Healthy Michigan Plan Marketplace Option Operational Protocol · III. Enrollment MDHHS will identify Healthy Michigan Plan beneficiaries who meet the criteria for enrollment in the

Healthy Michigan Plan Marketplace Option Operational Protocol

I. Overview

As required by the Section 1115 Demonstration Amendment approved by the Centers forMedicare & Medicaid Services (CMS) and P.A. 107 of 2013, certain Healthy MichiganPlan beneficiaries must obtain health care coverage through a Qualified Health Plan(QHP) participating on the federal marketplace or a health plan meeting the criteria forQHP certification (herein both types of health plans are referred to as a QHP). Thisprocess will begin in April 2018. Issuers will be approved to participate by the MichiganDepartment of Insurance and Financial Services (DIFS) and the Michigan Department ofHealth and Human Services (MDHHS) as described herein.

II. Eligible Enrollees

The Marketplace Option will be effective as of April 1, 2018, with rolling enrollmentthereafter. Healthy Michigan Plan beneficiaries who have incomes above 100% of theFederal Poverty Level (FPL) and have not completed the healthy behavior requirementsoutlined in the Healthy Behaviors Protocol must transition to the Marketplace Option,absent an applicable exception. MDHHS will use information from the State’s Medicaideligibility system to determine a beneficiary’s income and will assess healthy behaviorcompletion status in accordance with the Healthy Behaviors Protocol before initiating thetransition process. Individuals who are not otherwise excluded, have income above100% of the FPL and have satisfied the State’s healthy behavior requirements will also begiven the choice of transitioning to the Marketplace Option, consistent with the SpecialTerms and Conditions (STCs).

Healthy Michigan Plan enrollees will have a grace period of 12 months from their healthplan enrollment date to complete the healthy behavior requirements described in theHealthy Behaviors Protocol. If the individual fails to meet these requirements by the endof the 12-month grace period, he or she will transition to the Marketplace Option.

As required by state law, individuals who are considered medically frail in accordancewith 42 CFR 440.315 are not eligible for the Marketplace Option. An individual mayself-report his or her medically frail status, be identified through retrospective claimsanalysis, or by provider referral. Additional details on the state’s three-pronged strategyfor the identification of these individuals are included in Exhibit A.

Finally, those exempt from premiums and cost-sharing pursuant to 42 CFR 447.56 areexcluded from enrollment and will remain in the Healthy Michigan Plan. This includes,but is not limited to, pregnant women and children under 21 years of age. In the event anindividual’s exemption status changes (e.g. they turn 21 years old), he or she willtransition to the Marketplace Option after the 12-month grace period, assuming othereligibility criteria are met.

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

III. Enrollment

MDHHS will identify Healthy Michigan Plan beneficiaries who meet the criteria forenrollment in the Marketplace Option and notify them of the required transition as well asits impact on the scope and cost of their health care coverage. Any notices regarding thistransition will be compliant with the timing and content requirements set forth in theSTCs. MDHHS will also provide information on the healthy behavior requirements andmedically frail exemption process, including how beneficiaries may utilize these optionsto remain in, or return to the Healthy Michigan Plan. MDHHS will also provideinstructions on how to select a QHP as well as information on the auto-assignmentprocess and care transitions.

MDHHS will utilize an enrollment broker to facilitate enrollment into a QHP.Individuals may enroll online, by phone or in person, but must select a QHP within 30days of being determined eligible for the Marketplace Option. If the individual does notchoose a QHP within that time frame, he or she will be auto-assigned in accordance witha methodology approved by MDHHS and CMS.

After an individual selects or is auto-assigned to a QHP, the State will submit enrolleeinformation to the issuer using an 834 transaction. Upon receipt of this information, theissuer will send an enrollment package to the individual, which will include the QHPbenefit card, handbook and other relevant coverage information. MDHHS and the issuerwill reconcile eligible enrollees at least monthly, using a process agreed to by MDHHSand the issuer. MDHHS will enter into a Memorandum of Understanding (MOU) witheach participating issuer to effectuate the requirements of this protocol and the STCs, andto address any other relevant responsibilities.

Once an individual is enrolled in the Marketplace Option, he or she will remain there fora period of 12 months unless he or she loses Medicaid eligibility, is determined medicallyfrail (consistent with the process outlined in Exhibit A) or becomes eligible for anotherhealth care coverage program administered by MDHHS. Prior to the end of the 12-month period, MDHHS will review the information available on all Marketplace Optionenrollees and determine whether they meet the criteria for continued enrollment in theMarketplace Option or may transition back to the Healthy Michigan Plan. In the event anindividual meets the criteria to transition back to the Healthy Michigan Plan, MDHHSwill notify the beneficiary and assist them in making the transition.

Marketplace Option enrollees remain obligated to report changes impacting theireligibility for health care coverage to MDHHS. In addition, individuals transitioning tothe Marketplace Option will not undergo an additional eligibility determination and willretain their original redetermination date. In the event an individual is determinedeligible for a program other than the Healthy Michigan Plan at redetermination, he or shewill transition to that program from the QHP as soon as is practicable. Finally, if anenrollee experiences an income drop to 100% of the FPL or lower or becomes exemptfrom cost-sharing (as recorded in the State’s eligibility system), he or she will remain inthe Marketplace Option (absent another exemption) but will not be charged premiums for

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

QHP coverage going forward. Average co-pays will continue to be charged, but will not exceed the cost-sharing limits as described in 42 CFR 447.56(f)

IV. Benefits

The Marketplace Option enrollees will have access to the Essential Health Benefits inaccordance with the Affordable Care Act and its implementing regulations. Enrollees willreceive these Essential Health Benefits from the defined QHP provider network. Allparticipating issuers must meet the network and service area requirements as required byDIFS, including all essential community provider requirements specified by CMS.Additional wrap-around benefits will also be available, consistent with the State’sapproved Alternative Benefit Plan (ABP) for the Marketplace Option. These wrap-around benefits are limited to Non-Emergency Medical Transportation, family planningservices provided by out-of-network providers and any ABP Marketplace OptionMedicaid-covered services provided by a Federally Qualified Health Center, TribalHealth Center, or Rural Health Clinic when not otherwise covered by their QHP.MDHHS will provide Marketplace Option enrollees with information on how to accesscovered benefits outside of the QHP as part of the transition process.

V. Cost-Sharing

Individuals enrolled in the Marketplace Option will be responsible for contributing to thecost of their coverage. A monthly premium that will not exceed 2% of income and anaverage monthly co-pay amount will be charged. Total premiums and average co-payamounts will not exceed cost-sharing limits as described in 42 CFR 447.56(f). If aMarketplace Option enrollee satisfies the Healthy Behavior requirements outlined in theState’s Healthy Behaviors Protocol, premiums will be reduced by 50% for the remainderof the QHP enrollment period. MDHHS, through a vendor, will be responsible for thecollection of Marketplace Option enrollee cost-sharing. Individuals who fail to payrequired cost-sharing amounts may have their state tax refunds and lottery winningsoffset by MDHHS. Marketplace Option enrollees will not lose coverage for failure topay premiums or average co-pay requirements.

VI. Payments

MDHHS will pay the issuers the full cost of the plan premium, any applicabledeductibles, and cost-sharing reductions, and will pay the Marketplace Option enrollee’smonthly premium and advanced cost-sharing reduction payment (as determined usingCMS’ cost-sharing reduction methodology). MDHHS will use standard Marketplacestructures, including the 820 transaction, to pay these amounts directly to the relevantissuer, so long as the individual is deemed eligible for and participating in theMarketplace Option.

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

VII. Appeals Appeals related to benefits and services provided by a QHP are governed by DIFS. Marketplace Option enrollees will have the same rights to internal and external review as any other individuals enrolled in the QHP under Michigan state law. In addition, Marketplace Option enrollees will have access to a fair hearing through MDHHS for actions taken with respect to eligibility or MDHHS covered benefits, consistent with federal regulations. Issuers will be required to honor the outcome of any relevant state fair hearing process. MDHHS will notify Marketplace Option enrollees about these rights as part of the transition process. Additional obligations of the QHPs with respect to grievance and appeal processes for Marketplace Option enrollees may be set forth in the MOU.

VIII. Exhibits Exhibit A- Medically Frail Process

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

Exhibit A

Medically Frail Process

MDHHS will use a three-pronged strategy to identify individuals who are medically frail: 1) Self-identification, 2) claims analysis, and 3) provider referral. Details of each strategy are provided below.

1) Self-Identification

MDHHS will allow individuals to self-attest to medically frail status using the application for health care coverage or a medical exception process developed by MDHHS. MDHHS will process these requests as they are received and designate the individual as medically frail. With respect to the application, individuals who answer “yes” to either of these questions will be designated as medically frail and exempt from the Marketplace Option.

A. (Paper Application) – Does the applicant “have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?”

B. (Online Application) – Do any of these people: i. “Have a physical disability or mental health condition that limits their ability to

work, attend school, or take care of their daily needs?” ii. “Need help with activities of daily living (like bathing, dressing, and using the

bathroom), or live in a medical facility or nursing home?” If an individual becomes medically frail after transitioning to the Marketplace Option, he or she may update his or her application information or complete the medical exemption process at any time throughout the year. Once MDHHS receives this updated information, the individual will be transitioned back to the Healthy Michigan Plan in the next available month.

2) Retrospective Claims Analysis

MDHHS will consider information within its data warehouse and Medicaid Management Information System (MMIS) to identify individuals considered medically frail. This will primarily involve the review of historical claims information (from the preceding 12 months) for the presence of select diagnosis codes. The initial list of codes is included here as Appendix A. MDHHS may pursue updates to this list on an annual basis, in consultation with CMS as appropriate.

The claims data to be reviewed include the following: a. ICD-10 diagnosis codes (over 2,600 codes selected) that identify:

o Individuals with disabling mental disorders; o Individuals with serious and complex medical conditions;

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

o Individuals with a physical disability that significantly impairs the ability to perform one or more activities of daily living; and

o Individuals with an intellectual or developmental disability that significantly impairs their ability to perform one or more activities of daily living; intellectual or developmental disability defined by the Michigan Mental Health Code.

b. Whether a beneficiary is in a nursing home, hospice, or Children’s Special Health CareServices (CSHCS), or is receiving home help services (Note: beneficiaries will beconsidered medically frail during the month they are receiving these services), or

c. A Prepaid Inpatient Health Plan (PIHP) relationship (two or more PIHP encounterswithin the past year).

3) Provider Referral

Both health care providers and participating health plans (Medicaid Health Plans and HMPQHPs) may recommend medically frail status for an individual at any time. MDHHS willprocess these referral requests and designate the individual as medically frail. Individualswho are determined to be medically frail through the referral process will be exempt fromenrollment in the Marketplace Option, or if already enrolled, transitioned back to the HealthyMichigan Plan in the next available month.

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONA150 TUBERCULOSIS OF LUNGA154 TUBERCULOSIS OF INTRATHORACIC LYMPH NODESA155 TUBERCULOSIS OF LARYNX TRACHEA AND BRONCHUSA156 TUBERCULOUS PLEURISYA157 PRIMARY RESPIRATORY TUBERCULOSISA158 OTHER RESPIRATORY TUBERCULOSISA159 RESPIRATORY TUBERCULOSIS UNSPECIFIEDA170 TUBERCULOUS MENINGITISA171 MENINGEAL TUBERCULOMAA1781 TUBERCULOMA OF BRAIN AND SPINAL CORDA1782 TUBERCULOUS MENINGOENCEPHALITISA1783 TUBERCULOUS NEURITISA1789 OTHER TUBERCULOSIS OF NERVOUS SYSTEMA179 TUBERCULOSIS OF NERVOUS SYSTEM UNSPECIFIEDA1801 TUBERCULOSIS OF SPINEA1802 TUBERCULOUS ARTHRITIS OF OTHER JOINTSA1803 TUBERCULOSIS OF OTHER BONESA1809 OTHER MUSCULOSKELETAL TUBERCULOSISA1810 TUBERCULOSIS OF GENITOURINARY SYSTEM UNSPECIFIEDA1811 TUBERCULOSIS OF KIDNEY AND URETERA1812 TUBERCULOSIS OF BLADDERA1813 TUBERCULOSIS OF OTHER URINARY ORGANSA1814 TUBERCULOSIS OF PROSTATEA1815 TUBERCULOSIS OF OTHER MALE GENITAL ORGANSA1816 TUBERCULOSIS OF CERVIXA1817 TUBERCULOUS FEMALE PELVIC INFLAMMATORY DISEASEA1818 TUBERCULOSIS OF OTHER FEMALE GENITAL ORGANSA182 TUBERCULOUS PERIPHERAL LYMPHADENOPATHYA1831 TUBERCULOUS PERITONITISA1832 TUBERCULOUS ENTERITISA1839 RETROPERITONEAL TUBERCULOSISA184 TUBERCULOSIS OF SKIN AND SUBCUTANEOUS TISSUEA1850 TUBERCULOSIS OF EYE UNSPECIFIEDA1851 TUBERCULOUS EPISCLERITISA1852 TUBERCULOUS KERATITISA1853 TUBERCULOUS CHORIORETINITISA1854 TUBERCULOUS IRIDOCYCLITISA1859 OTHER TUBERCULOSIS OF EYEA186 TUBERCULOSIS OF INNER MIDDLE EARA187 TUBERCULOSIS OF ADRENAL GLANDSA1881 TUBERCULOSIS OF THYROID GLANDA1882 TUBERCULOSIS OF OTHER ENDOCRINE GLANDSA1883 TUBERCULOSIS OF DIGESTIVE TRACT ORGANS NECA1884 TUBERCULOSIS OF HEARTA1885 TUBERCULOSIS OF SPLEEN

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTION

A1889 TUBERCULOSIS OF OTHER SITESA190 ACUTE MILIARY TB OF A SINGLE SPECIFIED SITEA191 ACUTE MILIARY TUBERCULOSIS OF MULTIPLE SITESA192 ACUTE MILIARY TUBERCULOSIS UNSPECIFIEDA198 OTHER MILIARY TUBERCULOSISA199 MILIARY TUBERCULOSIS UNSPECIFIEDA5275 SYPHILIS OF KIDNEY AND URETERB180 CHRONIC VIRAL HEPATITIS B WITH DELTA-AGENTB181 CHRONIC VIRAL HEPATITIS B WITHOUT DELTA-AGENTB182 CHRONIC VIRAL HEPATITIS CB20 HUMAN IMMUNODEFICIENCY VIRUS HIV DISEASEB520 PLASMODIUM MALARIAE MALARIA WITH NEPHROPATHYB900 SEQUELAE OF CENTRAL NERVOUS SYSTEM TUBERCULOSISB901 SEQUELAE OF GENITOURINARY TUBERCULOSISB902 SEQUELAE OF TUBERCULOSIS OF BONES AND JOINTSB908 SEQUELAE OF TUBERCULOSIS OF OTHER ORGANSB909 SEQUELAE OF RESPIRATORY AND UNS TUBERCULOSISC000 MALIGNANT NEOPLASM OF EXTERNAL UPPER LIPC001 MALIGNANT NEOPLASM OF EXTERNAL LOWER LIPC002 MALIGNANT NEOPLASM OF EXTERNAL LIP UNSPECIFIEDC003 MALIGNANT NEOPLASM OF UPPER LIP INNER ASPECTC004 MALIGNANT NEOPLASM OF LOWER LIP INNER ASPECTC005 MALIGNANT NEOPLASM OF LIP UNS INNER ASPECTC006 MALIGNANT NEOPLASM COMMISSURE LIP UNSPECIFIEDC008 MALIGNANT NEOPLASM OF OVERLAPPING SITES OF LIPC009 MALIGNANT NEOPLASM OF LIP UNSPECIFIEDC01 MALIGNANT NEOPLASM OF BASE OF TONGUEC020 MALIGNANT NEOPLASM OF DORSAL SURFACE OF TONGUEC021 MALIGNANT NEOPLASM OF BORDER OF TONGUEC022 MALIGNANT NEOPLASM OF VENTRAL SURFACE OF TONGUEC023 MALIGNANT NEOPLASM ANTERIOR 2/3 TONGUE PART UNSC024 MALIGNANT NEOPLASM OF LINGUAL TONSILC028 MALIGNANT NEOPLASM OVERLAPPING SITES OF TONGUEC029 MALIGNANT NEOPLASM OF TONGUE UNSPECIFIEDC030 MALIGNANT NEOPLASM OF UPPER GUMC031 MALIGNANT NEOPLASM OF LOWER GUMC039 MALIGNANT NEOPLASM OF GUM UNSPECIFIEDC040 MALIGNANT NEOPLASM OF ANTERIOR FLOOR OF MOUTHC041 MALIGNANT NEOPLASM OF LATERAL FLOOR OF MOUTHC048 MALIGNANT NEOPLASM OVERLAPPING SITES FLOOR MOUTHC049 MALIGNANT NEOPLASM OF FLOOR OF MOUTH UNSPECIFIEDC050 MALIGNANT NEOPLASM OF HARD PALATEC051 MALIGNANT NEOPLASM OF SOFT PALATEC052 MALIGNANT NEOPLASM OF UVULAC058 MALIGNANT NEOPLASM OVERLAPPING SITES OF PALATE

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONC059 MALIGNANT NEOPLASM OF PALATE UNSPECIFIEDC060 MALIGNANT NEOPLASM OF CHEEK MUCOSAC061 MALIGNANT NEOPLASM OF VESTIBULE OF MOUTHC062 MALIGNANT NEOPLASM OF RETROMOLAR AREAC0680 MALIGNANT NEOPLASM OVERLAP SITES UNS PARTS MOUTHC0689 MALIGNANT NEOPLASM OVERLAP SITES OTH PARTS MOUTHC069 MALIGNANT NEOPLASM OF MOUTH UNSPECIFIEDC07 MALIGNANT NEOPLASM OF PAROTID GLANDC080 MALIGNANT NEOPLASM OF SUBMANDIBULAR GLANDC081 MALIGNANT NEOPLASM OF SUBLINGUAL GLANDC089 MALIGNANT NEOPLASM OF MAJOR SALIVARY GLAND UNSC090 MALIGNANT NEOPLASM OF TONSILLAR FOSSAC091 MALIGNANT NEOPLASM OF TONSILLAR PILLARC098 MALIGNANT NEOPLASM OF OVERLAPPING SITES TONSILC099 MALIGNANT NEOPLASM OF TONSIL UNSPECIFIEDC100 MALIGNANT NEOPLASM OF VALLECULAC101 MALIGNANT NEOPLASM ANTERIOR SURFACE EPIGLOTTISC102 MALIGNANT NEOPLASM OF LATERAL WALL OF OROPHARYNXC103 MALIGNANT NEOPLASM OF POSTERIOR WALL OF OROPHARYC104 MALIGNANT NEOPLASM OF BRANCHIAL CLEFTC108 MALIGNANT NEOPLASM OVERLAPPING SITES OROPHARYNXC109 MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIEDC110 MALIGNANT NEOPLASM SUPERIOR WALL OF NASOPHARYNXC111 MALIGNANT NEOPLASM POSTERIOR WALL OF NASOPHARYNXC112 MALIGNANT NEOPLASM LATERAL WALL OF NASOPHARYNXC113 MALIGNANT NEOPLASM ANTERIOR WALL OF NASOPHARYNXC118 MALIGNANT NEOPLASM OVERLAPPING SITES NASOPHARYNXC119 MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIEDC12 MALIGNANT NEOPLASM OF PYRIFORM SINUSC130 MALIGNANT NEOPLASM OF POSTCRICOID REGIONC132 MALIGNANT NEOPLASM POSTERIOR WALL OF HYPOPHARYNXC138 MALIGNANT NEOPLASM OVERLAPPING SITES HYPOPHARYNXC139 MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIEDC140 MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIEDC142 MALIGNANT NEOPLASM OF WALDEYERS RINGC153 MALIGNANT NEOPLASM OF UPPER THIRD OF ESOPHAGUSC154 MALIGNANT NEOPLASM OF MIDDLE THIRD OF ESOPHAGUSC155 MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUSC158 MALIGNANT NEOPLASM OVERLAPPING SITES ESOPHAGUSC159 MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIEDC160 MALIGNANT NEOPLASM OF CARDIAC161 MALIGNANT NEOPLASM OF FUNDUS OF STOMACHC162 MALIGNANT NEOPLASM OF BODY OF STOMACHC163 MALIGNANT NEOPLASM OF PYLORIC ANTRUMC164 MALIGNANT NEOPLASM OF PYLORUS

