Automated World Health
L29416
SYPHILIS TEST
01/01/2010
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.
o 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
o skin
o eyes
o teeth
o cardiovascular system
o Central nervous system that suggest syphilitic infection.
• Quantitative syphilis testing (CPT 86593) is indicated only when
o there has been previous positive result of either 86592 or 86780 but is
o Never indicated when 86592 is negative.
• Confirmatory and specific treponemal testing is indicated only when
o there has been a previous positive test result of qualitative syphilis testing (86592) and
o 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.
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 HERPES ZOSTER WITH MENINGITIS
053.10 HERPES ZOSTER WITH UNSPECIFIED NERVOUS SYSTEM COMPLICATION
053.11 GENICULATE HERPES ZOSTER
053.12 POSTHERPETIC TRIGEMINAL NEURALGIA
053.13 POSTHERPETIC POLYNEUROPATHY
053.14 HERPES ZOSTER MYELITIS
053.19 HERPES ZOSTER WITH OTHER NERVOUS SYSTEM COMPLICATIONS
053.20 HERPES ZOSTER DERMATITIS OF EYELID
053.21 HERPES ZOSTER KERATOCONJUNCTIVITIS
053.22 HERPES ZOSTER IRIDOCYCLITIS
053.29 HERPES ZOSTER WITH OTHER OPHTHALMIC COMPLICATIONS
053.71 OTITIS EXTERNA DUE TO HERPES ZOSTER
053.79 HERPES ZOSTER WITH OTHER SPECIFIED COMPLICATIONS
053.8 HERPES ZOSTER WITH UNSPECIFIED COMPLICATION
053.9 HERPES ZOSTER WITHOUT COMPLICATION
054.0 ECZEMA HERPETICUM
054.10 GENITAL HERPES UNSPECIFIED
054.11 HERPETIC VULVOVAGINITIS
054.12 HERPETIC ULCERATION OF VULVA
054.13 HERPETIC INFECTION OF PENIS
054.19 OTHER GENITAL HERPES
054.2 HERPETIC GINGIVOSTOMATITIS
054.3 HERPETIC MENINGOENCEPHALITIS
054.40 HERPES SIMPLEX WITH UNSPECIFIED OPHTHALMIC COMPLICATION
054.41 HERPES SIMPLEX DERMATITIS OF EYELID
054.42 DENDRITIC KERATITIS
054.43 HERPES SIMPLEX DISCIFORM KERATITIS
054.44 HERPES SIMPLEX IRIDOCYCLITIS
054.49 HERPES SIMPLEX WITH OTHER OPHTHALMIC COMPLICATIONS
054.5 HERPETIC SEPTICEMIA
054.6 HERPETIC WHITLOW
054.71 VISCERAL HERPES SIMPLEX
054.72 HERPES SIMPLEX MENINGITIS
054.73 HERPES SIMPLEX OTITIS EXTERNA
054.74 HERPES SIMPLEX MYELITIS
054.79 HERPES SIMPLEX WITH OTHER SPECIFIED COMPLICATIONS
054.8 HERPES SIMPLEX WITH UNSPECIFIED COMPLICATION
054.9 HERPES SIMPLEX WITHOUT COMPLICATION
070.0 VIRAL HEPATITIS A WITH HEPATIC COMA
070.1 VIRAL HEPATITIS A WITHOUT HEPATIC COMA
070.20 VIRAL HEPATITIS B WITH HEPATIC COMA ACUTE OR UNSPECIFIED WITHOUT HEPATITIS DELTA
070.21 VIRAL HEPATITIS B WITH HEPATIC COMA ACUTE OR UNSPECIFIED WITH HEPATITIS DELTA
070.22 CHRONIC VIRAL HEPATITIS B WITH HEPATIC COMA WITHOUT HEPATITIS DELTA
070.23 CHRONIC VIRAL HEPATITIS B WITH HEPATIC COMA WITH HEPATITIS DELTA
070.30 VIRAL HEPATITIS B WITHOUT HEPATIC COMA ACUTE OR UNSPECIFIED WITHOUT HEPATITIS DELTA
070.31 VIRAL HEPATITIS B WITHOUT HEPATIC COMA ACUTE OR UNSPECIFIED WITH HEPATITIS DELTA
070.32 CHRONIC VIRAL HEPATITIS B WITHOUT HEPATIC COMA WITHOUT HEPATITIS DELTA
070.33 CHRONIC VIRAL HEPATITIS B WITHOUT HEPATIC COMA WITH HEPATITIS DELTA
