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Contractor Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LCD Database ID Number

L762

LCD Title

Syphilis Testing

Contractor's Determination Number

97-13-R3

AMA/CPT and ADA/CDT Copyright Statement

CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply. CDT-4 codes and descriptions are ©2002 American Dental Associat6ion. All rights reserved.

CMS National Coverage Policy

• Establishment of national policy supersedes all previous contractor policy statements, including Local Medical Policy coverage guidelines
• 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 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

Oversight Region

Region III

CMS Consortium

Northeast

DMERC Region LCD Covers

N/A

Original Determination Effective Date

04/28/1997

Revision Effective Date

10/01/2004

07/15/2002

08/27/1999

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

Description

• Venereal Disease Research Laboratory Test (VDRL) and the Rapid Plasma Reagin Test (RPR) are two of the most common and frequently used screening tests currently being performed to aid in the diagnosing of syphilis.
• Other tests include the:
• Automated Reagin Test (ART),
• Kahn Test,
• Kline Test,
• Mazzini, and;
• Wasserman.

Indications

Syphilis testing is performed to:

• Assist in the diagnosis of primary and secondary syphilis,
• Confirm primary, secondary, or tertiary syphilis in the presence of syphilitic lesions, and;
• Monitor response to treatment.

Coverage Topic

Diagnostic Tests and X-Rays
Lab Services

Bill Type Codes

30X

Revenue Codes

13X, 14X, 83X

CPT/HCPCS Codes

The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT book for the long description of the following code(s):

86592	©	Syphilis test, qualitative (e.g., VDRL, RPR, ART)
86593	©	Syphilis test, quantitative

© CPT American Medical Association

Does the “CPT 30% Coding Rule” Apply?

N/A

ICD-9 Codes that Support Medical Necessity

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the claim is submitted.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid.

Medicare is establishing the following limited coverage for codes 86592 and 86593:

Covered for:

042	Human immunodeficiency virus (HIV) infection
054.10	Genital herpes, unspecified
054.11	Herpetic vulvovaginitis
054.12	Herpetic ulceration of vulva
054.13	Herpetic infection of penis
054.19	Other
078.0	Molluscum contagiosum
078.10	Viral warts, unspecified
078.11	Condyloma acuminatum
078.19	Other specified viral warts
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
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	Other viscera
091.7	Secondary syphilis, relapse
091.81	Acute syphilitic meningitis (secondary)
091.82	Syphilitic alopecia
091.89	Other
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	Valve unspecified
093.21	Mitral valve
093.22	Aortic valve
093.23	Tricuspid valve
093.24	Pulmonary valve
093.81	Syphilitic pericarditis
093.82	Syphilitic myocarditis
093.89	Other
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
094.9	Neurosyphilis, unspecified
095.0	Syphilitic episcleritis
095.1	Syphilis of lung
095.2	Syphilitic of 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	Acute, of lower genitourinary tract
098.10	Gonococcal infection (acute) of upper genitourinary
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
098.2	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
098.40	Gonococcal conjunctivitis (neonatorum)
098.41	Gonococcal iridocyclitis
098.42	Gonococcal endophthalmia
098.43	Gonococcal keratitis
098.49	Other
098.50	Gonococcal arthritis
098.51	Gonococcal synovitis and tenosynovitis
098.52	Gonococcal bursitis
098.53	Gonococcal spondylitis
098.59	Other
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	Other
099.0	Chancroid
099.1	Lymphogranuloma venereum
099.2	Granuloma inguinale
099.3	Reiter's disease
099.40	Unspecified
099.41	Chlamydia trachomatis
099.49	Other specified organism
099.50	Unspecified site
099.51	Pharynx
099.52	Anus and rectum
099.53	Lower genitourinary sites
099.54	Other genitourinary sites
099.55	Unspecified genitourinary site
099.56	Peritoneum
099.59	Other specified site
099.8	Other specified venereal disease
099.9	Venereal disease, unspecified
104.0	Nonvenereal endemic syphilis
131.00	Urogenital trichomoniasis, unspecified
131.01	Trichomonal vulvovaginitis
131.02	Trichomonal urethritis
131.03	Trichomonal prostatitis
131.09	Other
131.8	Other specified sites
131.9	Trichomoniasis, unspecified
289.1	Chronic lymphadenitis
290.0	Senile dementia, uncomplicated
290.10	Presenile dementia, uncomplicated
298.9	Unspecified psychosis
310.1	Personality change due to conditions classified elsewhere
331.0	Alzheimer's disease
331.2	Senile degeneration of brain
352.9	Unspecified disorder of cranial nerves
356.0	Hereditary peripheral neuropathy
356.4	Idiopathic progressive polyneuropathy
356.9	Unspecified
379.40	Abnormal pupillary function, unspecified
424.1	Aortic valve disorders
436	Acute, but ill-defined cerebrovascular disease
441.2	Thoracic aneurysm without mention of rupture
441.7	Thoracoabdominal aneurysm without mention of rupture
447.6	Arteritis , 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
604.99	Other
607.2	Other inflammatory disorders of penis
608.4	Other inflammatory disorder of male genital organs
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
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	Inflammatory diseases of uterus, except cervix, acute
615.1	Inflammatory diseases of uterus, except cervix, chronic
615.9	Unspecified inflammatory disease of uterus
616.0	Cervicitis and endocervicitis
616.10	Vaginitis and vulvovaginitis
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
616.8	Other specified inflammatory disease of cervix, vagina, and vulva
616.9	Unspecified inflammatory diseases of cervix, vagina, and vulva
710.0	Systemic lupus erythematosus
711.90	Unspecified infective arthritis, site unspecified
711.91	Unspecified infective arthritis, shoulder
711.92	Unspecified infective arthritis, upper arm
711.93	Unspecified infective arthritis, forearm
711.94	Unspecified infective arthritis, hand
711.95	Unspecified infective arthritis, pelvic region and thigh
711.96	Unspecified infective arthritis, lower leg
711.97	Unspecified infective arthritis, ankle and foot
711.98	Unspecified infective arthritis, other specified sites
711.99	Unspecified infective arthritis, multiple sites
727.00	Synovitis and tenosynovitis, unspecified
760.2	Maternal infections
781.2	Abnormality of gait
782.1	Rash and other non-specific skin eruption
V01.6	Contact with or exposure to venereal diseases

Diagnoses that Support Medical Necessity

N/A

ICD-9 Codes that DO NOT Support Medical Necessity

N/A

Diagnoses that DO NOT Support Medical Necessity

N/A

Documentation Requirements

• Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and available to Medicare upon request.

Utilization Guidelines

Medicare will monitor the utilization of this laboratory test through the Medical Review process.

Sources of Information and Basis for Decision

TrailBlazer Health Enterprises, Inc., Provider Bulletin No. 013, September 27, 1996.

Advisory Committee Notes

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

Advisory Committee Meeting Date:

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period

07/28/1999

Revision History

Number	Date	Change
R3	10/01/2004	Change in descriptor of ICD-9 code 310.1 per Transmittal 210, CR 3303.
		Converted from LMRP to LCD format.
R2	07/15/2002	ICD-9-CM codes that were ranged in the policy have been listed
		individually. Under Utilization Guidelines, deleted "Focused" from
		FMR and updated it to "Medical Review" process.
R1	07/28/1999	Addition of CPT code 86593 and expanded coverage of
		ICD-9-CM codes to assure consistency of the policy between
		intermediary and carrier. (07/28/1999 Provider Bulletin)

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE FROM OUR WEBSITE AT www.marylandmedicare.com

Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.