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONC165 MALIGNANT NEOPLASM LESSER CURVATURE STOMACH UNSC166 MALIGNANT NEOPLASM GREATER CURVATURE STOMACH UNSC168 MALIGNANT NEOPLASM OVERLAPPING SITES OF STOMACHC169 MALIGNANT NEOPLASM OF STOMACH UNSPECIFIEDC170 MALIGNANT NEOPLASM OF DUODENUMC171 MALIGNANT NEOPLASM OF JEJUNUMC172 MALIGNANT NEOPLASM OF ILEUMC178 MALIGNANT NEOPLASM OVERLAP SITES SMALL INTESTINEC179 MALIG NEOPLASM OF SMALL INTESTINE UNSPECIFIEDC180 MALIGNANT NEOPLASM OF CECUMC181 MALIGNANT NEOPLASM OF APPENDIXC182 MALIGNANT NEOPLASM OF ASCENDING COLONC183 MALIGNANT NEOPLASM OF HEPATIC FLEXUREC184 MALIGNANT NEOPLASM OF TRANSVERSE COLONC185 MALIGNANT NEOPLASM OF SPLENIC FLEXUREC186 MALIGNANT NEOPLASM OF DESCENDING COLONC187 MALIGNANT NEOPLASM OF SIGMOID COLONC188 MALIGNANT NEOPLASM OF OVERLAPPING SITES OF COLONC189 MALIGNANT NEOPLASM OF COLON UNSPECIFIEDC19 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTIONC20 MALIGNANT NEOPLASM OF RECTUMC210 MALIGNANT NEOPLASM OF ANUS UNSPECIFIEDC211 MALIGNANT NEOPLASM OF ANAL CANALC212 MALIGNANT NEOPLASM OF CLOACOGENIC ZONEC218 MAL NEOPLASM OVERLAP SITE RECTUM ANUS ANAL CANALC228 MALIGNANT NEOPLASM LIVER PRIMARY UNS AS TO TYPEC229 MALIGNANT NEOPLASM LIVER NOT SPEC PRIMARY/SECONDC23 MALIGNANT NEOPLASM OF GALLBLADDERC240 MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCTC241 MALIGNANT NEOPLASM OF AMPULLA OF VATERC248 MALIGNANT NEOPLASM OVERLAP SITE OF BILIARY TRACTC249 MALIGNANT NEOPLASM OF BILIARY TRACT UNSPECIFIEDC250 MALIGNANT NEOPLASM OF HEAD OF PANCREASC251 MALIGNANT NEOPLASM OF BODY OF PANCREASC252 MALIGNANT NEOPLASM OF TAIL OF PANCREASC253 MALIGNANT NEOPLASM OF PANCREATIC DUCTC254 MALIGNANT NEOPLASM OF ENDOCRINE PANCREASC257 MALIGNANT NEOPLASM OF OTHER PARTS OF PANCREASC258 MALIGNANT NEOPLASM OVERLAPPING SITES OF PANCREASC259 MALIGNANT NEOPLASM OF PANCREAS UNSPECIFIEDC260 MALIGNANT NEOPLASM INTESTINAL TRACT PART UNSC261 MALIGNANT NEOPLASM OF SPLEENC269 MALIGNANT NEOPLASM ILL-DEFIND SITE DIGESTIVE SYSC300 MALIGNANT NEOPLASM OF NASAL CAVITYC301 MALIGNANT NEOPLASM OF MIDDLE EAR

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONC310 MALIGNANT NEOPLASM OF MAXILLARY SINUSC311 MALIGNANT NEOPLASM OF ETHMOIDAL SINUSC312 MALIGNANT NEOPLASM OF FRONTAL SINUSC313 MALIGNANT NEOPLASM OF SPHENOID SINUSC318 MALIGNANT NEOPLASM OVERLAP SITES ACCSSRY SINUSESC319 MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSC320 MALIGNANT NEOPLASM OF GLOTTISC321 MALIGNANT NEOPLASM OF SUPRAGLOTTISC322 MALIGNANT NEOPLASM OF SUBGLOTTISC323 MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGEC328 MALIGNANT NEOPLASM OF OVERLAPPING SITES LARYNXC329 MALIGNANT NEOPLASM OF LARYNX UNSPECIFIEDC33 MALIGNANT NEOPLASM OF TRACHEAC3400 MALIGNANT NEOPLASM OF UNSPECIFIED MAIN BRONCHUSC3401 MALIGNANT NEOPLASM OF RIGHT MAIN BRONCHUSC3402 MALIGNANT NEOPLASM OF LEFT MAIN BRONCHUSC3410 MALIGNANT NEOPLASM UPPER LOBE UNS BRONCHUS/LUNGC3411 MALIGNANT NEOPLASM UPPER LOBE RT BRONCHUS/LUNGC3412 MALIGNANT NEOPLASM UPPER LOBE LT BRONCHUS/LUNGC342 MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS/LUNGC3430 MALIGNANT NEOPLASM LOWER LOBE UNS BRONCHUS/LUNGC3431 MALIGNANT NEOPLASM LOWER LOBE RT BRONCHUS/LUNGC3432 MALIGNANT NEOPLASM LOWER LOBE LT BRONCHUS/LUNGC3480 MALIGNANT NEOPLASM OVRLAP SITE UNS BRONCH & LUNGC3481 MALIGNANT NEOPLASM OVERLAP SITE RT BRONCH & LUNGC3482 MALIGNANT NEOPLASM OVERLAP SITE LT BRONCH & LUNGC3490 MALIGNANT NEOPLASM UNS PART UNS BRONCHUS/LUNGC3491 MALIGNANT NEOPLASM UNS PART RIGHT BRONCHUS/LUNGC3492 MALIGNANT NEOPLASM UNS PART LEFT BRONCHUS/LUNGC37 MALIGNANT NEOPLASM OF THYMUSC380 MALIGNANT NEOPLASM OF HEARTC381 MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUMC382 MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUMC383 MALIGNANT NEOPLASM OF MEDIASTINUM PART UNSC384 MALIGNANT NEOPLASM OF PLEURAC388 MALIG NEOPLASM OVERLAP SITE HEART MEDIAST PLEURAC390 MALIGNANT NEOPLASM UPPER RESP TRACT PART UNSC399 MALIGNANT NEOPLASM LOWER RESP TRACT PART UNSC4000 MALIGNANT NEOPLASM SCAP & LONG BONES UNS UP LIMBC4001 MALIGNANT NEOPLASM SCAP & LONG BONES RT UP LIMBC4002 MALIGNANT NEOPLASM SCAP & LONG BONES LT UP LIMBC4010 MALIGNANT NEOPLASM SHORT BONES UNS UPPER LIMBC4011 MALIGNANT NEOPLASM SHORT BONES RIGHT UPPER LIMBC4012 MALIGNANT NEOPLASM SHORT BONES LEFT UPPER LIMBC4020 MALIGNANT NEOPLASM LONG BONES UNS LOWER LIMB

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONC4021 MALIGNANT NEOPLASM LONG BONES RIGHT LOWER LIMBC4022 MALIGNANT NEOPLASM LONG BONES LEFT LOWER LIMBC4030 MALIGNANT NEOPLASM SHORT BONES UNS LOWER LIMBC4031 MALIGNANT NEOPLASM SHORT BONES RIGHT LOWER LIMBC4032 MALIGNANT NEOPLASM SHORT BONES LEFT LOWER LIMBC4080 MALIGNANT NEOPLASM OVERLAP SITE BONE AC UNS LIMBC4081 MALIGNANT NEOPLASM OVERLAP SITES BONE AC RT LIMBC4082 MALIGNANT NEOPLASM OVERLAP SITES BONE AC LT LIMBC4090 MALIGNANT NEOPLASM UNS BONES & AC OF UNS LIMBC4091 MALIGNANT NEOPLASM UNS BONES & AC OF RIGHT LIMBC4092 MALIGNANT NEOPLASM UNS BONES & AC OF LEFT LIMBC410 MALIGNANT NEOPLASM OF BONES OF SKULL AND FACEC411 MALIGNANT NEOPLASM OF MANDIBLEC412 MALIGNANT NEOPLASM OF VERTEBRAL COLUMNC413 MALIGNANT NEOPLASM OF RIBS STERNUM AND CLAVICLEC414 MALIGNANT NEOPLASM PELVIC BONES SACRUM & COCCYXC419 MALIGNANT NEOPLASM BONE ARTICULAR CARTILAGE UNSC4400 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIPC4409 OTHER SPECIFIED MALIGNANT NEOPLASM SKIN OF LIPC44101 UNS MALIG NEOPLASM SKIN UNS EYELID INCL CANTHUSC44102 UNS MALIG NEOPLASM SKIN RT EYELID INCL CANTHUSC44109 UNS MALIG NEOPLASM SKIN LT EYELID INCL CANTHUSC44191 OTH SPEC MALIG NEOPLSM SKN UNS EYELD W/ CANTHUSC44192 OTH SPEC MALIG NEOPLSM SKN RT EYELD INCL CANTHUSC44199 OTH SPEC MALIG NEOPLSM SKN LT EYELD INCL CANTHUSC44201 UNS MAL NEOPLSM SKN UNS EAR EXT AURICULAR CANALC44202 UNS MALIG NEOPLSM SKN RT EAR EXT AURICULAR CANALC44209 UNS MALIG NEOPLSM SKN LT EAR EXT AURICULAR CANALC44300 UNS MALIGNANT NEOPLASM SKIN UNS PART FACEC44301 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF NOSEC44309 UNS MALIGNANT NEOPLASM SKIN OTHER PARTS FACEC44390 OTHER SPEC MALIG NEOPLASM SKIN UNS PARTS FACEC44391 OTHER SPECIFIED MALIGNANT NEOPLASM SKIN OF NOSEC44399 OTHER SPEC MALIG NEOPLASM SKIN OTHER PARTS FACEC4440 UNSPECIFIED MALIGNANT NEOPLASM SKIN SCALP & NECKC4449 OTHER SPEC MALIGNANT NEOPLASM SKIN SCALP & NECKC44500 UNSPECIFIED MALIGNANT NEOPLASM OF ANAL SKINC44501 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF BREASTC44509 UNS MALIGNANT NEOPLASM SKIN OTHER PART TRUNKC44590 OTHER SPECIFIED MALIGNANT NEOPLASM OF ANAL SKINC44591 OTHER SPECIFIED MALIGNANT NEOPLASM SKIN BREASTC44599 OTHER SPEC MALIG NEOPLASM SKIN OTHER PART TRUNKC44601 UNS MALIG NEOPLASM SKIN UNS UP LIMB INCL SHLDRC44602 UNS MALIG NEOPLASM SKIN RT UPPER LIMB INCL SHLDRC44609 UNS MALIG NEOPLASM SKIN LT UPPER LIMB INCL SHLDR

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONC44691 OTH SPEC MALIG NEOPLSM SKN UNS UP LIMB W/ SHLDRC44692 OTH SPEC MALIG NEOPLSM SKN RT UP LIMB INCL SHLDRC44699 OTH SPEC MALIG NEOPLSM SKN LT UP LIMB INCL SHLDRC44701 UNS MALIG NEOPLASM SKIN UNS LOWER LIMB INCL HIPC44702 UNS MALIG NEOPLASM SKIN RT LOWER LIMB INCL HIPC44709 UNS MALIG NEOPLASM SKIN LT LOWER LIMB INCL HIPC44791 OTH SPEC MALIG NEOPLSM SKN UNS LOW LIMB INCL HIPC44792 OTH SPEC MALIG NEOPLSM SKIN RT LOW LIMB INCL HIPC44799 OTH SPEC MALIG NEOPLSM SKIN LT LOW LIMB INCL HIPC4480 UNS MALIGNANT NEOPLASM OVERLAPPING SITES SKINC4489 OTHER SPEC MALIG NEOPLASM OVERLAPPING SITES SKINC4490 UNSPECIFIED MALIGNANT NEOPLASM SKIN UNSPECIFIEDC4499 OTHER SPEC MALIGNANT NEOPLASM SKIN UNSPECIFIEDC470 MALIGNANT NEOPLASM PERIPH NERVES HEAD FACE NECKC4710 MAL NEOPLASM PERIPH NERVE UNS UP LIMB INCL SHLDRC4711 MAL NEOPLASM PERIPH NERVES RT UP LIMB INCL SHLDRC4712 MAL NEOPLASM PERIPH NERVES LT UP LIMB INCL SHLDRC4720 MAL NEOPLASM PERIPH NERVES UNS LOW LIMB INCL HIPC4721 MAL NEOPLASM PERIPH NERVES RT LOW LIMB INCL HIPC4722 MAL NEOPLASM PERIPH NERVES LT LOW LIMB INCL HIPC473 MALIGNANT NEOPLASM PERIPHERAL NERVES OF THORAXC474 MALIGNANT NEOPLASM PERIPHERAL NERVES OF ABDOMENC475 MALIGNANT NEOPLASM PERIPHERAL NERVES OF PELVISC476 MALIGNANT NEOPLASM PERIPHERAL NERVES TRUNK UNSC478 MALIGNANT NEOPLASM OVERLAP SITES PERIPH & ANSC479 MALIGNANT NEOPLASM PERIPH NERVES & ANS UNSC480 MALIGNANT NEOPLASM OF RETROPERITONEUMC481 MALIGNANT NEOPLASM OF SPEC PARTS OF PERITONEUMC482 MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIEDC488 MALIGNANT NEOPLASM OVERLAP SITES RP & PERITONEUMC490 MALIGNANT NEOPLASM CONN SOFT TISS HEAD FACE NECKC4910 MALIG NEOPLASM CONN SOFT TISS UNS UP LMB W/SHLDRC4911 MALIG NEOPLASM CONN SOFT TISS RT UP LIMB W/SHLDRC4912 MALIG NEOPLASM CONN SOFT TISS LT UP LIMB W/SHLDRC4920 MALIG NEOPLASM CONN SOFT TISS UNS LOW LIMB W/HIPC4921 MALIG NEOPLASM CONN SOFT TISS RT LOW LIMB W/HIPC4922 MALIG NEOPLASM CONN SOFT TISS LT LOW LIMB W/HIPC493 MALIGNANT NEOPLASM CONNECTIVE & SOFT TISS THORAXC494 MALIGNANT NEOPLASM CONNECTIVE & SOFT TISS ABDOMNC495 MALIGNANT NEOPLASM CONNECTIVE & SOFT TISS PELVISC496 MALIGNANT NEOPLASM CONN & SOFT TISS TRUNK UNSC498 MALIGNANT NEOPLASM OVERLAP SITES CONN SOFT TISSC499 MALIGNANT NEOPLASM CONNECTIVE & SOFT TISSUE UNSC50011 MALIG NEOPLASM NIPPLE & AREOLA RT FEMALE BREASTC50012 MALIG NEOPLASM NIPPLE & AREOLA LT FEMALE BREAST

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONC50019 MALIG NEOPLASM NIPPLE & AREOLA UNS FEMALE BREASTC50021 MALIG NEOPLASM NIPPLE & AREOLA RIGHT MALE BREASTC50022 MALIG NEOPLASM NIPPLE & AREOLA LEFT MALE BREASTC50029 MALIG NEOPLASM NIPPLE & AREOLA UNS MALE BREASTC50111 MALIG NEOPLASM CENTRAL PORTION RT FEMALE BREASTC50112 MALIG NEOPLASM CENTRAL PORTION LT FEMALE BREASTC50119 MALIG NEOPLASM CENTRAL PORTION UNS FEMALE BREASTC50121 MALIG NEOPLASM CENTRAL PORTION RIGHT MALE BREASTC50122 MALIG NEOPLASM CENTRAL PORTION LEFT MALE BREASTC50129 MALIG NEOPLASM CENTRAL PORTION UNS MALE BREASTC50211 MALIG NEOPLASM UPPER-INNER QUAD RT FEMALE BREASTC50212 MALIG NEOPLASM UPPER-INNER QUAD LT FEMALE BREASTC50219 MALIG NEOPLASM UPPR-INNER QUAD UNS FEMALE BREASTC50221 MALIG NEOPLASM UPPER-INNER QUAD RT MALE BREASTC50222 MALIG NEOPLASM UPPER-INNER QUAD LT MALE BREASTC50229 MALIG NEOPLASM UPPER-INNER QUAD UNS MALE BREASTC50311 MALIG NEOPLASM LOWER-INNER QUAD RT FEMALE BREASTC50312 MALIG NEOPLASM LOWER-INNER QUAD LT FEMALE BREASTC50319 MALIG NEOPLASM LOWER-INNER QUAD UNS FEMALE BRSTC50321 MALIG NEOPLASM LOWER-INNER QUAD RT MALE BREASTC50322 MALIG NEOPLASM LOWER-INNER QUAD LT MALE BREASTC50329 MALIG NEOPLASM LOWER-INNER QUAD UNS MALE BREASTC50411 MALIG NEOPLASM UPPER-OUTER QUAD RT FEMALE BREASTC50412 MALIG NEOPLASM UPPER-OUTER QUAD LT FEMALE BREASTC50419 MALIG NEOPLASM UPPER-OUTER QUAD UNS FEMALE BRSTC50421 MALIG NEOPLASM UPPER-OUTER QUAD RT MALE BREASTC50422 MALIG NEOPLASM UPPER-OUTER QUAD LT MALE BREASTC50429 MALIG NEOPLASM UPPER-OUTER QUAD UNS MALE BREASTC50511 MALIG NEOPLASM LOWER-OUTER QUAD RT FEMALE BREASTC50512 MALIG NEOPLASM LOWER-OUTER QUAD LT FEMALE BREASTC50519 MALIG NEOPLASM LOWER-OUTER QUAD UNS FEMALE BRSTC50521 MALIG NEOPLASM LOWER-OUTER QUAD RT MALE BREASTC50522 MALIG NEOPLASM LOWER-OUTER QUAD LT MALE BREASTC50529 MALIG NEOPLASM LOWER-OUTER QUAD UNS MALE BREASTC50611 MALIGNANT NEOPLASM AXILLARY TAIL RT FEMALE BRSTC50612 MALIGNANT NEOPLASM AXILLARY TAIL LT FEMALE BRSTC50619 MALIGNANT NEOPLASM AXILLARY TAIL UNS FEMALE BRSTC50621 MALIGNANT NEOPLASM AXILLARY TAIL RT MALE BREASTC50622 MALIGNANT NEOPLASM AXILLARY TAIL LT MALE BREASTC50629 MALIGNANT NEOPLASM AXILLARY TAIL UNS MALE BREASTC50811 MALIGNANT NEOPLASM OVERLAP SITE RT FEMALE BREASTC50812 MALIGNANT NEOPLASM OVERLAP SITE LT FEMALE BREASTC50819 MALIGNANT NEOPLASM OVERLAP SITE UNS FEMAL BREASTC50821 MALIGNANT NEOPLASM OVERLAP SITES RT MALE BREASTC50822 MALIGNANT NEOPLASM OVERLAP SITES LT MALE BREAST

