviewing results of laboratory tests, phoning results to patients, filing such results, and such activities as obtaining, reviewing, and analyzing the appropriate diagnostic tests, etc., are services which are covered by the program, and payment for these services is included in the payment for the evaluation and management (E&M) services of the patient.

Medicare covered qualitative syphilis testing (CPT 86592) is indicated only when there are clinical findings of the skin, eyes, teeth, cardiovascular system, or central nervous system that suggest syphilitic infection. Quantitative syphilis testing (CPT 86593) is indicated only when there has been previous positive result of either 86592 or 86780 but is never indicated when 86592 is negative. Confirmatory and specific treponemal testing is indicated only when there has been a previous positive test result of qualitative syphilis testing (86592) and very rarely when clinical disease particularly in the central nervous system (CNS) suggests tertiary syphilitic disease of meningoencephalitis, tabes dorsalis, or general paresis, despite a negative qualitative test for syphilis (86592). Quantitative syphilis testing (CPT 86593) is indicated in the follow up of previous positive testing at periodic intervals not to exceed semiannually until seronegativity occurs.

Coding Information

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.

999x Not Applicable

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.

99999 Not Applicable

CPT/HCPCS Codes

86592 SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)

86593 SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUANTITATIVE

86780 ANTIBODY; TREPONEMA PALLIDUM

ICD-9 Codes that Support Medical Necessity

042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE

053.0 - 053.9 opens in new window HERPES ZOSTER WITH MENINGITIS - HERPES ZOSTER WITHOUT COMPLICATION

054.0 - 054.9 opens in new window ECZEMA HERPETICUM - HERPES SIMPLEX WITHOUT COMPLICATION

070.0 - 070.9 opens in new window

VIRAL HEPATITIS A WITH HEPATIC COMA - UNSPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA

078.0 MOLLUSCUM CONTAGIOSUM

078.10 - 078.19 opens in new window VIRAL WARTS UNSPECIFIED - OTHER SPECIFIED VIRAL WARTS

078.88 OTHER SPECIFIED DISEASES DUE TO CHLAMYDIAE

079.4 HUMAN PAPILLOMAVIRUS IN CONDITIONS CLASSIFIED ELSEWHERE AND OF UNSPECIFIED SITE

079.50 - 079.59 opens in new window RETROVIRUS UNSPECIFIED - OTHER SPECIFIED RETROVIRUS

079.88 OTHER SPECIFIED CHLAMYDIAL INFECTION

090.0 - 090.9 opens in new window

EARLY CONGENITAL SYPHILIS SYMPTOMATIC - CONGENITAL SYPHILIS UNSPECIFIED

091.0 - 091.9 opens in new window

092.0 - 092.9 opens in new window

093.0 - 093.9 opens in new window

094.0 - 094.9 opens in new window

GENITAL SYPHILIS (PRIMARY) - UNSPECIFIED SECONDARY SYPHILIS

EARLY SYPHILIS LATENT SEROLOGICAL RELAPSE AFTER TREATMENT - EARLY SYPHILIS LATENT UNSPECIFIED

ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC - CARDIOVASCULAR SYPHILIS UNSPECIFIED

window TABES DORSALIS - NEUROSYPHILIS UNSPECIFIED

095.0 - 095.9 opens in new window SYPHILITIC EPISCLERITIS - LATE SYMPTOMATIC SYPHILIS UNSPECIFIED

096 LATE SYPHILIS LATENT

097.0 - 097.9 opens in new window LATE SYPHILIS UNSPECIFIED - SYPHILIS UNSPECIFIED