070.41 ACUTE HEPATITIS C WITH HEPATIC COMA
070.42 HEPATITIS DELTA WITHOUT ACTIVE HEPATITIS B DISEASE WITH HEPATIC COMA HEPATITIS DELTA WITH HEPATITIS B CARRIER STATE
070.43 HEPATITIS E WITH HEPATIC COMA
070.44 CHRONIC HEPATITIS C WITH HEPATIC COMA
070.49 OTHER SPECIFIED VIRAL HEPATITIS WITH HEPATIC COMA
070.51 ACUTE HEPATITIS C WITHOUT MENTION OF HEPATIC COMA
070.52 HEPATITIS DELTA WITHOUT ACTIVE HEPATITIS B DISEASE OR HEPATIC COMA
070.53 HEPATITIS E WITHOUT HEPATIC COMA
070.54 CHRONIC HEPATITIS C WITHOUT HEPATIC COMA
070.59 OTHER SPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA
070.6 UNSPECIFIED VIRAL HEPATITIS WITH HEPATIC COMA
070.70 UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA
070.71 UNSPECIFIED VIRAL HEPATITIS C WITH HEPATIC COMA
070.9 UNSPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA
078.0 MOLLUSCUM CONTAGIOSUM
078.10 VIRAL WARTS UNSPECIFIED
078.11 CONDYLOMA ACUMINATUM
078.12 PLANTAR WART
078.19 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 RETROVIRUS UNSPECIFIED
079.51 HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE I [HTLV-I]
079.52 HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE II [HTLV-II]
079.53 HUMAN IMMUNODEFICIENCY VIRUS TYPE 2 [HIV-2]
079.59 OTHER SPECIFIED RETROVIRUS
079.88 OTHER SPECIFIED CHLAMYDIAL INFECTION
090.0 EARLY CONGENITAL SYPHILIS SYMPTOMATIC
090.1 EARLY CONGENITAL SYPHILIS LATENT
090.2 EARLY CONGENITAL SYPHILIS UNSPECIFIED
090.3 SYPHILITIC INTERSTITIAL KERATITIS
090.40 JUVENILE NEUROSYPHILIS UNSPECIFIED
090.41 CONGENITAL SYPHILITIC ENCEPHALITIS
090.42 CONGENITAL SYPHILITIC MENINGITIS
090.49 OTHER JUVENILE NEUROSYPHILIS
090.5 OTHER LATE CONGENITAL SYPHILIS SYMPTOMATIC
090.6 LATE CONGENITAL SYPHILIS LATENT
090.7 LATE CONGENITAL SYPHILIS UNSPECIFIED
090.9 CONGENITAL SYPHILIS UNSPECIFIED
091.0 GENITAL SYPHILIS (PRIMARY)
091.1 PRIMARY ANAL SYPHILIS
091.2 OTHER PRIMARY SYPHILIS
091.3 SECONDARY SYPHILIS OF SKIN OR MUCOUS MEMBRANES
091.4 ADENOPATHY DUE TO SECONDARY SYPHILIS
091.50 SYPHILITIC UVEITIS UNSPECIFIED
091.51 SYPHILITIC CHORIORETINITIS (SECONDARY)
091.52 SYPHILITIC IRIDOCYCLITIS (SECONDARY)
091.61 SECONDARY SYPHILITIC PERIOSTITIS
091.62 SECONDARY SYPHILITIC HEPATITIS
091.69 SECONDARY SYPHILIS OF OTHER VISCERA
091.7 SECONDARY SYPHILIS RELAPSE
091.81 ACUTE SYPHILITIC MENINGITIS (SECONDARY)
091.82 SYPHILITIC ALOPECIA
091.89 OTHER FORMS OF SECONDARY SYPHILIS
091.9 UNSPECIFIED SECONDARY SYPHILIS
092.0 EARLY SYPHILIS LATENT SEROLOGICAL RELAPSE AFTER TREATMENT
092.9 EARLY SYPHILIS LATENT UNSPECIFIED
093.0 ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC
093.1 SYPHILITIC AORTITIS
093.20 SYPHILITIC ENDOCARDITIS OF VALVE UNSPECIFIED
093.21 SYPHILITIC ENDOCARDITIS OF MITRAL VALVE
093.22 SYPHILITIC ENDOCARDITIS OF AORTIC VALVE
093.23 SYPHILITIC ENDOCARDITIS OF TRICUSPID VALVE
093.24 SYPHILITIC ENDOCARDITIS OF PULMONARY VALVE
093.81 SYPHILITIC PERICARDITIS
093.82 SYPHILITIC MYOCARDITIS
093.89 OTHER SPECIFIED CARDIOVASCULAR SYPHILIS
093.9 CARDIOVASCULAR SYPHILIS UNSPECIFIED