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONC50829 MALIGNANT NEOPLASM OVERLAP SITES UNS MALE BREASTC50911 MALIGNANT NEOPLASM UNS SITE RIGHT FEMALE BREASTC50912 MALIGNANT NEOPLASM UNS SITE LEFT FEMALE BREASTC50919 MALIGNANT NEOPLASM UNS SITE UNS FEMALE BREASTC50921 MALIGNANT NEOPLASM OF UNS SITE RIGHT MALE BREASTC50922 MALIGNANT NEOPLASM OF UNS SITE LEFT MALE BREASTC50929 MALIGNANT NEOPLASM OF UNS SITE UNS MALE BREASTC510 MALIGNANT NEOPLASM OF LABIUM MAJUSC511 MALIGNANT NEOPLASM OF LABIUM MINUSC512 MALIGNANT NEOPLASM OF CLITORISC518 MALIGNANT NEOPLASM OF OVERLAPPING SITES OF VULVAC519 MALIGNANT NEOPLASM OF VULVA UNSPECIFIEDC52 MALIGNANT NEOPLASM OF VAGINAC530 MALIGNANT NEOPLASM OF ENDOCERVIXC531 MALIGNANT NEOPLASM OF EXOCERVIXC538 MALIGNANT NEOPLASM OVERLAPPING SITE CERVIX UTERIC539 MALIGNANT NEOPLASM OF CERVIX UTERI UNSPECIFIEDC540 MALIGNANT NEOPLASM OF ISTHMUS UTERIC541 MALIGNANT NEOPLASM OF ENDOMETRIUMC542 MALIGNANT NEOPLASM OF MYOMETRIUMC543 MALIGNANT NEOPLASM OF FUNDUS UTERIC548 MALIGNANT NEOPLASM OVERLAPPING SITE CORPUS UTERIC549 MALIGNANT NEOPLASM OF CORPUS UTERI UNSPECIFIEDC55 MALIGNANT NEOPLASM OF UTERUS PART UNSPECIFIEDC561 MALIGNANT NEOPLASM OF RIGHT OVARYC562 MALIGNANT NEOPLASM OF LEFT OVARYC569 MALIGNANT NEOPLASM OF UNSPECIFIED OVARYC5700 MALIGNANT NEOPLASM OF UNSPECIFIED FALLOPIAN TUBEC5701 MALIGNANT NEOPLASM OF RIGHT FALLOPIAN TUBEC5702 MALIGNANT NEOPLASM OF LEFT FALLOPIAN TUBEC5710 MALIGNANT NEOPLASM OF UNSPECIFIED BROAD LIGAMENTC5711 MALIGNANT NEOPLASM OF RIGHT BROAD LIGAMENTC5712 MALIGNANT NEOPLASM OF LEFT BROAD LIGAMENTC5720 MALIGNANT NEOPLASM OF UNSPECFIED ROUND LIGAMENTC5721 MALIGNANT NEOPLASM OF RIGHT ROUND LIGAMENTC5722 MALIGNANT NEOPLASM OF LEFT ROUND LIGAMENTC573 MALIGNANT NEOPLASM OF PARAMETRIUMC574 MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIEDC577 MALIG NEOPLASM OTH SPEC FEMALE GENITAL ORGANSC579 MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN UNSC58 MALIGNANT NEOPLASM OF PLACENTAC600 MALIGNANT NEOPLASM OF PREPUCEC601 MALIGNANT NEOPLASM OF GLANS PENISC602 MALIGNANT NEOPLASM OF BODY OF PENISC608 MALIGNANT NEOPLASM OF OVERLAPPING SITES OF PENIS

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONC609 MALIGNANT NEOPLASM OF PENIS UNSPECIFIEDC61 MALIGNANT NEOPLASM OF PROSTATEC6200 MALIGNANT NEOPLASM UNS UNDESCENDED TESTISC6201 MALIGNANT NEOPLASM OF UNDESCENDED RIGHT TESTISC6202 MALIGNANT NEOPLASM OF UNDESCENDED LEFT TESTISC6210 MALIGNANT NEOPLASM UNSPECIFIED DESCENDED TESTISC6211 MALIGNANT NEOPLASM OF DESCENDED RIGHT TESTISC6212 MALIGNANT NEOPLASM OF DESCENDED LEFT TESTISC6290 MALIGNANT NEOPLASM UNS TESTIS UNS DESC/UNDESCENDC6291 MALIGNANT NEOPLASM RT TESTIS UNS DESC/UNDESCENDC6292 MALIGNANT NEOPLASM LT TESTIS UNS DESC/UNDESCENDC6300 MALIGNANT NEOPLASM OF UNSPECIFIED EPIDIDYMISC6301 MALIGNANT NEOPLASM OF RIGHT EPIDIDYMISC6302 MALIGNANT NEOPLASM OF LEFT EPIDIDYMISC6310 MALIGNANT NEOPLASM OF UNSPECIFIED SPERMATIC CORDC6311 MALIGNANT NEOPLASM OF RIGHT SPERMATIC CORDC6312 MALIGNANT NEOPLASM OF LEFT SPERMATIC CORDC632 MALIGNANT NEOPLASM OF SCROTUMC637 MALIGNANT NEOPLASM OTH SPEC MALE GENITAL ORGANSC638 MAL NEOPLASM OVERLAPPING SITES MALE GENITAL ORGNC639 MALIGNANT NEOPLASM MALE GENITAL ORGAN UNSPECC641 MALIGNANT NEOPLASM RT KIDNEY EXCEPT RENAL PELVISC642 MALIGNANT NEOPLASM LT KIDNEY EXCEPT RENAL PELVISC649 MALIGNANT NEOPLASM UNS KIDNEY EXCEPT RENL PELVISC651 MALIGNANT NEOPLASM OF RIGHT RENAL PELVISC652 MALIGNANT NEOPLASM OF LEFT RENAL PELVISC659 MALIGNANT NEOPLASM OF UNSPECIFIED RENAL PELVISC661 MALIGNANT NEOPLASM OF RIGHT URETERC662 MALIGNANT NEOPLASM OF LEFT URETERC669 MALIGNANT NEOPLASM OF UNSPECIFIED URETERC670 MALIGNANT NEOPLASM OF TRIGONE OF BLADDERC671 MALIGNANT NEOPLASM OF DOME OF BLADDERC672 MALIGNANT NEOPLASM OF LATERAL WALL OF BLADDERC673 MALIGNANT NEOPLASM OF ANTERIOR WALL OF BLADDERC674 MALIGNANT NEOPLASM OF POSTERIOR WALL OF BLADDERC675 MALIGNANT NEOPLASM OF BLADDER NECKC676 MALIGNANT NEOPLASM OF URETERIC ORIFICEC677 MALIGNANT NEOPLASM OF URACHUSC678 MALIGNANT NEOPLASM OVERLAPPING SITES OF BLADDERC679 MALIGNANT NEOPLASM OF BLADDER UNSPECIFIEDC680 MALIGNANT NEOPLASM OF URETHRAC681 MALIGNANT NEOPLASM OF PARAURETHRAL GLANDSC688 MALIGNANT NEOPLASM OVERLAP SITES URINARY ORGANSC689 MALIGNANT NEOPLASM OF URINARY ORGAN UNSPECIFIEDC6900 MALIGNANT NEOPLASM OF UNSPECIFIED CONJUNCTIVA

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONC6901 MALIGNANT NEOPLASM OF RIGHT CONJUNCTIVAC6902 MALIGNANT NEOPLASM OF LEFT CONJUNCTIVAC6910 MALIGNANT NEOPLASM OF UNSPECIFIED CORNEAC6911 MALIGNANT NEOPLASM OF RIGHT CORNEAC6912 MALIGNANT NEOPLASM OF LEFT CORNEAC6920 MALIGNANT NEOPLASM OF UNSPECIFIED RETINAC6921 MALIGNANT NEOPLASM OF RIGHT RETINAC6922 MALIGNANT NEOPLASM OF LEFT RETINAC6930 MALIGNANT NEOPLASM OF UNSPECIFIED CHOROIDC6931 MALIGNANT NEOPLASM OF RIGHT CHOROIDC6932 MALIGNANT NEOPLASM OF LEFT CHOROIDC6940 MALIGNANT NEOPLASM OF UNSPECIFIED CILIARY BODYC6941 MALIGNANT NEOPLASM OF RIGHT CILIARY BODYC6942 MALIGNANT NEOPLASM OF LEFT CILIARY BODYC6950 MALIGNANT NEOPLASM UNS LACRIMAL GLAND & DUCTC6951 MALIGNANT NEOPLASM RIGHT LACRIMAL GLAND AND DUCTC6952 MALIGNANT NEOPLASM LEFT LACRIMAL GLAND AND DUCTC6960 MALIGNANT NEOPLASM OF UNSPECIFIED ORBITC6961 MALIGNANT NEOPLASM OF RIGHT ORBITC6962 MALIGNANT NEOPLASM OF LEFT ORBITC6980 MALIGNANT NEOPLASM OVERLAP SITES UNS EYE&ADNEXAC6981 MALIGNANT NEOPLASM OVERLAP SITES RT EYE & ADNEXAC6982 MALIGNANT NEOPLASM OVERLAP SITES LT EYE & ADNEXAC6990 MALIGNANT NEOPLASM UNSPECIFIED SITE UNSPEC EYEC6991 MALIGNANT NEOPLASM OF UNSPECIFIED SITE RIGHT EYEC6992 MALIGNANT NEOPLASM OF UNSPECIFIED SITE LEFT EYEC700 MALIGNANT NEOPLASM OF CEREBRAL MENINGESC701 MALIGNANT NEOPLASM OF SPINAL MENINGESC709 MALIGNANT NEOPLASM OF MENINGES UNSPECIFIEDC710 MALIGNANT NEOPLASM CEREBRUM NO LOBES VENTRICLESC711 MALIGNANT NEOPLASM OF FRONTAL LOBEC712 MALIGNANT NEOPLASM OF TEMPORAL LOBEC713 MALIGNANT NEOPLASM OF PARIETAL LOBEC714 MALIGNANT NEOPLASM OF OCCIPITAL LOBEC715 MALIGNANT NEOPLASM OF CEREBRAL VENTRICLEC716 MALIGNANT NEOPLASM OF CEREBELLUMC717 MALIGNANT NEOPLASM OF BRAIN STEMC718 MALIGNANT NEOPLASM OF OVERLAPPING SITES OF BRAINC719 MALIGNANT NEOPLASM OF BRAIN UNSPECIFIEDC720 MALIGNANT NEOPLASM OF SPINAL CORDC721 MALIGNANT NEOPLASM OF CAUDA EQUINAC7220 MALIGNANT NEOPLASM UNSPECIFIED OLFACTORY NERVEC7221 MALIGNANT NEOPLASM OF RIGHT OLFACTORY NERVEC7222 MALIGNANT NEOPLASM OF LEFT OLFACTORY NERVEC7230 MALIGNANT NEOPLASM OF UNSPECIFIED OPTIC NERVE

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONC7231 MALIGNANT NEOPLASM OF RIGHT OPTIC NERVEC7232 MALIGNANT NEOPLASM OF LEFT OPTIC NERVEC7240 MALIGNANT NEOPLASM OF UNSPECIFIED ACOUSTIC NERVEC7241 MALIGNANT NEOPLASM OF RIGHT ACOUSTIC NERVEC7242 MALIGNANT NEOPLASM OF LEFT ACOUSTIC NERVEC7250 MALIGNANT NEOPLASM OF UNSPECIFIED CRANIAL NERVEC7259 MALIGNANT NEOPLASM OF OTHER CRANIAL NERVESC729 MALIGNANT NEOPLASM OF CENTRAL NERVOUS SYSTEM UNSC73 MALIGNANT NEOPLASM OF THYROID GLANDC7400 MALIGNANT NEOPLASM CORTEX UNS ADRENAL GLANDC7401 MALIGNANT NEOPLASM CORTEX OF RIGHT ADRENAL GLANDC7402 MALIGNANT NEOPLASM CORTEX OF LEFT ADRENAL GLANDC7410 MALIGNANT NEOPLASM MEDULLA UNS ADRENAL GLANDC7411 MALIGNANT NEOPLASM MEDULLA RIGHT ADRENAL GLANDC7412 MALIGNANT NEOPLASM MEDULLA LEFT ADRENAL GLANDC7490 MALIGNANT NEOPLASM UNS PART UNS ADRENAL GLANDC7491 MALIGNANT NEOPLASM UNS PART RIGHT ADRENAL GLANDC7492 MALIGNANT NEOPLASM UNS PART LEFT ADRENAL GLANDC750 MALIGNANT NEOPLASM OF PARATHYROID GLANDC751 MALIGNANT NEOPLASM OF PITUITARY GLANDC752 MALIGNANT NEOPLASM OF CRANIOPHARYNGEAL DUCTC753 MALIGNANT NEOPLASM OF PINEAL GLANDC754 MALIGNANT NEOPLASM OF CAROTID BODYC755 MALIGNANT NEOPLASM AORTIC BODY & OTH PARAGANGLIAC758 MALIGNANT NEOPLASM W/PLURIGLANDULAR INVLV UNSC759 MALIGNANT NEOPLASM OF ENDOCRINE GLAND UNSC760 MALIGNANT NEOPLASM OF HEAD FACE AND NECKC761 MALIGNANT NEOPLASM OF THORAXC762 MALIGNANT NEOPLASM OF ABDOMENC763 MALIGNANT NEOPLASM OF PELVISC7640 MALIGNANT NEOPLASM OF UNSPECIFIED UPPER LIMBC7641 MALIGNANT NEOPLASM OF RIGHT UPPER LIMBC7642 MALIGNANT NEOPLASM OF LEFT UPPER LIMBC7650 MALIGNANT NEOPLASM OF UNSPECIFIED LOWER LIMBC7651 MALIGNANT NEOPLASM OF RIGHT LOWER LIMBC7652 MALIGNANT NEOPLASM OF LEFT LOWER LIMBC768 MALIG NEOPLASM OVRLAP SITE OTH ILL-DEFINED SITESC772 SEC & UNS MALIG NEOPLASM INTRA-ABD LYMPH NODESC774 SEC & UNS MALIG NEOPLASM INGUINAL LOW LIMB NODESC775 SEC & UNS MALIG NEOPLASM INTRAPELVIC LYMPH NODESC778 SEC & UNS MALIG NEOPLASM LYMPH NODES MX REGIONSC779 SECONDARY & UNS MALIG NEOPLASM LYMPH NODE UNSC7800 SECONDARY MALIGNANT NEOPLASM OF UNSPECIFIED LUNGC7801 SECONDARY MALIGNANT NEOPLASM OF RIGHT LUNGC7802 SECONDARY MALIGNANT NEOPLASM OF LEFT LUNG

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONC781 SECONDARY MALIGNANT NEOPLASM OF MEDIASTINUMC782 SECONDARY MALIGNANT NEOPLASM OF PLEURAC7830 SECONDARY MALIG NEOPLASM UNS RESPIRATORY ORGANC7839 SECONDARY MALIGNANT NEOPLASM OF OTHER RESPIRATORC784 SECONDARY MALIGNANT NEOPLASM OF SMALL INTESTINEC785 SECONDARY MAL NEOPLASM LARGE INTESTINE & RECTUMC786 SEC MALIG NEOPLASM RETROPERITONEUM & PERITONEUMC787 SECONDARY MALIG NEOPLASM LIVER & INTRAHEPATIC BDC7880 SECONDARY MALIG NEOPLASM UNS DIGESTIVE ORGANC7889 SECONDARY MALIG NEOPLASM OF OTH DIGESTIVE ORGANSC7900 SECONDARY MALIG NEOPLASM UNS KIDNEY RENAL PELVISC7901 SECONDARY MALIG NEOPLASM RT KIDNEY & RENAL PELVC7902 SECONDARY MALIG NEOPLASM LT KIDNEY & RENAL PELVC7910 SECONDARY MALIGNANT NEOPLASM UNS URINARY ORGANSC7911 SECONDARY MALIGNANT NEOPLASM OF BLADDERC7919 SECONDARY MALIGNANT NEOPLASM OTH URINARY ORGANSC792 SECONDARY MALIGNANT NEOPLASM OF SKINC7931 SECONDARY MALIGNANT NEOPLASM OF BRAINC7932 SECONDARY MALIGNANT NEOPLASM CEREBRAL MENINGESC7940 SECONDARY MALIGNANT NEOPLASM UNS PART NERV SYSC7949 SECONDARY MALIGNANT NEOPLASM OTH PARTS NERV SYSC7951 SECONDARY MALIGNANT NEOPLASM OF BONEC7952 SECONDARY MALIGNANT NEOPLASM OF BONE MARROWC7960 SECONDARY MALIGNANT NEOPLASM UNSPECIFIED OVARYC7961 SECONDARY MALIGNANT NEOPLASM OF RIGHT OVARYC7962 SECONDARY MALIGNANT NEOPLASM OF LEFT OVARYC7970 SECONDARY MALIGNANT NEOPLASM UNS ADRENAL GLANDC7971 SECONDARY MALIGNANT NEOPLASM RIGHT ADRENAL GLANDC7972 SECONDARY MALIGNANT NEOPLASM LEFT ADRENAL GLANDC7981 SECONDARY MALIGNANT NEOPLASM OF BREASTC7982 SECONDARY MALIGNANT NEOPLASM OF GENITAL ORGANSC7989 SECONDARY MALIGNANT NEOPLASM OTH SPECIFIED SITESC799 SECONDARY MALIGNANT NEOPLASM OF UNSPECIFIED SITEC800 DISSEMINATED MALIGNANT NEOPLASM UNSPECIFIEDC801 MALIGNANT PRIMARY NEOPLASM UNSPECIFIEDC802 MALIGNANT NEOPLASM ASSOC W/TRANSPLANTED ORGANC969 MAL NEOPLSM LYMPHOID HEMATOPOIET & REL TISS UNSC96Z OTH MAL NEOPLSM LYMPHOID HEMATOPOIET & REL TISSD3701 NEOPLASM OF UNCERTAIN BEHAVIOR OF LIPD3702 NEOPLASM OF UNCERTAIN BEHAVIOR OF TONGUED37030 NEOPLASM UNCERTAIN BHV PAROTID SALIVARY GLANDSD37031 NEOPLASM UNCERTAIN BEHAVIOR SUBL SALIVARY GLANDSD37032 NEOPLASM UNCERTAIN BEHAVIOR SUBMAND SALIV GLANDSD37039 NEOPLASM UNCERTAIN BHV MAJOR SALIVARY GLANDS UNSD3704 NEOPLASM UNCERTAIN BEHAVIOR MIN SALIVARY GLANDS

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIOND3705 NEOPLASM OF UNCERTAIN BEHAVIOR OF PHARYNXD3709 NEOPLASM UNCERTAIN BHV OTH SPEC SITES ORAL CAVD371 NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACHD372 NEOPLASM UNCERTAIN BEHAVIOR OF SMALL INTESTINED373 NEOPLASM OF UNCERTAIN BEHAVIOR OF APPENDIXD374 NEOPLASM OF UNCERTAIN BEHAVIOR OF COLOND375 NEOPLASM OF UNCERTAIN BEHAVIOR OF RECTUMD376 NEOPLASM UNCERTAIN BHV LIVER GALLBLADDER & BDD378 NEOPLASM UNCERTAIN BHV OTH SPEC DIGESTIVE ORGAND379 NEOPLASM UNCERTAIN BEHAVIOR DIGESTIVE ORGAN UNSD380 NEOPLASM OF UNCERTAIN BEHAVIOR OF LARYNXD381 NEOPLASM UNCERTAIN BHV TRACHEA BRONCHUS & LUNGD382 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLEURAD383 NEOPLASM OF UNCERTAIN BEHAVIOR OF MEDIASTINUMD384 NEOPLASM OF UNCERTAIN BEHAVIOR OF THYMUSD385 NEOPLASM UNCERTAIN BEHAVIOR OTH RESPIRATORY ORGD386 NEOPLASM UNCERTAIN BEHAVIOR RESP ORGAN UNSD390 NEOPLASM OF UNCERTAIN BEHAVIOR OF UTERUSD3910 NEOPLASM UNCERTAIN BEHAVIOR OF UNSPECIFIED OVARYD3911 NEOPLASM OF UNCERTAIN BEHAVIOR OF RIGHT OVARYD3912 NEOPLASM OF UNCERTAIN BEHAVIOR OF LEFT OVARYD392 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLACENTAD398 NEOPLASM UNCERTAIN BHV OTH SPEC FEMALE GEN ORGAND399 NEOPLASM UNCERTAIN BHV FEMALE GENITAL ORGANS UNSD400 NEOPLASM OF UNCERTAIN BEHAVIOR OF PROSTATED4010 NEOPLASM OF UNCERTAIN BEHAVIOR UNS TESTISD4011 NEOPLASM OF UNCERTAIN BEHAVIOR OF RIGHT TESTISD4012 NEOPLASM OF UNCERTAIN BEHAVIOR OF LEFT TESTISD408 NEOPLASM UNCERTAIN BHV OTH SPEC MALE GENIT ORGAND409 NEOPLASM UNCERTAIN BEHAVIOR MALE GENITAL ORG UNSD4100 NEOPLASM OF UNCERTAIN BEHAVIOR UNS KIDNEYD4101 NEOPLASM OF UNCERTAIN BEHAVIOR OF RIGHT KIDNEYD4102 NEOPLASM OF UNCERTAIN BEHAVIOR OF LEFT KIDNEYD4110 NEOPLASM OF UNCERTAIN BEHAVIOR UNS RENAL PELVISD4111 NEOPLASM OF UNCERTAIN BEHAVIOR RT RENAL PELVISD4112 NEOPLASM OF UNCERTAIN BEHAVIOR LT RENAL PELVISD4120 NEOPLASM OF UNCERTAIN BEHAVIOR UNS URETERD4121 NEOPLASM OF UNCERTAIN BEHAVIOR OF RIGHT URETERD4122 NEOPLASM OF UNCERTAIN BEHAVIOR OF LEFT URETERD413 NEOPLASM OF UNCERTAIN BEHAVIOR OF URETHRAD414 NEOPLASM OF UNCERTAIN BEHAVIOR OF BLADDERD418 NEOPLASM OFUNCERTAIN BHV OTH SPEC URINARY ORGAND419 NEOPLASM OF UNCERTAIN BEHAVIOR UNS URINARY ORGAND420 NEOPLASM OF UNCERTAIN BEHAVIOR CEREBRAL MENINGESD421 NEOPLASM OF UNCERTAIN BEHAVIOR SPINAL MENINGES