098.0 - 098.89 opens in new window

099.0 - 099.9 opens in new

GONOCOCCAL INFECTION (ACUTE) OF LOWER GENITOURINARY TRACT - GONOCOCCAL INFECTION OF OTHER SPECIFIED SITES

window CHANCROID - VENEREAL DISEASE UNSPECIFIED

104.0 NONVENEREAL ENDEMIC SYPHILIS

131.00 UROGENITAL TRICHOMONIASIS UNSPECIFIED

131.2 TRICHOMONAL URETHRITIS

131.3 TRICHOMONAL PROSTATITIS

131.09 OTHER UROGENITAL TRICHOMONIASIS

131.8 TRICHOMONIASIS OF OTHER SPECIFIED SITES

131.9 TRICHOMONIASIS UNSPECIFIED

290.10 - 290.13 opens in new window

PRESENILE DEMENTIA UNCOMPLICATED - PRESENILE DEMENTIA WITH DEPRESSIVE FEATURES

293.1 DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE

293.2 SUBACUTE DELIRIUM

294.8 OTHER PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE

296.82 ATYPICAL DEPRESSIVE DISORDER

310.1 PERSONALITY CHANGE DUE TO CONDITIONS CLASSIFIED ELSEWHERE

331.0 ALZHEIMER'S DISEASE

331.2 SENILE DEGENERATION OF BRAIN

331.9 CEREBRAL DEGENERATION UNSPECIFIED

356.0 HEREDITARY PERIPHERAL NEUROPATHY

356.9 UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

389.10 SENSORINEURAL HEARING LOSS 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

614.0 - 614.9 opens in new window

615.0 - 615.9 opens in new window

616.0 - 616.9 opens in new window

ACUTE SALPINGITIS AND OOPHORITIS - UNSPECIFIED INFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS AND TISSUES

ACUTE INFLAMMATORY DISEASES OF UTERUS EXCEPT CERVIX - UNSPECIFIED INFLAMMATORY DISEASE OF UTERUS

CERVICITIS AND ENDOCERVICITIS - UNSPECIFIED INFLAMMATORY DISEASE OF CERVIX VAGINA AND VULVA

760.2 MATERNAL INFECTIONS AFFECTING FETUS OR NEWBORN

781.2 ABNORMALITY OF GAIT

782.1 RASH AND OTHER NONSPECIFIC SKIN ERUPTION

785.6 ENLARGEMENT OF LYMPH NODES

V01.6 CONTACT WITH OR EXPOSURE TO VENEREAL DISEASES

V02.7 CARRIER OR SUSPECTED CARRIER OF GONORRHEA

V02.8 CARRIER OR SUSPECTED CARRIER OF OTHER VENEREAL DISEASES

V08 ASYMPTOMATIC HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION STATUS

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentations Requirements

Documentation supporting the medical necessity of this procedure must be kept on the provider’s record and available to be furnished upon request. Failure to do so may result in rejection or denial of claim(s). This document should include but is not limited to: history and physical examination, notes documenting evaluation and management with relevant clinical signs, symptoms or abnormal laboratory test results. The patient's clinical record should further indicate changes/alterations and response or non-response in medications prescribed for the treatment of the patient's condition.

It is understood that any diagnosis information submitted must have (in the patient record) medical justification for components of the procedure. Subsequent determination that the medical record is lacking such justification

will result in a retroactive denial under 1862(a)(1)(A)

Appendices

Utilization Guidelines

Sources of Information and Basis for Decision Revision 3:

CPT 2008

ICD-9-CM 2008

Other Contractors LCD's NIH

HHS NIAID

Articles: JClin Microbiol 2003; 41:250-253: Evaluation of an enzyme immunoassay technique for detection of antibodies against Treponema pallidum.

Mayo Foundation for Clinical Education and Research (MFMER) Syphillis

J Clin Microbiol1991 March;29(3):444-448 Specific Immunofluorescence staining of Treponema Pallidum in smears and tissues.

HSJethwa, JL Schmitz, GDallabetta, F Behets, I Hoffmann et alComparison of molecular and microscopic techniques for detection of Treponema pallidum in genital ulcers.

CDC Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and TB prevention

- ICD-9-CM, 2005

- CPT-2000

- ICD-9-CM, 1999

- CDC’s Guidelines for Treatment of Sexually Transmitted Disease, 1998

- CMD Clinical Laboratory Workgroup

- Current Medical Literature Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from

numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 01/01/2010

Revision History Number 1

Revision History Explanation Revision Number:1 Start Date of Comment Period:N/A

Start Date of Notice Period:01/01/2010 Revised Effective Date: 01/01/2010

LCR B2010- 012

December 2009 Update

Explanation of Revision: Annual 2010 HCPCS Update. Added CPT code 86780. Deleted CPT code 86781. Revised descriptors for CPT codes 86592 and 86593. Revisions will be effective based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) there was no previous LCD on this subject. This document (L29416) is effective on 02/02/2009.

11/15/2009 - The description for CPT/HCPCS code 86592 was changed in group 1 11/15/2009 - The description for CPT/HCPCS code 86593 was changed in group 1

11/15/2009 - CPT/HCPCS code 86781 was deleted from group 1

Reason for Change