094.0 TABES DORSALIS
094.1 GENERAL PARESIS
094.2 SYPHILITIC MENINGITIS
094.3 ASYMPTOMATIC NEUROSYPHILIS
094.81 SYPHILITIC ENCEPHALITIS
094.82 SYPHILITIC PARKINSONISM
094.83 SYPHILITIC DISSEMINATED RETINOCHOROIDITIS
094.84 SYPHILITIC OPTIC ATROPHY
094.85 SYPHILITIC RETROBULBAR NEURITIS
094.86 SYPHILITIC ACOUSTIC NEURITIS
094.87 SYPHILITIC RUPTURED CEREBRAL ANEURYSM
094.89 OTHER SPECIFIED NEUROSYPHILIS
094.9 NEUROSYPHILIS UNSPECIFIED
095.0 SYPHILITIC EPISCLERITIS
095.1 SYPHILIS OF LUNG
095.2 SYPHILITIC PERITONITIS
095.3 SYPHILIS OF LIVER
095.4 SYPHILIS OF KIDNEY
095.5 SYPHILIS OF BONE
095.6 SYPHILIS OF MUSCLE
095.7 SYPHILIS OF SYNOVIUM TENDON AND BURSA
095.8 OTHER SPECIFIED FORMS OF LATE SYMPTOMATIC SYPHILIS
095.9 LATE SYMPTOMATIC SYPHILIS UNSPECIFIED
096 LATE SYPHILIS LATENT
097.0 LATE SYPHILIS UNSPECIFIED
097.1 LATENT SYPHILIS UNSPECIFIED
097.9 SYPHILIS UNSPECIFIED
098.0 GONOCOCCAL INFECTION (ACUTE) OF LOWER GENITOURINARY TRACT
098.10 GONOCOCCAL INFECTION (ACUTE) OF UPPER GENITOURINARY TRACT SITE UNSPECIFIED
098.11 GONOCOCCAL CYSTITIS (ACUTE)
098.12 GONOCOCCAL PROSTATITIS (ACUTE)
098.13 GONOCOCCAL EPIDIDYMO-ORCHITIS (ACUTE)
098.14 GONOCOCCAL SEMINAL VESICULITIS (ACUTE)
098.15 GONOCOCCAL CERVICITIS (ACUTE)
098.16 GONOCOCCAL ENDOMETRITIS (ACUTE)
098.17 GONOCOCCAL SALPINGITIS SPECIFIED AS ACUTE
098.19 OTHER GONOCOCCAL INFECTION (ACUTE) OF UPPER GENITOURINARY TRACT
098.2 GONOCOCCAL INFECTION CHRONIC OF LOWER GENITOURINARY TRACT
098.30 CHRONIC GONOCOCCAL INFECTION OF UPPER GENITOURINARY TRACT SITE UNSPECIFIED
098.31 GONOCOCCAL CYSTITIS CHRONIC
098.32 GONOCOCCAL PROSTATITIS CHRONIC
098.33 GONOCOCCAL EPIDIDYMO-ORCHITIS CHRONIC
098.34 GONOCOCCAL SEMINAL VESICULITIS CHRONIC
098.35 GONOCOCCAL CERVICITIS CHRONIC
098.36 GONOCOCCAL ENDOMETRITIS CHRONIC
098.37 GONOCOCCAL SALPINGITIS (CHRONIC)
098.39 OTHER CHRONIC GONOCOCCAL INFECTION OF UPPER GENITOURINARY TRACT
098.40 GONOCOCCAL CONJUNCTIVITIS (NEONATORUM)
098.41 GONOCOCCAL IRIDOCYCLITIS
098.42 GONOCOCCAL ENDOPHTHALMIA
098.43 GONOCOCCAL KERATITIS
098.49 OTHER GONOCOCCAL INFECTION OF EYE
098.50 GONOCOCCAL ARTHRITIS
098.51 GONOCOCCAL SYNOVITIS AND TENOSYNOVITIS
098.52 GONOCOCCAL BURSITIS
098.53 GONOCOCCAL SPONDYLITIS
098.59 OTHER GONOCOCCAL INFECTION OF JOINT
098.6 GONOCOCCAL INFECTION OF PHARYNX
098.7 GONOCOCCAL INFECTION OF ANUS AND RECTUM
098.81 GONOCOCCAL KERATOSIS (BLENNORRHAGICA)
098.82 GONOCOCCAL MENINGITIS
098.83 GONOCOCCAL PERICARDITIS
098.84 GONOCOCCAL ENDOCARDITIS
098.85 OTHER GONOCOCCAL HEART DISEASE
098.86 GONOCOCCAL PERITONITIS
098.89 GONOCOCCAL INFECTION OF OTHER SPECIFIED SITES
099.0 CHANCROID
099.1 LYMPHOGRANULOMA VENEREUM
099.2 GRANULOMA INGUINALE
099.3 REITER'S DISEASE
099.40 OTHER NONGONOCOCCAL URETHRITIS UNSPECIFIED
099.41 OTHER NONGONOCOCCAL URETHRITIS CHLAMYDIA TRACHOMATIS
099.49 OTHER NONGONOCOCCAL URETHRITIS OTHER SPECIFIED ORGANISM
099.50 OTHER VENEREAL DISEASES DUE TO CHLAMYDIA TRACHOMATIS UNSPECIFIED SITE
099.51 OTHER VENEREAL DISEASES DUE TO CHLAMYDIA TRACHOMATIS PHARYNX