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIOND429 NEOPLASM OF UNCERTAIN BEHAVIOR OF MENINGES UNSD430 NEOPLASM UNCERTAIN BEHAVIOR BRAIN SUPRATENTORIALD431 NEOPLASM UNCERTAIN BEHAVIOR BRAIN INFRATENTORIALD432 NEOPLASM OF UNCERTAIN BEHAVIOR BRAIN UNSPECIFIEDD433 NEOPLASM OF UNCERTAIN BEHAVIOR OF CRANIAL NERVESD434 NEOPLASM OF UNCERTAIN BEHAVIOR OF SPINAL CORDD438 NEOPLASM OF UNCERTAIN BEHAVIOR OTH SPEC PART CNSD439 NEOPLASM OF UNCERTAIN BEHAVIOR CNS UNSPECIFIEDD440 NEOPLASM OF UNCERTAIN BEHAVIOR OF THYROID GLANDD4410 NEOPLASM OF UNCERTAIN BEHAVIOR UNS ADRENAL GLANDD4411 NEOPLASM OF UNCERTAIN BEHAVIOR RT ADRENAL GLANDD4412 NEOPLASM OF UNCERTAIN BEHAVIOR LT ADRENAL GLANDD442 NEOPLASM OF UNCERTAIN BEHAVIOR PARATHYROID GLANDD443 NEOPLASM OF UNCERTAIN BEHAVIOR PITUITARY GLANDD444 NEOPLASM OF UNCERTAIN BHV CRANIOPHARYNGEAL DUCTD445 NEOPLASM OF UNCERTAIN BEHAVIOR OF PINEAL GLANDD446 NEOPLASM OF UNCERTAIN BEHAVIOR OF CAROTID BODYD447 NEOPLASM UNCERT BHV AORTIC BODY OTH PARAGANGLIAD449 NEOPLASM UNCERTAIN BEHAVIOR UNS ENDOCRINE GLANDD479 NEOPLASM UNCERT BHV LYMPHOID HP & REL TISSUE UNSD480 NEOPLASM UNCERTAIN BHV BONE & ARTICULR CARTILAGED481 NEOPLASM UNCERTAIN BHV CONNCTIVE & OTH SOFT TISSD482 NEOPLASM UNCERTAIN BHV PERIPHERAL NERVES & ANSD483 NEOPLASM UNCERTAIN BEHAVIOR OF RETROPERITONEUMD484 NEOPLASM OF UNCERTAIN BEHAVIOR OF PERITONEUMD485 NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIND4860 NEOPLASM OF UNCERTAIN BEHAVIOR UNS BREASTD4861 NEOPLASM OF UNCERTAIN BEHAVIOR OF RIGHT BREASTD4862 NEOPLASM OF UNCERTAIN BEHAVIOR OF LEFT BREASTD487 NEOPLASM OF UNCERTAIN BEHAVIOR OTHER SPEC SITESD489 NEOPLASM OF UNCERTAIN BEHAVIOR UNSPECIFIEDD490 NEOPLASM OF UNS BEHAVIOR DIGESTIVE SYSTEMD491 NEOPLASM OF UNS BEHAVIOR RESPIRATORY SYSTEMD492 NEOPLASM OF UNS BEHAVIOR BONE SOFT TISSUE & SKIND493 NEOPLASM OF UNSPECIFIED BEHAVIOR OF BREASTD494 NEOPLASM OF UNSPECIFIED BEHAVIOR OF BLADDERD495 NEOPLASM OF UNS BEHAVIOR OTH GENITOURINRY ORGANSD496 NEOPLASM OF UNSPECIFIED BEHAVIOR OF BRAIND497 NEOPLASM OF UNS BHV ENDOCRN GLAND & OTH PART NSD4981 NEOPLASM OF UNSPECIFIED BEHAVIOR RETINA CHOROIDD4989 NEOPLASM OF UNSPECIFIED BEHAVIOR OTH SPEC SITESD499 NEOPLASM OF UNSPECIFIED BEHAVIOR UNS SITED5700 HB-SS DISEASE WITH CRISIS UNSPECIFIEDD5701 HB-SS DISEASE WITH ACUTE CHEST SYNDROMED5702 HB-SS DISEASE WITH SPLENIC SEQUESTRATION

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIOND571 SICKLE-CELL DISEASE WITHOUT CRISISD5720 SICKLE-CELL/HB-C DISEASE WITHOUT CRISISD57211 SICKLE-CELL/HB-C DISEASE WITH ACUTE CHEST SYNDD57212 SICKLE-CELL/HB-C DISEASE W/SPLENIC SEQUESTRATIOND57219 SICKLE-CELL/HB-C DISEASE WITH CRISIS UNSPECIFIEDD5740 SICKLE-CELL THALASSEMIA WITHOUT CRISISD57411 SICKLE-CELL THALASSEMIA WITH ACUTE CHEST SYNDD57412 SICKLE-CELL THALASSEMIA W/SPLENIC SEQUESTRATIOND57419 SICKLE-CELL THALASSEMIA WITH CRISIS UNSPECIFIEDD5780 OTHER SICKLE-CELL DISORDERS WITHOUT CRISISD57811 OTHER SICKLE-CELL DISORDERS W/ACUTE CHEST SYNDD57812 OTH SICKLE-CELL DISORDER W/SPLENIC SEQUESTRATIOND57819 OTHER SICKLE-CELL DISORDERS WITH CRISIS UNSD593 HEMOLYTIC-UREMIC SYNDROMED600 CHRONIC ACQUIRED PURE RED CELL APLASIAD601 TRANSIENT ACQUIRED PURE RED CELL APLASIAD608 OTHER ACQUIRED PURE RED CELL APLASIASD609 ACQUIRED PURE RED CELL APLASIA UNSPECIFIEDD6101 CONSTITUTIONAL PURE RED BLOOD CELL APLASIAD6109 OTHER CONSTITUTIONAL APLASTIC ANEMIAD611 DRUG-INDUCED APLASTIC ANEMIAD612 APLASTIC ANEMIA DUE TO OTHER EXTERNAL AGENTSD613 IDIOPATHIC APLASTIC ANEMIAD61810 ANTINEOPLASTIC CHEMOTHERAPY INDUCED PANCYTOPENIAD61810 ANTINEOPLASTIC CHEMOTHERAPY INDUCED PANCYTOPENIAD61811 OTHER DRUG-INDUCED PANCYTOPENIAD61818 OTHER PANCYTOPENIAD6182 MYELOPHTHISISD6189 OTH SPEC APLASTIC ANEMIAS & OTH BM FAILURE SYNDSD619 APLASTIC ANEMIA UNSPECIFIEDD630 ANEMIA IN NEOPLASTIC DISEASED6481 ANEMIA DUE TO ANTINEOPLASTIC CHEMOTHERAPYD66 HEREDITARY FACTOR VIII DEFICIENCYD67 HEREDITARY FACTOR IX DEFICIENCYD680 VON WILLEBRANDS DISEASED681 HEREDITARY FACTOR XI DEFICIENCYD682 HEREDITARY DEFICIENCY OTHER CLOTTING FACTORSD68311 ACQUIRED HEMOPHILIAD68312 ANTIPHOSPHOLIPID ANTIBODY W/HEMORRHAGIC D/OD68318 OTH HEMORR DISORDER D/T INT CIRC AC AB INHIBITORD6832 HEMORRHAGIC D/O DUE EXTRINSIC CIRC ANTICOAGULANTD684 ACQUIRED COAGULATION FACTOR DEFICIENCYD6851 ACTIVATED PROTEIN C RESISTANCED6852 PROTHROMBIN GENE MUTATIOND6859 OTHER PRIMARY THROMBOPHILIA

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIOND6861 ANTIPHOSPHOLIPID SYNDROMED6862 LUPUS ANTICOAGULANT SYNDROMED6869 OTHER THROMBOPHILIAD688 OTHER SPECIFIED COAGULATION DEFECTSD689 COAGULATION DEFECT UNSPECIFIEDD808 OTHER IMMUNODEF W/PREDOMINANTLY ANTIBODY DEFECTSD809 IMMUNODEF W/PREDOMINANTLY ANTIBODY DEFECTS UNSD810 SEVERE COMBINED IMMUNODEF W/RETICULAR DYSGENESISD811 SEVERE COMBINED IMMUNODEF LOW T & B-CELL NUMBERSD812 SEVERE COMBINED IMMULODEF W/NORMAL B-CELL NUMBRSD813 ADENOSINE DEAMINASE DEFICIENCYD814 NEZELOFS SYNDROMED815 PURINE NUCLEOSIDE PHOSPHORYLASE DEFICIENCYD816 MAJ HISTOCOMPATIBILITY COMPLX CLASS I DEFICIENCYD817 MAJ HISTOCOMPATIBILTY COMPLX CLASS II DEFICIENCYD81810 BIOTINIDASE DEFICIENCYD81818 OTHER BIOTIN-DEPENDENT CARBOXYLASE DEFICIENCYD81819 BIOTIN-DEPENDENT CARBOXYLASE DEFICIENCY UNSD8189 OTHER COMBINED IMMUNODEFICIENCIESD819 COMBINED IMMUNODEFICIENCY UNSPECIFIEDD820 WISKOTT-ALDRICH SYNDROMED821 DI GEORGES SYNDROMED823 IMMUNODEFIC FLW HEREDITARY DEFECT RESPONS TO EBVD828 IMMUNODEFIC ASSOCIATED W/OTH SPEC MAJOR DEFECTD829 IMMUNODEFICIENCY ASSOCIATED W/MAJOR DEFECTS UNSD830 CVI W/PREDOMINANT ABN OF B-CELL NUMBERS & FUNCTD831 CVI W/PREDOMINANT IMMUNOREGULATORY T-CELL D/OD832 CVI WITH AUTOANTIBODIES TO B- OR T-CELLSE0800 DM UNDERLYING COND W/HYPEROSMOLARITY W/O NKHHCE0801 DM D/T UNDERLYING COND W/HYPEROSMOLARITY W/COMAE0810 DM DUE TO UNDERLYING COND W/KETOACIDOS W/O COMAE0811 DM D/T UNDERLYING COND W/KETOACIDOSIS W/COMAE0821 DM D/T UNDERLYING COND W/DIABETIC NEPHROPATHYE0822 DM D/T UNDERLYING COND W/DIABETIC CHRN KIDNEY DZE0829 DM D/T UNDERLY COND W/OTH DIABETIC KIDNEY COMPE08311 DM D/T UNDERLY UNS DIAB RETINPATHY MACULR EDEMAE08319 DM UNDERLY UNS DIAB RETINPATH NO MACULR EDEMAE08321 DM D/T UNDERLY MILD NONPROLIF DIAB RETINPATHY MEE08329 DM UNDERLY MILD NONPROLIF DIAB RETINPATHY W/O MEE08331 DM UNDERLY COND MOD NONPROLIF DIAB RETINPATHY MEE08339 DM UNDERLY MOD NONPROLIF DIAB RETINPATHY NO MEE08341 DM UNDERLY COND SEV NONPROLIF DIAB RETINPATHY MEE08349 DM UNDERLY SEV NONPROLIF DIAB RETINPATHY NO MEE08351 DM UNDERLY PROLIF DIAB RETINPATH W/MACULAR EDEMAE08359 DM D/T UNDERLY COND PROLIF DIAB RETINPATH W/O ME

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONE0836 DM D/T UNDERLYING CONDITION W/DIABETIC CATARACTE0839 DM D/T UNDERLY COND W/OTH DIAB OPHTHALMIC COMPE0840 DM D/T UNDERLYING CONDITON W/DIAB NEUROPATHY UNSE0841 DM D/T UNDERLYING COND W/DIABETIC MONONEUROPATHYE0842 DM D/T UNDERLYING COND W/DIABETIC POLYNEUROPATHYE0843 DM D/T UNDERLY W/DIAB AUTONOMIC POLYNEURPATHYE0844 DIAB MELLITUS D/T UNDERLY COND W/DIAB AMYOTROPHYE0849 DM D/T UNDERLYING COND W/OTH DIABETIC NEURO COMPE0851 DM D/T UNDERLY DIAB PERIPH ANGIOPATH NO GANGRENEE0852 DM D/T UNDERLY DIAB PERIPH ANGIOPATHY W/GANGRENEE0859 DM D/T UNDERLYING COND W/OTH CIRCULATORY COMPE08610 DM D/T UNDERLY COND W/DIAB NEUROPATH ARTHROPATHYE08618 DM D/T UNDERLY COND W/OTH DIABETIC ARTHROPATHYE08620 DIAB MELLITUS D/T UNDERLY COND W/DIAB DERMATITISE08621 DIABETES MELLITUS D/T UNDERLY COND W/FOOT ULCERE08622 DIAB MELLITUS D/T UNDERLY COND W/OTH SKIN ULCERE08628 DIAB MELLITUS D/T UNDERLY COND W/OTH SKIN COMPE08630 DIAB MELLITUS D/T UNDERLY COND W/PERIODONTAL DZE08638 DIAB MELLITUS D/T UNDERLY COND W/OTH ORAL COMPE08641 DM D/T UNDERLY CONDITION W/HYPOGLYCEMIA W/COMAE08649 DM D/T UNDERLYING COND W/HYPOGLYCEMIA W/O COMAE0865 DM D/T UNDERLYING CONDITION WITH HYPERGLYCEMIAE0869 DM D/T UNDERLYING COND W/OTHER SPEC COMPLICATIONE088 DM D/T UNDERLY CONDITION W/UNSPEC COMPLICATIONSE089 DIABETES MELLITUS D/T UNDERLYING COND W/O COMPE0900 DRUG/CHEM INDUCED DM W/HYPEROSMOLARITY W/O NKHHCE0901 DRUG/CHEM INDUCED DM W/HYPEROSMOLARITY W/COMAE0910 DRUG/CHEMICAL INDUCED DM W/KETOACIDOSIS W/O COMAE0911 DRUG/CHEMICAL INDUCED DM W/KETOACIDOSIS W/COMAE0921 DRUG/CHEMICAL INDUCED DM W/DIABETIC NEPHROPATHYE0922 DRUG/CHEM INDUCED DM W/DIAB CHRON KIDNEY DISEASEE0929 DRUG/CHEMICAL INDUCED DM W/OTH DIAB KIDNEY COMPE09311 DRUG/CHEM INDUCED DM W/UNS DIAB RETINOPATHY W/MEE09319 DRUG/CHEM INDUCED DM W/UNS DIAB RETINOPATH NO MEE09321 RX/CHEM INDUCD DM MILD NONPROLIF DR MEE09329 RX/CHM INDUCD DM MILD NONPRLIF DR NO MEE09331 DRUG/CHEM INDUCED DM W/MOD NONPROLIF DR W/MEE09339 DRUG/CHEM INDUCED DM W/MOD NONPROLIF DR W/O MEE09341 DRUG/CHEMICAL INDUCED DM SEVERE NONPROLIF DR MEE09349 DRUG/CHEM INDUCED DM W/SEV NONPROLIF DR W/O MEE09351 DRUG/CHEM INDUCED DM PROLIF DIAB RETINOPATH W/MEE09359 DRUG/CHEM INDUCD DM W/PROLIF DR NO MACULAR EDEMAE0936 DRUG/CHEM INDUCED DIAB MELLITUS W/DIAB CATARACTE0939 DRUG/CHEM INDUCED DM W/OTH DIAB OPHTHALMIC COMPE0940 RX/CHEM INDUCD DM NEURO COMP DIAB NEUROPATHY UNS

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONE0941 RX/CHEM INDUCD DM W/NEURO COMP DIAB MONONEURPATHE0942 RX/CHEM INDUCD DM W/NEURO COMP DIAB POLYNEURPATHE0943 RX/CHEM INDC DM NEURO COMP DIAB AUTONOM NEURPATHE0944 DRUG/CHEM INDUCED DM NEURO COMP DIAB AMYOTROPHYE0949 RX/CHEM INDUCD DM NEURO COMP OTH DIAB NEURO COMPE0951 RX/CHEM INDUCD DM DIAB PERIPH ANGOPATH NO GNGRENE0952 RX/CHEM INDUCED DM DIAB PERIPH ANGIOPATH GANGRENE0959 DRUG/CHEMICAL INDUCED DM W/OTH CIRCULATORY COMPE09610 DRUG/CHEM INDUCED DM W/DIAB NEUROPATH ARTHROPATHE09618 DRUG/CHEM INDUCED DM W/OTH DIABETIC ARTHROPATHYE09620 DRUG/CHEMICAL INDUCED DM W/DIABETIC DERMATITISE09621 DRUG/CHEM INDUCED DIABETES MELLITUS W/FOOT ULCERE09622 DRUG/CHEM INDUCED DIAB MELLITUS W/OTH SKIN ULCERE09628 DRUG/CHEM INDUCED DIAB MELLITUS W/OTH SKIN COMPE09630 DRUG/CHEM INDUCED DIAB MELLITUS W/PERIODONTAL DZE09638 DRUG/CHEM INDUCED DIAB MELLITUS W/OTH ORAL COMPE09641 DRUG/CHEMICAL INDUCED DM W/HYPOGLYCEMIA W/COMAE09649 DRUG/CHEMICAL INDUCED DM W/HYPOGLYCEMIA W/O COMAE0965 DRUG/CHEM INDUCED DIAB MELLITUS W/HYPERGLYCEMIAE0969 DRUG/CHEM INDUCED DIAB MELLITUS W/OTH SPEC COMPE098 DRUG/CHEM INDUCED DIABETES MELLITUS W/UNS COMPE099 DRUG/CHEMICAL INDUCED DIABETES MELLITUS W/O COMPE1010 TYPE 1 DIABETES MELLITUS W/KETOACIDOSIS W/O COMAE1011 TYPE 1 DIABETES MELLITUS W/KETOACIDOSIS W/COMAE1021 TYPE 1 DIABETES MELLITUS W/DIABETIC NEPHROPATHYE1022 TYPE 1 DIABETES MELLITUS W/DIAB CHRON KIDNEY DZE1029 TYPE 1 DIABETES MELLITUS W/OTH DIAB KIDNEY COMPE10311 TYPE 1 DM W/UNS DIAB RETINPATHY W/MACULAR EDEMAE10319 TYPE 1 DM W/UNS DIAB RETINPATH W/O MACULAR EDEMAE10321 TYPE 1 DM W/MILD NONPROLIF DIAB RETINPATHY W/MEE10329 TYPE 1 DM MILD NONPROLIF DIAB RETINPATHY W/O MEE10331 TYPE 1 DM W/MOD NONPROLIF DIAB RETINPATHY W/MEE10339 TYPE 1 DM W/MOD NONPROLIF DIAB RETINPATH W/O MEE10341 TYPE 1 DM W/SEVERE NONPROLIF DIAB RETINPATH W/MEE10349 TYPE 1 DM W/SEV NONPROLIF DIAB RETINOPATH W/O MEE10351 TYPE 1 DM W/PROLIF DIABETIC RETINOPATHY W/MEE10359 TYPE 1 DM WPROLIFERATIVE DIAB RETINOPATHY W/O MEE1036 TYPE 1 DIABETES MELLITUS W/DIABETIC CATARACTE1039 TYPE 1 DIAB MELLITUS W/OTH DIAB OPHTHALMIC COMPE1040 TYPE 1 DIABETES MELLITUS W/DIAB NEUROPATHY UNSE1041 TYPE 1 DIABETES MELLITUS W/DIAB MONONEUROPATHYE1042 TYPE 1 DIABETES MELLITUS W/DIAB POLYNEUROPATHYE1043 TYPE 1 DM W/DIABETIC AUTONOMIC POLYNEUROPATHYE1044 TYPE 1 DIABETES MELLITUS W/DIABETIC AMYOTROPHYE1049 TYPE 1 DM W/OTH DIABETIC NEUROLOGICAL COMP

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONE1051 TYPE 1 DM W/DIAB PERIPH ANGIOPATHY W/O GANGRENEE1052 TYPE 1 DM W/DIAB PERIPH ANGIOPATHY W/GANGRENEE1059 TYPE 1 DIABETES MELLITUS W/OTH CIRCULATORY COMPE10610 TYPE 1 DM W/DIABETIC NEUROPATHIC ARTHROPATHYE10618 TYPE 1 DIABETES MELLITUS W/OTH DIAB ARTHROPATHYE10620 TYPE 1 DIABETES MELLITUS W/DIABETIC DERMATITISE10621 TYPE 1 DIABETES MELLITUS WITH FOOT ULCERE10622 TYPE 1 DIABETES MELLITUS WITH OTHER SKIN ULCERE10628 TYPE 1 DIABETES MELLITUS W/OTH SKIN COMPLICATIONE10630 TYPE 1 DIABETES MELLITUS W/PERIODONTAL DISEASEE10638 TYPE 1 DIABETES MELLITUS W/OTH ORAL COMPLICATIONE10641 TYPE 1 DIABETES MELLITUS W/HYPOGLYCEMIA W/COMAE10649 TYPE 1 DIABETES MELLITUS W/HYPOGLYCEMIA W/O COMAE1065 TYPE 1 DIABETES MELLITUS WITH HYPERGLYCEMIAE1069 TYPE 1 DIABETES MELLITUS W/OTH SPEC COMPLICATIONE108 TYPE 1 DIABETES MELLITUS W/UNSPEC COMPLICATIONSE109 TYPE 1 DIABETES MELLITUS WITHOUT COMPLICATIONSE1100 TYPE 2 DM W/HYPEROSMOLARITY W/O NKHHCE1101 TYPE 2 DIAB MELLITUS W/HYPEROSMOLARITY W/COMAE1121 TYPE 2 DIABETES MELLITUS W/DIABETIC NEPHROPATHYE1122 TYPE 2 DIABETES MELLITUS W/DIAB CHRON KIDNEY DZE1129 TYPE 2 DIABETES MELLITUS W/OTH DIAB KIDNEY COMPE11311 TYPE 2 DM W/UNS DIAB RETINPATHY W/MACULAR EDEMAE11319 TYPE 2 DM W/UNS DIAB RETINPATH W/O MACULAR EDEMAE11321 TYPE 2 DM W/MILD NONPROLIF DIAB RETINOPATHY W/MEE11329 TYPE 2 DM W/MILD NONPROLIF DIAB RETINPATH W/O MEE11331 TYPE 2 DM W/MOD NONPROLIF DIAB RETINOPATHY W/MEE11339 TYPE 2 DM W/MOD NONPROLIF DM RETINOPATHY W/O MEE11341 TYPE 2 DM W/SEV NONPROLIF DIAB RETINOPATHY W/MEE11349 TYPE 2 DM W/SEV NONPROLIF DIAB RETINOPATH W/O MEE11351 TYPE 2 DM W/PROLIFERATIVE DIAB RETINOPATHY W/MEE11359 TYPE 2 DM PROLIF DM RETINOPATHY NO MACULAR EDEMAE1136 TYPE 2 DIABETES MELLITUS WITH DIABETIC CATARACTE1139 TYPE 2 DIABETES MELLITUS OTH DIAB OPHTHALM COMPE1140 TYPE 2 DM WITH DIABETIC NEUROPATHY UNSPECIFIEDE1141 TYPE 2 DIABETES MELLITUS W/DIAB MONONEUROPATHYE1142 TYPE 2 DIABETES MELLITUS W/DIAB POLYNEUROPATHYE1143 TYPE 2 DM W/DIABETIC AUTONOMIC POLYNEUROPATHYE1144 TYPE 2 DIABETES MELLITUS W/DIABETIC AMYOTROPHYE1149 TYPE 2 DIABETES MELLITUS W/OTH DIAB NEURO COMPE1151 TYPE 2 DM W/DIAB PERIPH ANGIOPATHY W/O GANGRENEE1152 TYPE 2 DM W/DIAB PERIPH ANGIOPATHY W/GANGRENEE1159 TYPE 2 DIABETES MELLITUS W/OTH CIRCULATORY COMPE11610 TYPE 2 DM W/DIABETIC NEUROPATHIC ARTHROPATHYE11618 TYPE 2 DIABETES MELLITUS W/OTH DIAB ARTHROPATHY

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONE11620 TYPE 2 DIABETES MELLITUS W/DIABETIC DERMATITISE11621 TYPE 2 DIABETES MELLITUS WITH FOOT ULCERE11622 TYPE 2 DIABETES MELLITUS WITH OTHER SKIN ULCERE11628 TYPE 2 DIABETES MELLITUS W/OTH SKIN COMPE11630 TYPE 2 DIABETES MELLITUS W/PERIODONTAL DISEASEE11638 TYPE 2 DIABETES MELLITUS W/OTH ORAL COMPE11641 TYPE 2 DIABETES MELLITUS W/HYPOGLYCEMIA W/COMAE11649 TYPE 2 DIABETES MELLITUS W/HYPOGLYCEMIA W/O COMAE1165 TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIAE1169 TYPE 2 DIABETES MELLITUS W/OTH SPEC COMPLICATIONE118 TYPE 2 DIABETES MELLITUS W/UNS COMPLICATIONSE119 TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONSE1300 OTH SPEC DM W/HYPEROSMOLARITY W/O NKHHCE1301 OTH SPEC DIABETES MELLITUS HYPEROSMOLARITY COMAE1310 OTHER SPECIFIED DIAB W/KETOACIDOSIS W/O COMAE1311 OTH SPEC DIABETES MELLITUS W/KETOACIDOSIS W/COMAE1321 OTH SPEC DIABETES MELLITUS W/DIAB NEPHROPATHYE1322 OTH SPEC DIABETES MELLITUS DIAB CHRON KIDNEY DZE1329 OTH SPEC DM W/OTH DIABETIC KIDNEY COMPLICATIONE13311 OTH DM W/UNS DIAB RETINOPATHY W/MACULAR EDEMAE13319 OTH SPEC DM W/UNS DIABETIC RETINOPATHY W/O MEE13321 OTH SPEC DM MILD NONPROLIF DIAB RETINOPATHY W/MEE13329 OTH DM W/MILD NONPROLIF DIAB RETINOPATHY W/O MEE13331 OTHER SPEC DM MOD NONPROLIF DIAB RETINOPATHY MEE13339 OTH SPEC DM MOD NONPROLIF DIAB RETINPATH W/O MEE13341 OTH SPEC DM SEV NONPROLIF DIAB RETINOPATHY W/MEE13349 OTH DM W/SEV NONPROLIF DIAB RETINOPATHY W/O MEE13351 OTH DM W/PROLIF DIAB RETINOPATHY W/MACULAR EDEMAE13359 OTH DM W/PROLIF DIAB RETINOPATH NO MACULAR EDEMAE1336 OTH SPEC DIABETES MELLITUS W/DIABETIC CATARACTE1339 OTH SPEC DM W/OTH DIABETIC OPHTHALMIC COMPE1340 OTHER SPEC DM W/DIABETIC NEUROPATHY UNSPECIFIEDE1341 OTH SPEC DIABETES MELLITUS W/DIAB MONONEUROPATHYE1342 OTH SPEC DIABETES MELLITUS W/DIAB POLYNEUROPATHYE1343 OTH SPEC DM W/DIABETIC AUTONOMIC POLYNEUROPATHYE1344 OTH SPEC DIABETES MELLITUS W/DIABETIC AMYOTROPHYE1349 OTH SPEC DM W/OTH DIABETIC NEUROLOGICAL COMPE1351 OTH SPEC DM W/DIAB PERIPH ANGIOPATHY NO GANGRENEE1352 OTH SPEC DM W/DIAB PERIPH ANGIOPATHY W/GANGRENEE1359 OTH SPEC DIABETES MELLITUS OTH CIRCULATORY COMPE13610 OTH SPEC DM W/DIABETIC NEUROPATHIC ARTHROPATHYE13618 OTH SPEC DIABETES MELLITUS W/OTH DIAB ARTHROPATHE13620 OTH SPEC DIABETES MELLITUS W/DIABETIC DERMATITISE13621 OTH SPECIFIED DIABETES MELLITUS WITH FOOT ULCERE13622 OTH SPEC DIABETES MELLITUS W/OTH SKIN ULCER

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONE13628 OTH SPEC DIABETES MELLITUS W/OTH SKIN COMPE13630 OTH SPECIFIED DIABETES MELLITUS W/PERIODONTAL DZE13638 OTH SPEC DIABETES MELLITUS W/OTH ORAL COMPE13641 OTH SPEC DIABETES MELLITUS W/HYPOGLYCEMIA W/COMAE13649 OTH SPEC DIAB MELLITUS W/HYPOGLYCEMIA W/O COMAE1365 OTH SPEC DIABETES MELLITUS WITH HYPERGLYCEMIAE1369 OTH SPEC DIABETES MELLITUS W/OTH SPECIFIED COMPE138 OTH SPEC DIABETES MELLITUS W/UNS COMPLICATIONSE139 OTH SPEC DIABETES MELLITUS W/O COMPLICATIONSE230 HYPOPITUITARISM E3120 MULTIPLE ENDOCRINE NEOPLASIA SYNDROME UNSE3121 MULTIPLE ENDOCRINE NEOPLASIA TYPE IE3122 MULTIPLE ENDOCRINE NEOPLASIA TYPE IIAE3123 MULTIPLE ENDOCRINE NEOPLASIA TYPE IIBE701 OTHER HYPERPHENYLALANINEMIAS E7502 TAY-SACHS DISEASEE7521 FABRY-ANDERSON DISEASEE7522 GAUCHER DISEASEE7523 Krabbe diseaseE75240 NIEMANN-PICK DISEASE TYPE AE75241 NIEMANN-PICK DISEASE TYPE BE75242 NIEMANN-PICK DISEASE TYPE CE75243 NIEMANN-PICK DISEASE TYPE DE75248 OTHER NIEMANN-PICK DISEASEE75249 NIEMANN-PICK DISEASE UNSPECIFIEDE7525 Metachromatic leukodystrophyE7529 Other sphingolipidosisE840 CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONSE8411 MECONIUM ILEUS IN CYSTIC FIBROSISE8419 CYSTIC FIBROSIS W/OTH INTESTINAL MANIFESTATIONSE848 CYSTIC FIBROSIS WITH OTHER MANIFESTATIONSE849 CYSTIC FIBROSIS UNSPECIFIEDE8840 MITOCHONDRIAL METABOLISM DISORDER UNSPECIFIEDF0150 VASCULAR DEMENTIA WITHOUT BEHAVIORAL DISTURBANCEF0151 VASCULAR DEMENTIA WITH BEHAVIORAL DISTURBANCEF0280 DEMENTIA OTH DZ CLASS ELSW W/O BEHAVRL DISTURBF0281 DEMENTIA OTH DISEAS CLASS W/BEHAVIORAL DISTURBF0390 UNSPEC DEMENTIA WITHOUT BEHAVIORAL DISTURBANCEF0391 UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCEF04 AMNESTIC DISORDER DUE KNOWN PHYSIOLOGICAL CONDF05 DELIRIUM DUE TO KNOWN PHYSIOLOGICAL CONDITIONF060 PSYCHOTIC D/O W/HALLUCINATION DUE TO PHYSIO CONDF061 CATATONIC D/O DUE TO KNOWN PHYSIOLOGICAL CONDF062 PSYCHOTIC D/O DELUSIONS DUE KNOWN PHYSIO CONDF0630 MOOD DISORDER KNOWN PHYSIOLOGICAL CONDITION UNS

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONF0631 MOOD DISORDER PHYSIO COND W/DEPRESSIVE FEATUREF0632 MOOD DISORDER PHYSIO COND MAJ DEPRSSIVE EPISODEF0633 MOOD DISORDER PHYSIO COND W/MANIC FEATUREF0634 MOOD DISORDER PHYSIO COND W/MIXED FEATUREF064 ANXIETY DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDF068 OTH SPEC MENTAL D/O DUE KNOWN PHYSIOLOGICAL CONDF070 PERSONALITY CHANGE DUE KNOWN PHYSIOLOGICAL CONDF0781 POSTCONCUSSIONAL SYNDROMEF0789 OTH PERSONALITY & BEHAVIORAL D/O DUE PHYSIO CONDF09 UNS MENTAL DISORDER DUE KNOWN PHYSIOLOGICAL CONDF1010 ALCOHOL ABUSE UNCOMPLICATEDF10120 ALCOHOL ABUSE WITH INTOXICATION UNCOMPLICATEDF10121 ALCOHOL ABUSE WITH INTOXICATION DELIRIUMF10129 ALCOHOL ABUSE WITH INTOXICATION UNSPECIFIEDF1014 ALCOHOL ABUSE WITH ALCOHOL-INDUCED MOOD DISORDERF10150 ALCOHOL ABUSE W/INDUCED PSYCHOTIC D/O W/DELUSIONF10151 ALCOHOL ABUSE W/INDUCED PSYCHOTIC D/O W/HALLUCF10159 ALCOHOL ABUSE W/ALCOHOL-INDUCED PSYCHOT D/O UNSF10180 ALCOHOL ABUSE W/ALCOHOL-INDUCED ANXIETY DISORDERF10181 ALCOHOL ABUSE W/ALCOHOL-INDUCED SEXUAL DYSFUNCTF10182 ALCOHOL ABUSE W/ALCOHOL-INDUCED SLEEP DISORDERF10188 ALCOHOL ABUSE W/OTHER ALCOHOL-INDUCED DISORDERF1019 ALCOHOL ABUSE W/UNS ALCOHOL-INDUCED DISORDERF1020 ALCOHOL DEPENDENCE UNCOMPLICATEDF1021 ALCOHOL DEPENDENCE IN REMISSIONF10220 ALCOHOL DEPENDENCE W/INTOXICATION UNCOMPLICATEDF10221 ALCOHOL DEPENDENCE WITH INTOXICATION DELIRIUMF10229 ALCOHOL DEPENDENCE W/INTOXICATION UNSPECIFIEDF10230 ALCOHOL DEPENDENCE WITH WITHDRAWAL UNCOMPLICATEDF10231 ALCOHOL DEPENDENCE WITH WITHDRAWAL DELIRIUMF10232 ALCOHOL DEPENDENCE WITHDRAWAL PERCEPTUAL DISTURBF10239 ALCOHOL DEPENDENCE WITH WITHDRAWAL UNSF1024 ALCOHOL DEPENDENCE W/ALCOHOL-INDUCED MOOD D/OF10250 ALCOHOL DEPENDENCE INDUCD PSYCHOT D/O DELUSIONF10251 ALCOHOL DEPENDENCE INDUCED PSYCHOTIC D/O HALLUCF10259 ALCOHOL DEPENDENCE W/INDUCED PSYCHOTIC D/O UNSF1026 ALCOHOL DEPENDENCE W/INDUCD-PERSIST AMNESTIC D/OF1027 ALCOHOL DEPENDENCE W/INDUCED-PERSISTING DEMENTIAF10280 ALCOHOL DEPENDENCE W/ALCOHOL-INDUCED ANXIETY D/OF10281 ALCOHOL DEPENDENCE W/ALCOHOL-INDUCED SEXUAL DYSFF10282 ALCOHOL DEPENDENCE W/ALCOHOL-INDUCED SLEEP D/OF10288 ALCOHOL DEPENDENCE W/OTHER ALCOHOL-INDUCED D/OF1029 ALCOHOL DEPENDENCE W/UNS ALCOHOL-INDUCED D/OF10920 Alcohol use, unspecified with intoxication, uncomplicatedF10921 Alcohol use, unspecified with intoxication delirium

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONF10929 Alcohol use, unspecified with intoxication, unspecifiedF1094 Alcohol use, unspecified with alcohol-induced mood disorderF10950 Alcohol use, unspecified with alcohol-induced psychotic disorder with delusionsF10951 Alcohol use, unspecified with alcohol-induced psychotic disorder with hallucinationsF10959 Alcohol use, unspecified with alcohol-induced psychotic disorder, unspecifiedF1096 Alcohol use, unspecified with alcohol-induced persisting amnestic disorderF1097 ALCOHOL USE UNS W/INDUCED-PERSISTING DEMENTIAF10980 Alcohol use, unspecified with alcohol-induced anxiety disorderF10981 Alcohol use, unspecified with alcohol-induced sexual dysfunctionF10982 Alcohol use, unspecified with alcohol-induced sleep disorderF10988 Alcohol use, unspecified with other alcohol-induced disorderF1099 Alcohol use, unspecified with unspecified alcohol-induced disorderF1110 OPIOID ABUSE UNCOMPLICATEDF11120 OPIOID ABUSE WITH INTOXICATION UNCOMPLICATEDF11121 OPIOID ABUSE WITH INTOXICATION DELIRIUMF11122 OPIOID ABUSE W/INTOXICATION W/PERCEPTUAL DISTURBF11129 OPIOID ABUSE WITH INTOXICATION UNSPECIFIEDF1114 OPIOID ABUSE WITH OPIOID-INDUCED MOOD DISORDERF11150 OPIOID ABUSE W/INDUCD PSYCHOT D/O W/DELUSIONSF11151 OPIOID ABUSE W/INDUCD PSYCHOT D/O W/HALLUCINF11159 OPIOID ABUSE W/OPIOID-INDUCD PSYCHOT D/O UNSF11181 OPIOID ABUSE W/OPIOID-INDUCED SEXUAL DYSFUNCTIONF11182 OPIOID ABUSE WITH OPIOID-INDUCED SLEEP DISORDERF11188 OPIOID ABUSE WITH OTHER OPIOID-INDUCED DISORDERF1119 OPIOID ABUSE W/UNS OPIOID-INDUCED DISORDERF1120 OPIOID DEPENDENCE UNCOMPLICATEDF1121 OPIOID DEPENDENCE IN REMISSIONF11220 OPIOID DEPEND W/ INTOXICATION UNCOMPLICATEDF11221 OPIOID DEPEND W/ INTOXICATION DELIRIUMF11222 OPIOID DEPEND W/ INTOXICATION W/PERCEPTUAL DISTF11229 OPIOID DEPEND W/ INTOXICATION UNSPECIFIEDF1123 OPIOID DEPENDENCE WITH WITHDRAWALF1124 OPIOID DEPEND W/INDUCD MOOD DISORDERF11250 OPIOID DEPEND W/INDUCD PSYCHOTIC D/O W/DELUSIONSF11251 OPIOID DEPEND W/INDUCD PSYCHOTIC D/O W/HALLUCF11259 OPIOID DEPEND W/INDUCD PSYCHOTIC D/O UNSF11281 OPIOID DEPEND W/INDUCED SEXUAL DYSFUNCTIONF11282 OPIOID DEPEND W/OPIOID-INDUCED SLEEP DISORDERF11288 OPIOID DEPEND W/OTH OPIOID-INDUCED DISORDERF1129 OPIOID DEPEND W/UNS OPIOID-INDUCED DISORDERF1190 OPIOID USE UNSPECIFIED UNCOMPLICATEDF11920 OPIOID USE UNS W/INTOXICATION UNCOMPLICATEDF11921 OPIOID USE UNSPECIFIED W/ INTOXICATION DELIRIUMF11922 OPIOID USE UNS W/INTOXICATION W/PERCEPTUAL DISTF11929 OPIOID USE UNS W/INTOXICATION UNSPECIFIED