099.52 OTHER VENEREAL DISEASES DUE TO CHLAMYDIA TRACHOMATIS ANUS AND RECTUM
099.53 OTHER VENEREAL DISEASES DUE TO CHLAMYDIA TRACHOMATIS LOWER GENITOURINARY SITES
099.54 OTHER VENEREAL DISEASES DUE TO CHLAMYDIA TRACHOMATIS OTHER GENITOURINARY SITES
099.55 OTHER VENEREAL DISEASES DUE TO CHLAMYDIA TRACHOMATIS UNSPECIFIED GENITOURINARY SITE
099.56 OTHER VENEREAL DISEASES DUE TO CHLAMYDIA TRACHOMATIS PERITONEUM
099.59 OTHER VENEREAL DISEASES DUE TO CHLAMYDIA TRACHOMATIS OTHER SPECIFIED SITE
099.8 OTHER SPECIFIED VENEREAL DISEASES
099.9 VENEREAL DISEASE UNSPECIFIED
104.0 NONVENEREAL ENDEMIC SYPHILIS
131.00 UROGENITAL TRICHOMONIASIS UNSPECIFIED
131.02 TRICHOMONAL URETHRITIS
131.03 TRICHOMONAL PROSTATITIS
131.09 OTHER UROGENITAL TRICHOMONIASIS
131.8 TRICHOMONIASIS OF OTHER SPECIFIED SITES
131.9 TRICHOMONIASIS UNSPECIFIED
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
293.0 DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE
293.1 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 ACUTE SALPINGITIS AND OOPHORITIS
614.1 CHRONIC SALPINGITIS AND OOPHORITIS
614.2 SALPINGITIS AND OOPHORITIS NOT SPECIFIED AS ACUTE SUBACUTE OR CHRONIC
614.3 ACUTE PARAMETRITIS AND PELVIC CELLULITIS
614.4 CHRONIC OR UNSPECIFIED PARAMETRITIS AND PELVIC CELLULITIS
614.5 ACUTE OR UNSPECIFIED PELVIC PERITONITIS FEMALE
614.6 PELVIC PERITONEAL ADHESIONS FEMALE (POSTOPERATIVE) (POSTINFECTION)
614.7 OTHER CHRONIC PELVIC PERITONITIS FEMALE
614.8 OTHER SPECIFIED INFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS AND TISSUES
614.9 UNSPECIFIED INFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS AND TISSUES
615.0 ACUTE INFLAMMATORY DISEASES OF UTERUS EXCEPT CERVIX
615.1 CHRONIC INFLAMMATORY DISEASES OF UTERUS EXCEPT CERVIX
615.9 UNSPECIFIED INFLAMMATORY DISEASE OF UTERUS
616.0 CERVICITIS AND ENDOCERVICITIS
616.10 VAGINITIS AND VULVOVAGINITIS UNSPECIFIED
616.11 VAGINITIS AND VULVOVAGINITIS IN DISEASES CLASSIFIED ELSEWHERE
616.2 CYST OF BARTHOLIN'S GLAND
616.3 ABSCESS OF BARTHOLIN'S GLAND
616.4 OTHER ABSCESS OF VULVA
616.50 ULCERATION OF VULVA UNSPECIFIED
616.51 ULCERATION OF VULVA IN DISEASES CLASSIFIED ELSEWHERE
616.81 MUCOSITIS (ULCERATIVE) OF CERVIX, VAGINA, AND VULVA
616.89 OTHER INFLAMMATORY DISEASE OF CERVIX, VAGINA AND VULVA
616.9 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
Documentation Requirements
• Documentation supporting the medical necessity of this procedure must be kept on the provider’s record and available to be furnished upon request.
o Failure to do so may result in rejection or denial of claim(s).
o 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.
o 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.
o Subsequent determination that the medical record is lacking such justification will result in a retroactive denial under 1862(a)(1)(A)
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
01/01/2010
The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.
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.