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONF1193 OPIOID USE UNSPECIFIED WITH WITHDRAWALF1194 OPIOID USE UNS W/OPIOID-INDUCED MOOD DISORDERF11950 OPIOID USE UNS W/INDUCD PSYCHOT D/O W/DELUSIONSF11951 OPIOID USE UNS W/INDUCD PSYCHOT D/O W/HALLUCINF11959 OPIOID USE UNS W/OPIOID-INDUCD PSYCHOT D/O UNSF11981 OPIOID USE UNS W/OPIOID-INDUCED SEXUAL DYSFUNCTF11982 OPIOID USE UNS W/OPIOID-INDUCED SLEEP DISORDERF11988 OPIOID USE UNS W/OTHER OPIOID-INDUCED DISORDERF1199 OPIOID USE UNS W/UNS OPIOID-INDUCED DISORDERF1210 CANNABIS ABUSE UNCOMPLICATEDF12120 CANNABIS ABUSE WITH INTOXICATION UNCOMPLICATEDF12121 CANNABIS ABUSE WITH INTOXICATION DELIRIUMF12122 CANNABIS ABUSE W/INTOX W/PERCEPTUAL DISTURBF12129 CANNABIS ABUSE WITH INTOXICATION UNSPECIFIEDF12150 CANNABIS ABUSE W/PSYCHOTIC DISORDER W/ DELUSIONSF12151 CANNABIS ABUSE W/PSYCHOT D/O W/HALLUCINATIONSF12159 CANNABIS ABUSE W/ PSYCHOTIC DISORDER UNSPECIFIEDF12180 CANNABIS ABUSE W/CANNABIS-INDUCED ANXIETY D/OF12188 CANNABIS ABUSE W/OTH CANNABIS-INDUCED DISORDERF1219 CANNABIS ABUSE W/UNS CANNABIS-INDUCED DISORDERF1220 CANNABIS DEPENDENCE UNCOMPLICATEDF1221 CANNABIS DEPENDENCE IN REMISSIONF12220 CANNABIS DEPENDENCE W/INTOX UNCOMPLICATEDF12221 CANNABIS DEPENDENCE WITH INTOXICATION DELIRIUMF12222 CANNABIS DEPENDENCE W/INTOX W/PERCEPTUAL DISTF12229 CANNABIS DEPENDENCE W/INTOXICATION UNSPECIFIEDF12250 CANNABIS DEPENDENCE W/PSYCHOTIC D/O W/DELUSIONSF12251 CANNABIS DEPENDENCE W/PSYCHOT D/O W/HALLUCINF12259 CANNABIS DEPENDENCE W/PSYCHOTIC DISORDER UNSF12280 CANNABIS DEPENDENCE W/CANNABIS-INDUC ANXIETY D/OF12288 CANNABIS DEPENDENCE W/OTH CANNABIS-INDUCED D/OF1229 CANNABIS DEPENDENCE W/UNS CANNABIS-INDUCED D/OF1290 CANNABIS USE UNSPECIFIED UNCOMPLICATEDF12920 CANNABIS USE UNS W/INTOXICATION UNCOMPLICATEDF12921 CANNABIS USE UNS W/INTOXICATION DELIRIUMF12922 CANNABIS USE UNS W/INTOX W/PERCEPTUAL DISTF12929 CANNABIS USE UNSPECIFIED W/INTOXICATION UNSF12950 CANNABIS USE UNS W/PSYCHOT DISORDER W/DELUSIONSF12951 CANNABIS USE UNS W/PSYCHOT D/O W/HALLUCINATIONSF12959 CANNABIS USE UNS W/PSYCHOTIC DISORDER UNSF12980 CANNABIS USE UNSPECIFIED WITH ANXIETY DISORDERF12988 CANNABIS USE UNS W/OTH CANNABIS-INDUCED DISORDERF1299 CANNABIS USE UNS W/UNS CANNABIS-INDUCED DISORDERF1310 SEDATIVE HYPNOTIC/ANXIOLYTIC ABUSE UNCOMPLICATEDF13120 SEDATIVE HYPNOTIC/ANXIOLYT ABUSE W/INTOX UNCOMP

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONF13121 SEDATIVE HYPNOTIC/ANXIOLYT ABUS W/INTOX DELIRIUMF13129 SEDATIVE HYPNOTIC/ANXIOLYTIC ABUSE W/INTOX UNSF1314 SEDATIVE HYP/ANXIOLYTIC ABUSE W/INDUCED MOOD D/OF13150 SEDATV HYP/ANXIOLYTIC ABUSE IND PSYCH D/O DELUSF13151 SEDATV HYP/ANXIOLYTIC ABUSE IND PSYCH D/O HALLUCF13159 SEDATV HYP/ANXIOLYTIC ABUSE IND PSYCHOT D/O UNSF13180 SEDATV HYP/ANXIOLYTIC ABUSE W/INDUCD ANXIETY D/OF13181 SEDATV HYP/ANXIOLYTIC ABUSE W/INDUCD SEXUAL DYSFF13182 SEDATV HYP/ANXIOLYTIC ABUSE W/INDUCD SLEEP D/OF13188 SEDATV HYP/ANXIOLYTIC ABUSE W/OTH INDUCD D/OF1319 SEDATV HYP/ANXIOLYTIC ABUSE W/UNS INDUCD D/OF1320 SEDATIVE HYPNOTIC/ANXIOLYTIC DEPEND UNCOMPF1321 SEDATIVE HYPNOTIC/ANXIOLYTIC DEPEND REMISSIONF13220 SEDATIVE HYP/ANXIOLYTIC DEPEND W/INTOX UNCOMPF13221 SEDATIVE HYP/ANXIOLYTIC DEPEND W/INTOX DELIRIUMF13229 SEDATIVE HYPNOTIC/ANXIOLYTIC DEPEND W/INTOX UNSF13230 SEDATV HYP/ANXIOLYTIC DEPEND W/WITHDRAWAL UNCOMPF13231 SEDATV HYP/ANXIOLYTIC DEPEND W/WITHDRWL DELIRIUMF13232 SEDATV HYP/ANXIOLYTIC DEPEND W/D W/PERCEPTL DISTF13239 SEDATV HYP/ANXIOLYTIC DEPEND W/WITHDRAWAL UNSF1324 SEDATV HYP/ANXIOLYTIC DEPEND W/INDUCD MOOD D/OF13250 SEDATV HYP/ANXIOLYTIC DEPEND W/IND PSYCH D/O DELF13251 SEDATV HYP/ANXIOLYT DEPEND IND PSYCH D/O HALLUCF13259 SEDATV HYP/ANXIOLYT DEPEND W/IND PSYCH D/O UNSF1326 SEDATV HYP/ANXIOLYT DEPEND IND PERSIST AMNES D/OF1327 SEDATV HYP/ANXIOLYT DEPEND IND PERSIST DEMENTIAF13280 SEDATV HYP/ANXIOLYT DEPEND W/INDUC ANXIETY D/OF13281 SEDATV HYP/ANXIOLYT DEPEND W/INDUC SEXUAL DYSFF13282 SEDATV HYP/ANXIOLYT DEPEND W/INDUCD SLEEP D/OF13288 SEDATV HYP/ANXIOLYT DEPEND W/OTH INDUCED D/OF1329 SEDATV HYP/ANXIOLYT DEPEND W/UNS INDUCED D/OF1390 SEDATIVE HYPNOTIC/ANXIOLYTIC USE UNS UNCOMPF13920 SEDATIVE HYP/ANXIOLYTIC USE UNS W/INTOX UNCOMPF13921 SEDATIVE HYP/ANXIOLYTIC USE UNS W/INTOX DELIRIUMF13929 SEDATIVE HYP/ANXIOLYTIC USE UNS W/INTOX UNSF13930 SEDATV HYP/ANXIOLYTIC USE UNS W/WITHDRAWL UNCOMPF13931 SEDATV HYP/ANXIOLYTIC USE W/WITHDRAWL DELIRIUMF13932 SEDATV HYP/ANXIOLYTIC USE W/D W/PERCEPTUL DISTF13939 SEDATV HYP/ANXIOLYTIC USE UNS W/WITHDRAWAL UNSF1394 SEDATV HYP/ANXIOLYTIC USE UNS W/INDUC MOOD D/OF13950 SEDATV HYP/ANXIOLYT USE UNS IND PSYCH D/O DELUSF13951 SEDATV HYP/ANXIOLYT USE UNS IND PSYCH D/O HALLUCF13959 SEDATV HYP/ANXIOLYT USE UNS IND PSYCHOT D/O UNSF1396 SEDATV HYP/ANXIOLYT USE UNS IND PERSST AMNES D/OF1397 SEDATV HYP/ANXIOLYT USE UNS IND PERSIST DEMENTIA

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONF13980 SEDATV HYP/ANXIOLYTIC USE UNS W/IND ANXIETY D/OF13981 SEDATV HYP/ANXIOLYTIC USE UNS W/INDUCD SEXL DYSFF13982 SEDATV HYP/ANXIOLYTIC USE UNS W/INDUCD SLEEP D/OF13988 SEDATV HYP/ANXIOLYTIC USE UNS W/OTH INDUCED D/OF1399 SEDATV HYP/ANXIOLYTIC USE UNS W/UNS INDUCED D/OF1410 COCAINE ABUSE UNCOMPLICATEDF14120 COCAINE ABUSE WITH INTOXICATION UNCOMPLICATEDF14121 COCAINE ABUSE WITH INTOXICATION WITH DELIRIUMF14122 COCAINE ABUSE W/INTOXICATION W/PERCEPTUAL DISTF14129 COCAINE ABUSE WITH INTOXICATION UNSPECIFIEDF1414 COCAINE ABUSE WITH COCAINE-INDUCED MOOD DISORDERF14150 COCAINE ABUSE W/INDUCD PSYCHOT D/O W/DELUSIONSF14151 COCAINE ABUSE W/INDUCD PSYCHOT D/O W/HALLUCINF14159 COCAINE ABUSE W/COCAINE-INDUCD PSYCHOT D/O UNSF14180 COCAINE ABUSE W/COCAINE-INDUCED ANXIETY DISORDERF14181 COCAINE ABUSE W/COCAINE-INDUCED SEXUAL DYSFF14182 COCAINE ABUSE W/ COCAINE-INDUCED SLEEP DISORDERF14188 COCAINE ABUSE W/ OTHER COCAINE-INDUCED DISORDERF1419 COCAINE ABUSE W/UNS COCAINE-INDUCED DISORDERF1420 COCAINE DEPENDENCE UNCOMPLICATEDF1421 COCAINE DEPENDENCE IN REMISSIONF14220 COCAINE DEPENDENCE W/ INTOXICATION UNCOMPLICATEDF14221 COCAINE DEPENDENCE WITH INTOXICATION DELIRIUMF14222 COCAINE DEPENDENCE W/INTOX W/PERCEPTUAL DISTF14229 COCAINE DEPENDENCE WITH INTOXICATION UNSPECIFIEDF1423 COCAINE DEPENDENCE WITH WITHDRAWALF1424 COCAINE DEPENDENCE W/COCAINE-INDUCED MOOD D/OF14250 COCAINE DEPENDENCE W/INDUC PSYCHOT D/O W/DELUSNF14251 COCAINE DEPENDENCE W/INDUC PSYCHOT D/O W/HALLUCF14259 COCAINE DEPENDENCE W/INDUCED PSYCHOT D/O UNSF14280 COCAINE DEPENDENCE W/COCAINE-INDUCED ANXIETY D/OF14281 COCAINE DEPENDENCE W/COCAINE-INDUCED SEXUAL DYSFF14282 COCAINE DEPENDENCE W/COCAINE-INDUCED SLEEP D/OF14288 COCAINE DEPENDENCE W/OTH COCAINE-INDUCED D/OF1429 COCAINE DEPENDENCE W/UNS COCAINE-INDUCED D/OF1490 COCAINE USE UNSPECIFIED UNCOMPLICATEDF14920 COCAINE USE UNS W/INTOXICATION UNCOMPLICATEDF14921 COCAINE USE UNSPECIFIED W/ INTOXICATION DELIRIUMF14922 COCAINE USE UNS W/INTOXICATION W/PERCEPTUAL DISTF14929 COCAINE USE UNS W/INTOXICATION UNSPECIFIEDF1494 COCAINE USE UNS W/COCAINE-INDUCED MOOD DISORDERF14950 COCAINE USE UNS W/INDUCD PSYCHOT D/O W/DELUSIONSF14951 COCAINE USE UNS W/INDUCD PSYCHOT D/O W/HALLUCF14959 COCAINE USE UNS W/INDUCD PSYCHOT DISORDER UNSF14980 COCAINE USE UNS W/INDUCD ANXIETY DISORDER

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONF14981 COCAINE USE UNS W/COCAINE-INDUCED SEXUAL DYSFF14982 COCAINE USE UNS W/COCAINE-INDUCED SLEEP DISORDERF14988 COCAINE USE UNS W/OTHER COCAINE-INDUCED DISORDERF1499 COCAINE USE UNS W/UNS COCAINE-INDUCED DISORDERF1510 OTHER STIMULANT ABUSE UNCOMPLICATEDF15120 OTHER STIMULANT ABUSE W/INTOX UNCOMPLICATEDF15121 OTHER STIMULANT ABUSE WITH INTOXICATION DELIRIUMF15122 OTHER STIMULANT ABUSE W/INTOX W/PERCEPTUAL DISTF15129 OTHER STIMULANT ABUSE W/INTOXICATION UNSF1514 OTHER STIMULANT ABUSE W/INDUCED MOOD DISORDERF15150 OTHER STIMULANT ABUSE W/INDUCD PSYCHOT D/O W/DELF15151 OTHER STIMULANT ABUSE INDUC PSYCHOT D/O W/HALLUCF15159 OTHER STIMULANT ABUSE W/INDUC PSYCHOT D/O UNSF15180 OTHER STIMULANT ABUSE W/INDUCED ANXIETY DISORDERF15181 OTHER STIMULANT ABUSE W/INDUC SEXUAL DYSFUNCTIONF15182 OTHER STIMULANT ABUSE W/INDUCED SLEEP DISORDERF15188 OTHER STIMULANT ABUSE W/OTH INDUCED DISORDERF1519 OTHER STIMULANT ABUSE W/UNS INDUCED DISORDERF1520 OTHER STIMULANT DEPENDENCE UNCOMPLICATEDF1521 OTHER STIMULANT DEPENDENCE IN REMISSIONF15220 OTHER STIMULANT DEPENDENCE W/INTOX UNCOMPF15221 OTHER STIMULANT DEPENDENCE W/INTOX DELIRIUMF15222 OTHER STIMULANT DEPENDENCE INTOX W/PERCEPTL DISTF15229 OTHER STIMULANT DEPENDENCE W/INTOXICATION UNSF1523 OTHER STIMULANT DEPENDENCE WITH WITHDRAWALF1524 OTH STIMULANT DEPEND W/INDUCED MOOD DISORDERF15250 OTH STIMULANT DEPEND W/INDUCED PSYCHOT D/O W/DELF15251 OTH STIMULANT DEPEND INDUC PSYCHOT D/O W/HALLUCF15259 OTH STIMULANT DEPEND W/INDUCED PSYCHOT D/O UNSF15280 OTH STIMULANT DEPEND W/INDUCED ANXIETY DISORDERF15281 OTH STIMULANT DEPEND W/INDUCED SEXL DYSFF15282 OTH STIMULANT DEPEND W/INDUCED SLEEP DISORDERF15288 OTH STIMULANT DEPEND W/OTH INDUCED DISORDERF1529 OTH STIMULANT DEPEND W/UNS INDUCED DISORDERF1590 OTHER STIMULANT USE UNSPECIFIED UNCOMPLICATEDF15920 OTHER STIMULANT USE UNS W/INTOXICATION UNCOMPF15921 OTHER STIMULANT USE UNS W/INTOXICATION DELIRIUMF15922 OTHER STIMULANT USE UNS W/INTOX PERCEPTL DISTURBF15929 OTHER STIMULANT USE UNS W/INTOXICATION UNSF1593 OTHER STIMULANT USE UNSPECIFIED WITH WITHDRAWALF1594 OTHER STIMULANT USE UNS W/INDUCD MOOD DISORDERF15950 OTH STIMULANT USE UNS INDUC PSYCHOT D/O W/DELUSF15951 OTH STIMULANT USE UNS W/INDUC PSYCHOT D/O HALLUCF15959 OTH STIMULANT USE UNS W/INDUCD PSYCHOT D/O UNSF15980 OTH STIMULANT USE UNS W/INDUCED ANXIETY DISORDER

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONF15981 OTH STIMULANT USE UNS W/INDUCED SEXUAL DYSFUNCTF15982 OTH STIMULANT USE UNS W/INDUCD SLEEP DISORDERF15988 OTH STIMULANT USE UNS W/OTH INDUCED DISORDERF1599 OTH STIMULANT USE UNS W/UNS INDUCED DISORDERF1610 HALLUCINOGEN ABUSE UNCOMPLICATEDF16120 HALLUCINOGEN ABUSE W/INTOXICATION UNCOMPLICATEDF16121 HALLUCINOGEN ABUSE W/INTOXICATION WITH DELIRIUMF16122 HALLUCINOGEN ABUSE W/INTOX W/PERCEPTUAL DISTURBF16129 HALLUCINOGEN ABUSE WITH INTOXICATION UNSPECIFIEDF1614 HALLUCINOGEN ABUSE W/INDUCED MOOD DISORDERF16150 HALLUCINOGEN ABUSE W/INDUCED PSYCHOT D/O W/DELUSF16151 HALLUCINOGEN ABUSE W/INDUCD PSYCHOT D/O W/HALLUCF16159 HALLUCINOGEN ABUSE W/INDUCD PSYCHOT DISORDER UNSF16180 HALLUCINOGEN ABUSE W/INDUCED ANXIETY DISORDERF16183 HALLUCINOGEN ABUSE W/PERSISTING PERCEPTION D/OF16188 HALLUCINOGEN ABUSE W/OTH INDUCED DISORDERF1619 HALLUCINOGEN ABUSE W/UNS INDUCED DISORDERF1620 HALLUCINOGEN DEPENDENCE UNCOMPLICATEDF1621 HALLUCINOGEN DEPENDENCE IN REMISSIONF16220 HALLUCINOGEN DEPENDENCE W/INTOX UNCOMPLICATEDF16221 HALLUCINOGEN DEPENDENCE W/INTOX W/DELIRIUMF16229 HALLUCINOGEN DEPENDENCE W/INTOXICATION UNSF1624 HALLUCINOGEN DEPENDENCE W/INDUCED MOOD DISORDERF16250 HALLUCINOGEN DEPEND INDUC PSYCHOT D/O W/DELUSIONF16251 HALLUCINOGEN DEPEND INDUC PSYCHOT D/O W/HALLUCINF16259 HALLUCINOGEN DEPENDENCE W/INDUCD PSYCHOT D/O UNSF16280 HALLUCINOGEN DEPENDENCE W/INDUC ANXIETY DISORDERF16283 HALLUCINOGEN DEPENDENCE W/PERSIST PERCEPTION D/OF16288 HALLUCINOGEN DEPENDENCE W/OTH INDUCED DISORDERF1629 HALLUCINOGEN DEPENDENCE W/UNS INDUCED DISORDERF1690 HALLUCINOGEN USE UNSPECIFIED UNCOMPLICATEDF16920 HALLUCINOGEN USE UNS W/INTOXICATION UNCOMPF16921 HALLUCINOGEN USE UNS W/INTOXICATION W/DELIRIUMF16929 HALLUCINOGEN USE UNS W/INTOXICATION UNSPECIFIEDF1694 HALLUCINOGEN USE UNS W/INDUCD MOOD DISORDERF16950 HALLUCINOGEN USE UNS INDUC PSYCHOT D/O DELUSIONF16951 HALLUCINOGEN USE UNS INDUC PSYCHOT D/O W/HALLUCF16959 HALLUCINOGEN USE UNS W/INDUCD PSYCHOT D/O UNSF16980 HALLUCINOGEN USE UNS W/INDUCED ANXIETY DISORDERF16983 HALLUCINOGEN USE UNS W/PERSIST PERCEPTION D/OF16988 HALLUCINOGEN USE UNS W/OTH INDUCED DISORDERF1699 HALLUCINOGEN USE UNS W/UNS INDUCED DISORDERF1810 INHALANT ABUSE UNCOMPLICATEDF18120 INHALANT ABUSE WITH INTOXICATION UNCOMPLICATEDF18121 INHALANT ABUSE WITH INTOXICATION DELIRIUM

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONF18129 INHALANT ABUSE WITH INTOXICATION UNSPECIFIEDF1814 INHALANT ABUSE W/INHALANT-INDUCED MOOD DISORDERF18150 INHALANT ABUSE W/INDUCED PSYCHOT D/O W/DELUSIONSF18151 INHALANT ABUSE W/INDUCED PSYCHOT D/O W/HALLUCINF18159 INHALANT ABUSE W/INHALANT-INDUCD PSYCHOT D/O UNSF1817 INHALANT ABUSE WITH INHALANT-INDUCED DEMENTIAF18180 INHALANT ABUSE W/INHALANT-INDUCED ANXIETY D/OF18188 INHALANT ABUSE W/OTH INHALANT-INDUCED DISORDERF1819 INHALANT ABUSE W/UNS INHALANT-INDUCED DISORDERF1820 INHALANT DEPENDENCE UNCOMPLICATEDF1821 INHALANT DEPENDENCE IN REMISSIONF18220 INHALANT DEPENDENCE W/INTOXICATION UNCOMPLICATEDF18221 INHALANT DEPENDENCE WITH INTOXICATION DELIRIUMF18229 INHALANT DEPENDENCE W/INTOXICATION UNSPECIFIEDF1824 INHALANT DEPENDENCE W/INHALANT-INDUCED MOOD D/OF18250 INHALANT DEPEND W/INDUC PSYCHOT D/O W/DELUSIONSF18251 INHALANT DEPEND W/INDUC PSYCHOT D/O W/HALLUCINF18259 INHALANT DEPEND W/INHAL-INDUCD PSYCHOT D/O UNSF1827 INHALANT DEPENDENCE W/INHALANT-INDUCED DEMENTIAF18280 INHALANT DEPENDENCE W/INHAL-INDUCD ANXIETY D/OF18288 INHALANT DEPENDENCE W/OTH INHALANT-INDUCED D/OF1829 INHALANT DEPENDENCE W/UNS INHALANT-INDUCED D/OF1890 INHALANT USE UNSPECIFIED UNCOMPLICATEDF18920 INHALANT USE UNS W/INTOXICATION UNCOMPLICATEDF18921 INHALANT USE UNS W/INTOXICATION W/DELIRIUMF18929 INHALANT USE UNS W/INTOXICATION UNSPECIFIEDF1894 INHALANT USE UNS W/INHALANT-INDUCD MOOD DISORDERF18950 INHALANT USE UNS W/INDUCD PSYCHOT D/O DELUSIONSF18951 INHALANT USE UNS W/INDUCD PSYCHOT D/O W/HALLUCINF18959 INHALANT USE UNS W/INDUCED PSYCHOTIC D/O UNSF1897 INHALANT USE UNS W/INDUCED PERSISTING DEMENTIAF18980 INHALANT USE UNS W/INHALANT-INDUCED ANXIETY D/OF18988 INHALANT USE UNS W/OTH INHALANT-INDUCED DISORDERF1899 INHALANT USE UNS W/UNS INHALANT-INDUCED DISORDERF1910 OTHER PSYCHOACTIVE SUBSTANCE ABUSE UNCOMPLICATEDF19120 OTH PSYCHOACTIVE SBSTNC ABUSE W/INTOXICAT UNCOMPF19121 OTH PSYCHOACTIVE SBSTNC ABUSE INTOXICAT DELIRIUMF19122 OTH PSYCHOACTIVE SBSTNC ABUSE INTOX PERCEPT DISTF19129 OTH PSYCHOACTIVE SBSTNC ABUSE W/INTOXICATION UNSF1914 OTH PSYCHOACTIVE SBSTNC ABUSE W/INDUCD MOOD D/OF19150 OTH PSYCHOACTIV SBSTNC ABUSE IND PSYCHOT D/O DELF19151 OTH PSYCHOACTV SBSTNC ABUSE IND PSYCH D/O HALLUCF19159 OTH PSYCHOACTIV SBSTNC ABUSE INDUC PSYCH D/O UNSF1916 OTH PSYCHOACTV SBSTNC ABUS IND PERSIST AMNES D/OF1917 OTH PSYCHOACTV SBSTNC ABUSE INDUC PERSIST DEMENT

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONF19180 OTH PSYCHOACTIVE SBSTNC ABUSE INDUCD ANXIETY D/OF19181 OTH PSYCHOACTIVE SBSTNC ABUSE W/INDUCD SEXL DYSFF19182 OTH PSYCHOACTIVE SBSTNC ABUSE W/INDUCD SLEEP D/OF19188 OTH PSYCHOACTIVE SBSTNC ABUSE W/OTH INDUCED D/OF1919 OTH PSYCHOACTIVE SBSTNC ABUSE W/UNS INDUCED D/OF1920 OTH PSYCHOACTIVE SUBSTANCE DEPEND UNCOMPLICATEDF1921 OTH PSYCHOACTIVE SUBSTANCE DEPENDENCE REMISSIONF19220 OTH PSYCHOACTIVE SBSTNC DEPEND W/INTOX UNCOMPF19221 OTH PSYCHOACTIVE SBSTNC DEPEND INTOX DELIRIUMF19222 OTH PSYCHOACTV SBSTNC DEPEND INTOX PERCEPTL DISTF19229 OTH PSYCHOACTIVE SBSTNC DEPEND W/INTOXICAT UNSF19230 OTH PSYCHOACTIVE SBSTNC DEPND W/WITHDRAWL UNCOMPF19231 OTH PSYCHOACTIVE SBSTNC DEPEND WITH W/D DELIRIUMF19232 OTH PSYCHOACTV SBSTNC DEPEND W/D W/PERCEPTL DISTF19239 OTH PSYCHOACTIVE SBSTNC DEPEND W/WITHDRAWAL UNSF1924 OTH PSYCHOACTIVE SBSTNC DEPEND W/INDUCD MOOD D/OF19250 OTH PSYCHOACTV SBSTNC DEPEND IND PSYCH D/O W/DELF19251 OTH PSYCHOACTV SBSTNC DEPND IND PSYCH D/O HALLUCF19259 OTH PSYCHOACTV SBSTNC DEPEND INDUC PSYCH D/O UNSF1926 OTH PSYCHOACTV SBSTNC DEPEND IND PERSIST AMNESF1927 OTH PSYCHOACTV SBSTNC DEPEND IND PERSIST DEMENTF19280 OTH PSYCHOACTIVE SBSTNC DEP W/INDUC ANXIETY D/OF19281 OTH PSYCHOACTIVE SBSTNC DEPEND INDUCD SEXL DYSFF19282 OTH PSYCHOACTIVE SBSTNC DEPEND INDUCD SLEEP D/OF19288 OTH PSYCHOACTIVE SBSTNC DEPEND W/OTH INDUCD D/OF1929 OTH PSYCHOACTIVE SBSTNC DEPEND W/UNS INDUCD D/OF1990 OTH PSYCHOACTIVE SUBSTANCE USE UNS UNCOMPLICATEDF19920 OTH PSYCHOACTIVE SBSTNC USE UNS W/INTOX UNCOMPF19921 OTH PSYCHOACTIVE SBSTNC USE UNS INTOX W/DELIRIUMF19922 OTH PSYCHOACTV SBSTNC USE UNS INTOX PERCEPT DISTF19929 OTH PSYCHOACTIVE SBSTNC USE UNS W/INTOXICAT UNSF19930 OTH PSYCHOACTIVE SBSTNC USE UNS WITHDRAWL UNCOMPF19931 OTH PSYCHOACTV SBSTNC USE UNS WITHDRWL DELIRIUMF19932 OTH PSYCHOACTV SBSTNC USE UNS W/D PERCEPTL DISTF19939 OTH PSYCHOACTIVE SBSTNC USE UNS W/WITHDRAWAL UNSF1994 OTH PSYCHOACTIVE SBSTNC USE UNS W/INDUC MOOD D/OF19950 OTH PSYCHOACTV SBSTNC USE UNS IND PSYCH D/O DELF19951 OTH PSYCHOACTV SBST USE UNS IND PSYCH D/O HALLUF19959 OTH PSYCHOACTV SBSTNC USE UNS IND PSYCH D/O UNSF1996 OTH PSYCHOACTV SBSTNC USE UNS IND PERSIST AMNESF1997 OTH PSYCHOACTV SBSTNC USE UNS IND PERSIST DEMENTF19980 OTH PSYCHOACTIVE SBSTNC USE UNS IND ANXIETY D/OF19981 OTH PSYCHOACTIVE SBSTNC USE UNS W/IND SEXL DYSFF19982 OTH PSYCHOACTIVE SBSTNC USE UNS W/IND SLEEP D/OF19988 OTH PSYCHOACTIVE SBSTNC USE UNS W/OTH INDUCD D/O

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONF1999 OTH PSYCHOACTIVE SBSTNC USE UNS W/UNS INDUCD D/OF200 PARANOID SCHIZOPHRENIAF201 DISORGANIZED SCHIZOPHRENIAF202 CATATONIC SCHIZOPHRENIAF203 UNDIFFERENTIATED SCHIZOPHRENIAF205 RESIDUAL SCHIZOPHRENIAF2081 SCHIZOPHRENIFORM DISORDERF2089 OTHER SCHIZOPHRENIAF209 SCHIZOPHRENIA UNSPECIFIEDF21 SCHIZOTYPAL DISORDERF22 DELUSIONAL DISORDERSF23 BRIEF PSYCHOTIC DISORDERF24 SHARED PSYCHOTIC DISORDERF250 SCHIZOAFFECTIVE DISORDER BIPOLAR TYPEF251 SCHIZOAFFECTIVE DISORDER DEPRESSIVE TYPEF258 OTHER SCHIZOAFFECTIVE DISORDERSF259 SCHIZOAFFECTIVE DISORDER UNSPECIFIEDF28 OTH PSYCHOT D/O NOT DUE SUBSTANCE/PHYSIOLOG CONDF29 UNS PSYCHOSIS NOT DUE SUBSTANCE/PHYSIOLOG CONDF3010 MANIC EPISODE WITHOUT PSYCHOTIC SYMPTOMS UNSF3011 MANIC EPISODE WITHOUT PSYCHOTIC SYMPTOMS MILDF3012 MANIC EPISODE WITHOUT PSYCHOTIC SYMPTOM MODERATEF3013 MANIC EPISODE SEVERE WITHOUT PSYCHOTIC SYMPTOMSF302 MANIC EPISODE SEVERE WITH PSYCHOTIC SYMPTOMSF303 MANIC EPISODE IN PARTIAL REMISSIONF304 MANIC EPISODE IN FULL REMISSIONF308 OTHER MANIC EPISODESF309 MANIC EPISODE UNSPECIFIEDF310 BIPOLAR DISORDER CURRENT EPISODE HYPOMANICF3110 BIPOLAR D/O CURRENT MANIC W/O PSYCH FEATURE UNSF3111 BIPOLAR D/O CURRENT MANIC W/O PSYCH FEATURE MILDF3112 BIPOLAR D/O CURRENT MANIC W/O PSYCH FEATURE MODF3113 BIPOLAR D/O CURRENT MANIC W/O PSYCH FEATURE SEVF312 BIPOLAR D/O CURRENT EPIS MANIC W/PSYCH FEATUREF3130 BIPOLAR D/O CURRNT DEPRESS MILD/MOD SEVERITY UNSF3131 BIPOLAR D/O CURRENT EPISODE DEPRESSED MILDF3132 BIPOLAR D/O CURRENT EPISODE DEPRESSED MODERATEF314 BIPOLAR D/O CURR DEPRESS SEVERE W/O PSYCH FEATURF315 BIPOLAR D/O CURR DEPRESS SEVERE W/PSYCH FEATUREF3160 BIPOLAR DISORDER CURRENT EPISODE MIXED UNSF3161 BIPOLAR DISORDER CURRENT EPISODE MIXED MILDF3162 BIPOLAR DISORDER CURRENT EPISODE MIXED MODERATEF3163 BIPOLAR D/O CURR MIXED SEVERE W/O PSYCH FEATURESF3164 BIPOLAR D/O CURR MIXED SEVERE W/PSYCH FEATURESF3170 BIPOLAR D/O CURR REMISS MOST RECENT EPISODE UNS

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONF3171 BIPOLAR DISORDER PARTIAL REMISSION MRE HYPOMANICF3172 BIPOLAR DISORDER FULL REMISSION MRE HYPOMANICF3173 BIPOLAR DISORDER PARTIAL REMISSION MRE MANICF3174 BIPOLAR DISORDER FULL REMISSION MRE MANICF3175 BIPOLAR DISORDER PARTIAL REMISSION MRE DEPRESSEDF3176 BIPOLAR DISORDER FULL REMISSION MRE DEPRESSEDF3177 BIPOLAR DISORDER PARTIAL REMISSION MRE MIXEDF3178 BIPOLAR DISORDER FULL REMISSION MRE MIXEDF3181 BIPOLAR II DISORDERF3189 OTHER BIPOLAR DISORDERF319 BIPOLAR DISORDER UNSPECIFIEDF320 Major depressive disorder, single episode, mildF321 MAJOR DEPRESSIVE DISORDER SINGLE EPISODE MODF322 MAJ DEPRESS D/O SINGLE EPIS SEV W/O PSYCH FEATURF323 MAJ DEPRESS D/O SINGLE EPIS SEV W/PSYCH FEATURESF324 MAJOR DEPRESSIVE D/O SINGLE EPIS PART REMISSIONF325 MAJOR DEPRESSIVE D/O SINGLE EPIS FULL REMISSIONF328 Other depressive episodesF329 Major depressive disorder, single episode, unspecifiedF330 MAJOR DEPRESSIVE DISORDER RECURRENT MILDF331 MAJOR DEPRESSIVE DISORDER RECURRENT MODERATEF332 MAJ DEPRESS D/O RECURRENT SEV W/O PSYCH FEATURESF333 MAJ DEPRESS D/O RECURRENT SEV W/PSYCH SYMPTOMSF3340 MAJOR DEPRESSIVE D/O RECURRENT REMISSION UNSF3341 MAJOR DEPRESSIVE D/O RECURRENT PARTIAL REMISSIONF3342 MAJOR DEPRESSIVE D/O RECURRENT FULL REMISSIONF338 OTHER RECURRENT DEPRESSIVE DISORDERSF339 MAJOR DEPRESSIVE DISORDER RECURRENT UNSPECIFIEDF340 CYCLOTHYMIC DISORDERF341 DYSTHYMIC DISORDERF348 OTHER PERSISTENT MOOD AFFECTIVE DISORDERSF349 PERSISTENT MOOD AFFECTIVE DISORDER UNSPECIFIEDF39 Unspecified mood [affective] disorderF4000 Agoraphobia, unspecifiedF4001 Agoraphobia with panic disorderF4002 Agoraphobia without panic disorderF410 PANIC DISORDER WITHOUT AGORAPHOBIAF411 GENERALIZED ANXIETY DISORDERF413 OTHER MIXED ANXIETY DISORDERSF418 OTHER SPECIFIED ANXIETY DISORDERSF419 ANXIETY DISORDER UNSPECIFIEDF42 OBSESSIVE-COMPULSIVE DISORDERF430 ACUTE STRESS REACTIONF4310 POST-TRAUMATIC STRESS DISORDER UNSPECIFIEDF4311 POST-TRAUMATIC STRESS DISORDER ACUTE

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONF4312 POST-TRAUMATIC STRESS DISORDER CHRONICF4320 ADJUSTMENT DISORDER UNSPECIFIEDF4321 ADJUSTMENT DISORDER WITH DEPRESSED MOODF4322 ADJUSTMENT DISORDER WITH ANXIETYF4323 ADJUSTMENT DISORDER MIXED ANXIETY DEPRESSED MOODF4324 ADJUSTMENT DISORDER WITH DISTURBANCE OF CONDUCTF4325 ADJUSTMENT DISORDER MIXD DISTURB EMOTION CONDUCTF4329 ADJUSTMENT DISORDER WITH OTHER SYMPTOMSF438 OTHER REACTIONS TO SEVERE STRESSF439 REACTION TO SEVERE STRESS UNSPECIFIEDF440 DISSOCIATIVE AMNESIAF441 DISSOCIATIVE FUGUEF444 CONVERSION DISORDER W/MOTOR SYMPTOM OR DEFICITF445 CONVERSION DISORDER W/SEIZURES OR CONVULSIONSF446 CONVERSION DISORDER W/SENSORY SYMPTOM/DEFICITF447 CONVERSION DISORDER W/MIXED SYMPTOM PRESENTATIONF4481 DISSOCIATIVE IDENTITY DISORDERF4489 OTHER DISSOCIATIVE AND CONVERSION DISORDERSF449 DISSOCIATIVE AND CONVERSION DISORDER UNSPECIFIEDF450 SOMATIZATION DISORDERF451 UNDIFFERENTIATED SOMATOFORM DISORDERF4520 Hypochondriacal disorder, unspecifiedF4521 HypochondriasisF4522 BODY DYSMORPHIC DISORDERF4529 OTHER HYPOCHONDRIACAL DISORDERSF4541 PAIN DISORDERS EXLUSIVELY REL PSYCHOLOG FACTORSF4542 PAIN DISORDERS W/RELATED PSYCHOLOGICAL FACTORSF458 OTHER SOMATOFORM DISORDERSF459 SOMATOFORM DISORDER UNSPECIFIEDF481 DEPERSONALIZATION-DEREALIZATION SYNDROMEF482 PSEUDOBULBAR AFFECTF488 OTHER SPECIFIED NONPSYCHOTIC MENTAL DISORDERSF489 NONPSYCHOTIC MENTAL DISORDER UNSPECIFIEDF5000 ANOREXIA NERVOSA UNSPECIFIEDF5001 ANOREXIA NERVOSA RESTRICTING TYPEF5002 ANOREXIA NERVOSA BINGE EATING/PURGING TYPEF502 BULIMIA NERVOSAF508 OTHER EATING DISORDERSF509 EATING DISORDER UNSPECIFIEDF53 Puerperal psychosisF550 Abuse of antacidsF551 Abuse of herbal or folk remediesF552 Abuse of laxativesF553 Abuse of steroids or hormonesF554 Abuse of vitamins

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONF558 Abuse of other non-psychoactive substancesF600 PARANOID PERSONALITY DISORDERF601 SCHIZOID PERSONALITY DISORDERF602 ANTISOCIAL PERSONALITY DISORDERF603 BORDERLINE PERSONALITY DISORDERF604 HISTRIONIC PERSONALITY DISORDERF605 OBSESSIVE-COMPULSIVE PERSONALITY DISORDERF606 AVOIDANT PERSONALITY DISORDERF607 DEPENDENT PERSONALITY DISORDERF6081 NARCISSISTIC PERSONALITY DISORDERF6089 OTHER SPECIFIC PERSONALITY DISORDERSF609 PERSONALITY DISORDER UNSPECIFIEDF6381 Intermittent explosive disorderF639 Impulse disorder, unspecifiedF641 GENDER IDENTITY D/O IN ADOLESCENCE & ADULTHOODF642 GENDER IDENTITY DISORDER OF CHILDHOODF648 OTHER GENDER IDENTITY DISORDERSF649 GENDER IDENTITY DISORDER UNSPECIFIEDF70 Mild intellectual disabilitiesF71 Moderate intellectual disabilitiesF72 Severe intellectual disabilitiesF73 Profound intellectual disabilitiesF78 Other intellectual disabilitiesF79 Unspecified intellectual disabilitiesF801 Expressive language disorderF819 Developmental disorder of scholastic skills, unspecifiedF840 AUTISTIC DISORDERF843 Other childhood disintegrative disorderF845 ASPERGERS SYNDROMEF848 OTHER PERVASIVE DEVELOPMENTAL DISORDERSF849 PERVASIVE DEVELOPMENTAL DISORDER UNSPECIFIEDF89 Unspecified disorder of psychological developmentF900 Attention-deficit hyperactivity disorder, predominantly inattentive typeF901 Attention-deficit hyperactivity disorder, predominantly hyperactive typeF902 Attention-deficit hyperactivity disorder, combined typeF908 Attention-deficit hyperactivity disorder, other typeF909 Attention-deficit hyperactivity disorder, unspecified typeF913 Oppositional defiant disorderF919 Conduct disorder, unspecifiedF952 TOURETTES DISORDERG041 TROPICAL SPASTIC PARAPLEGIAG114 HEREDITARY SPASTIC PARAPLEGIAG1221 AMYOTROPHIC LATERAL SCLEROSISG130 PARANEOPLASTIC NEUROMYOPATHY AND NEUROPATHYG131 OTH SYSTEM ATROPHY PRIM AFFECT CNS NEOPLASTIC DZ

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONG231 PROGRESSIVE SUPRANUCLEAR OPHTHALMOPLEGIAG300 ALZHEIMERS DISEASE WITH EARLY ONSETG301 ALZHEIMERS DISEASE WITH LATE ONSETG308 OTHER ALZHEIMERS DISEASEG309 ALZHEIMERS DISEASE UNSPECIFIEDG3109 OTHER FRONTOTEMPORAL DEMENTIAG3183 DEMENTIA WITH LEWY BODIESG3184 Mild cognitive impairment, so statedG35 MULTIPLE SCLEROSISG40101 LOC-REL SX EPILEPSY W/SPS NOT INTRACT W/SEG40109 LOC-REL SX EPILEPSY W/SPS NOT INTRACT W/O SEG40111 LOC-REL SX EPILEPSY W/SPS INTRACT W/STAT EPIG40119 LOC-REL SX EPILEPSY W/SPS INTRACT W/O STAT EPIG40201 LOC-REL SX EPILEPSY W/CPS NOT INTRACT W/SEG40209 LOC-REL SX EPILEPSY W/CPS NOT INTRACT W/O SEG40211 LOC-REL SX EPILEPSY W/CPS INTRACT W/STAT EPIG40219 LOC-REL SX EPILEPSY W/CPS INTRACT W/O STAT EPIG40301 GEN IDIOPATHIC EPILEPSY NOT INTRACT W/STAT EPIG40309 GEN IDIOPATHIC EPILEPSY NOT INTRACT W/O STAT EPIG40311 GEN IDIOPATHIC EPILEPSY INTRACTABLE W/STATUS EPIG40319 GEN IDIOPATHIC EPILEPSY INTRACT W/O STATUS EPIG40401 OTH GEN EPILEPSY NOT INTRACTABLE W/STATUS EPIG40409 OTH GEN EPILEPSY NOT INTRACTABLE W/O STATUS EPIG40411 OTH GEN EPILEPSY INTRACTABLE W/STATUS EPIG40419 OTH GEN EPILEPSY INTRACTABLE W/O STATUS EPIG40501 EPILEPTIC SEIZ EXT CAUS NOT INTRACT W/STATUS EPIG40509 EPILEPTIC SEIZ EXT CAUS NOT INTRACT W/O STAT EPIG40801 OTHER EPILEPSY NOT INTRACT W/STATUS EPILEPTICUSG40802 OTHER EPILEPSY NOT INTRACTABLE WITHOUT SEG40803 OTHER EPILEPSY INTRACTABLE WITH STATUS EPILEPTICG40804 OTHER EPILEPSY INTRACTABLE WITHOUT STATUS EPILEPG40821 EPILEPTIC SPASMS NOT INTRACTABLE WITH STATUS EPIG40822 EPILEPTIC SPASMS NOT INTRACTABLE WITHOUT SEG40823 EPILEPTIC SPASMS INTRACTABL W/STATUS EPILEPTICUSG40824 EPILEPTIC SPASMS INTRACTABLE WITHOUT SEG40901 EPILEPSY UNS NOT INTRACT W/STATUS EPILEPTICUSG40909 EPILEPSY UNS NOT INTRACT W/O STATUS EPILEPTICUSG40911 EPILEPSY UNS INTRACTABLE W/STATUS EPILEPTICUSG40919 EPILEPSY UNS INTRACTABLE W/O STATUS EPILEPTICUSG40A01 ABSENCE EPILEPTIC SYNDROME NOT INTRACTABLE W/ SEG40A09 ABSENCE EPIL SYNDROME NOT INTRACTABLE W/O SEG40A11 ABSENCE EPILEPTIC SYNDROME INTRACTABLE WITH SEG40A19 ABSENCE EPILEPTIC SYNDROME INTRACTABLE W/O SEG40B01 JUVENILE MYOCLONIC EPIL NOT INTRACTABLE W/SEG40B09 JUVENILE MYOCLONIC EPIL NOT INTRACTABLE W/O SE

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONG40B11 JUVENILE MYOCLONIC EPILEPSY INTRACTABLE WITH SEG40B19 JUVENILE MYOCLONIC EPIL INTRACTABLE WITHOUT SEG44209 Tension-type headache, unspecified, not intractableG450 VERTEBRO-BASILAR ARTERY SYNDROMEG451 CAROTID ARTERY SYNDROME HEMISPHERICG452 MULTIPLE & BILATERAL PRECEREBRAL ARTERY SYNDG453 AMAUROSIS FUGAXG454 TRANSIENT GLOBAL AMNESIAG458 OTH TRANSIENT CERBRL ISCHEMIC ATTACKS & REL SYNDG459 TRANSIENT CEREBRAL ISCHEMIC ATTACK UNSPECIFIEDG460 MIDDLE CEREBRAL ARTERY SYNDROMEG461 ANTERIOR CEREBRAL ARTERY SYNDROMEG462 POSTERIOR CEREBRAL ARTERY SYNDROMEG710 MUSCULAR DYSTROPHYG731 LAMBERT-EATON SYNDROME IN NEOPLASTIC DISEASEG800 SPASTIC QUADRIPLEGIC CEREBRAL PALSYG801 SPASTIC DIPLEGIC CEREBRAL PALSYG802 SPASTIC HEMIPLEGIC CEREBRAL PALSYG803 ATHETOID CEREBRAL PALSYG804 ATAXIC CEREBRAL PALSYG808 OTHER CEREBRAL PALSYG809 CEREBRAL PALSY UNSPECIFIEDG8100 FLACCID HEMIPLEGIA AFFECTING UNSPECIFIED SIDEG8101 FLACCID HEMIPLEGIA AFFECTING RIGHT DOMINANT SIDEG8102 FLACCID HEMIPLEGIA AFFECTING LEFT DOMINANT SIDEG8103 FLACCID HEMIPLEGIA AFFECTING RT NONDOMINANT SIDEG8104 FLACCID HEMIPLEGIA AFFECTING LT NONDOMINANT SIDEG8110 SPASTIC HEMIPLEGIA AFFECTING UNSPECIFIED SIDEG8111 SPASTIC HEMIPLEGIA AFFECTING RIGHT DOMINANT SIDEG8112 SPASTIC HEMIPLEGIA AFFECTING LEFT DOMINANT SIDEG8113 SPASTIC HEMIPLEGIA AFFECTING RT NONDOMINANT SIDEG8114 SPASTIC HEMIPLEGIA AFFECTING LT NONDOMINANT SIDEG8190 HEMIPLEGIA UNS AFFECTING UNSPECIFIED SIDEG8191 HEMIPLEGIA UNS AFFECTING RIGHT DOMINANT SIDEG8192 HEMIPLEGIA UNS AFFECTING LEFT DOMINANT SIDEG8193 HEMIPLEGIA UNS AFFECTING RIGHT NONDOMINANT SIDEG8194 HEMIPLEGIA UNS AFFECTING LEFT NONDOMINANT SIDEG8220 PARAPLEGIA UNSPECIFIEDG8221 PARAPLEGIA COMPLETEG8222 PARAPLEGIA INCOMPLETEG8250 QUADRIPLEGIA UNSPECIFIEDG8251 QUADRIPLEGIA C1-C4 COMPLETEG8252 QUADRIPLEGIA C1-C4 INCOMPLETEG8253 QUADRIPLEGIA C5-C7 COMPLETEG8254 QUADRIPLEGIA C5-C7 INCOMPLETE

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONG830 DIPLEGIA OF UPPER LIMBSG8310 MONOPLEGIA LOWER LIMB AFFECTING UNSPECIFIED SIDEG8311 MONOPLEGIA LOWER LIMB RIGHT DOMINANT SIDEG8312 MONOPLEGIA LOWER LIMB LEFT DOMINANT SIDEG8313 MONOPLEGIA LOWER LIMB RIGHT NONDOMINANT SIDEG8314 MONOPLEGIA LOWER LIMB LEFT NONDOMINANT SIDEG8320 MONOPLEGIA UPPER LIMB AFFECTING UNSPECIFIED SIDEG8321 MONOPLEGIA UPPER LIMB RIGHT DOMINANT SIDEG8322 MONOPLEGIA UPPER LIMB LEFT DOMINANT SIDEG8323 MONOPLEGIA UPPER LIMB RIGHT NONDOMINANT SIDEG8324 MONOPLEGIA UPPER LIMB LEFT NONDOMINANT SIDEG8330 MONOPLEGIA UNS AFFECTING UNSPECIFIED SIDEG8331 MONOPLEGIA UNS AFFECTING RIGHT DOMINANT SIDEG8332 MONOPLEGIA UNS AFFECTING LEFT DOMINANT SIDEG8333 MONOPLEGIA UNS AFFECTING RIGHT NONDOMINANT SIDEG8334 MONOPLEGIA UNS AFFECTING LEFT NONDOMINANT SIDEG8384 TODDS PARALYSIS POSTEPILEPTICG893 NEOPLASM RELATED PAIN ACUTE CHRONICG910 COMMUNICATING HYDROCEPHALUSG911 OBSTRUCTIVE HYDROCEPHALUSG912 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUSG913 POST-TRAUMATIC HYDROCEPHALUS UNSPECIFIEDG914 HYDROCEPHALUS IN DISEASES CLASSIFIED ELSEWHEREG918 OTHER HYDROCEPHALUSG919 HYDROCEPHALUS UNSPECIFIEDG9340 ENCEPHALOPATHY UNSPECIFIEDG9341 METABOLIC ENCEPHALOPATHYG9349 OTHER ENCEPHALOPATHYH35031 HYPERTENSIVE RETINOPATHY RIGHT EYEH35032 HYPERTENSIVE RETINOPATHY LEFT EYEH35033 HYPERTENSIVE RETINOPATHY BILATERALH35039 HYPERTENSIVE RETINOPATHY UNSPECIFIED EYEH4742 DISORDERS OF OPTIC CHIASM DUE TO NEOPLASMH47521 DISORDERS VISUAL PATHWAYS DUE NEOPLASM RT SIDEH47522 DISORDERS VISUAL PATHWAYS DUE NEOPLASM LT SIDEH47529 DISORDERS VISUAL PATHWAYS DUE NEOPLASM UNS SIDEH47631 DISORDER VISUAL CORTX DUE NEOPLASM RT SIDE BRAINH47632 DISORDER VISUAL CORTX DUE NEOPLASM LT SIDE BRAINH47639 DISORDER VIS CORTEX DUE NEOPLASM UNS SIDE BRAINH4930 TOTAL EXTERNAL OPHTHALMOPLEGIA UNSPECIFIED EYEH4931 TOTAL EXTERNAL OPHTHALMOPLEGIA RIGHT EYEH4932 TOTAL EXTERNAL OPHTHALMOPLEGIA LEFT EYEH4933 TOTAL EXTERNAL OPHTHALMOPLEGIA BILATERALH4940 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA UNS EYEH4941 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA RIGHT EYE

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONH4942 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA LEFT EYEH4943 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA BILATERALH5120 INTERNUCLEAR OPHTHALMOPLEGIA UNSPECIFIED EYEH5121 INTERNUCLEAR OPHTHALMOPLEGIA RIGHT EYEH5122 INTERNUCLEAR OPHTHALMOPLEGIA LEFT EYEH5123 INTERNUCLEAR OPHTHALMOPLEGIA BILATERALH52511 INTERNAL OPHTHALMOPLEGIA COMPLETE TOTAL RT EYEH52512 INTERNAL OPHTHALMOPLEGIA COMPLETE TOTAL LT EYEH52513 INTERNAL OPHTHALMOPLEGIA COMPLETE TOTAL BILATH52519 INTERNAL OPHTHALMOPLEGIA COMPLETE TOTAL UNS EYEI0981 RHEUMATIC HEART FAILUREI110 HYPERTENSIVE HEART DISEASE WITH HEART FAILUREI119 HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILUREI120 HYPERTENSIVE CKD W/STAGE 5 CKD OR ESRDI129 HYPERTENSIVE CKD W/STAGE 1-4 CKD OR UNS CKDI130 HTN HEART & CKD W/HF & CKD STAGE 1-4 OR UNS CKDI1310 HTN HEART & CKD W/O HF W/STAGE 1-4 CKD/UNS CKDI1311 HTN HEART & CKD W/O HF W/STAGE 5 CKD OR ESRDI132 HTN HEART & CKD W/HF W/STAGE 5 CKD OR ESRDI132 HTN HEART & CKD W/HF W/STAGE 5 CKD OR ESRDI150 RENOVASCULAR HYPERTENSIONI151 HYPERTENSION SECONDARY TO OTHER RENAL DISORDERSI152 HYPERTENSION SECONDARY TO ENDOCRINE DISORDERSI200 UNSTABLE ANGINAI201 ANGINA PECTORIS WITH DOCUMENTED SPASMI208 OTHER FORMS OF ANGINA PECTORISI209 ANGINA PECTORIS UNSPECIFIEDI2101 ST ELEVATION MYOCARDIAL INFARCTION INVOLV LMCAI2102 ST ELEVATION MYOCARDIAL INFARCTION INVOLV LADCAI2109 ST ELEVATION MI INVOLV OTH CORONARY ART ANT WALLI2111 ST ELEVATION MYOCARDIAL INFARCTION INVOLVING RCAI2119 ST ELEVATION MI INVOLV OTH CORONARY ART INF WALLI2121 ST ELEVATION MI INVOLV LT CIRCUMFLEX COR ARTERYI2129 ST ELEVATION MYOCARDIAL INFARCT INVOLV OTH SITESI213 ST ELEVATION MYOCARDIAL INFARCTION UNS SITEI214 NON-ST ELEVATION MYOCARDIAL INFARCTIONI220 SUBSEQUENT ST ELEVATION MYOCARD INFARCT ANT WALLI221 SUBSEQUENT ST ELEVATION MYOCARD INFARCT INF WALLI222 SUBSEQUENT NON-ST ELEVATION MYOCARDIAL INFARCTI228 SUBSEQUENT ST ELEV MYOCARDIAL INFARCT OTH SITESI229 SUBSEQUENT ST ELEV MYOCARDIAL INFARCT UNS SITEI240 ACUTE CORONARY THROMBOSIS NOT RESULTING IN MII241 DRESSLERS SYNDROMEI248 OTHER FORMS OF ACUTE ISCHEMIC HEART DISEASEI249 ACUTE ISCHEMIC HEART DISEASE UNSPECIFIED

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONI2510 ASHD NATIVE CORONARY ARTERY W/O ANGINA PECTORISI25110 ASHD NATIVE COR ART W/UNSTABLE ANGINA PECTORISI25111 ASHD NATIVE COR ART W/ANGINA PECTORIS DOC SPASMI25118 ASHD NATIVE COR ART W/OTH FORMS ANGINA PECTORISI25119 ASHD NATIVE COR ARTREY W/UNS ANGINA PECTORISI252 OLD MYOCARDIAL INFARCTIONI253 ANEURYSM OF HEARTI2541 CORONARY ARTERY ANEURYSMI2542 CORONARY ARTERY DISSECTIONI255 ISCHEMIC CARDIOMYOPATHYI256 SILENT MYOCARDIAL ISCHEMIAI25700 ATHEROSCLEROSIS CABG UNS UNSTABL ANGINA PECTORISI25701 ATHEROSCLEROSIS CABG UNS W/AP DOCUMENTED SPASMI25708 ATHEROSCLEROSIS CABG UNS W/OTH ANGINA PECTORISI25709 ATHEROSCLEROSIS CABG UNS W/UNS ANGINA PECTORISI25710 ATHEROSCLEROSIS AUTOLOG VEIN CABG W/UNSTABLE API25711 ATHEROSCLEROSIS AUTOLOG VEIN CABG W/AP DOC SPASMI25718 ATHEROSCLEROSIS AUTOLOG VEIN CABG W/OTH FORMS API25719 ATHEROSCLEROSIS AUTOLOGOUS VEIN CABG W/UNS API25720 ATHEROSCLEROSIS AUTOLOG ART CABG W/UNSTABLE API25721 ATHEROSCLEROSIS AUTOLOG ART CABG W/AP DOC SPASMI25728 ATHEROSCLEROSIS AUTOLOG ART CABG W/OTH FORMS API25729 ATHEROSCLEROSIS AUTOLOGOUS ARTERY CABG W/UNS API25730 ATHEROSCLEROSIS NONAUTOLOG BIOL CABG W/UNSTBL API25731 ATHEROSCLER NONAUTOLOG BIOL CABG W/AP DOC SPASMI25738 ATHEROSCLER NONAUTOLOG BIOL CABG W/OTH FORMS API25739 ATHEROSCLEROSIS NONAUTOLOG BIOL CABG W/UNS API25750 ATHEROSCLER NATV COR ART TPLNT HRT W/UNSTABLE API25751 ATHEROSCLER NATV COR ART TPLNT HRT W/AP SPASMI25758 ATHEROSCLER NATV COR ART TPLNT HRT W/OTH FORM API25759 ATHEROSCLEROSIS NATV COR ART TPLNT HRT W/UNS API25760 ATHEROSCLER BP GRAFT COR ART TPLNT HRT UNSTBL API25761 ATHEROSCLER BP GRAFT COR ART TPLNT HRT AP SPASMI25768 ATHEROSCLER BP GRAFT COR ART TPLNT HRT W/OTH API25769 ATHEROSCLER BP GRAFT COR ART TPLNT HRT W/UNS API25790 ATHEROSCLER OTH COR ART BP GRAFT W/UNSTABLE API25791 ATHEROSCLER OTH COR ART BP GRAFT W/AP DOC SPASMI25798 ATHEROSCLER OTH COR ART BP GRAFT W/OTH FORMS API25799 ATHEROSCLER OTH COR ART BP GRAFT W/UNSTABLE API25810 ATHEROSCLEROSIS CABG WITHOUT ANGINA PECTORISI25811 ATHEROSCLEROSIS NATIVE COR ART TPLNT HRT W/O API25812 ATHEROSCLER BP GRAFT COR ART TPLNT HRT W/O API2582 CHRONIC TOTAL OCCLUSION OF CORONARY ARTERYI2583 CORONARY ATHEROSLEROSIS DUE TO LIPID RICH PLAQUEI259 CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONI270 PRIMARY PULMONARY HYPERTENSIONI2782 CHRONIC PULMONARY EMBOLISMI501 LEFT VENTRICULAR FAILUREI5020 UNSPECIFIED SYSTOLIC CONGESTIVE HEART FAILUREI5021 ACUTE SYSTOLIC CONGESTIVE HEART FAILUREI5022 CHRONIC SYSTOLIC CONGESTIVE HEART FAILUREI5023 ACUTE CHRON SYSTOLIC HEART FAILUREI5030 UNSPECIFIED DIASTOLIC CONGESTIVE HEART FAILUREI5031 ACUTE DIASTOLIC CONGESTIVE HEART FAILUREI5032 CHRONIC DIASTOLIC CONGESTIVE HEART FAILUREI5033 ACUTE ON CHRON DIASTOLIC CONGESTIV HEART FAILUREI5040 UNSPECIFIED COMBINED SYSTOLIC & DIASTOLIC CHFI5041 ACUTE COMBINED SYSTOLIC AND DIASTOLIC CHFI5042 CHRONIC COMBINED SYSTOLIC AND DIASTOLIC CHFI5043 ACUTE ON CHRONIC COMB SYSTOLIC & DIASTOLIC CHFI509 HEART FAILURE UNSPECIFIEDI517 CARDIOMEGALY I6000 NONTRAUM SUBARACH HEMOR UNS CAROTID SIPHON & BIFI6001 NONTRAUM SUBARACH HEMORR RT CAROTID SIPHON & BIFI6002 NONTRAUM SUBARACH HEMORR LT CAROTID SIPHON & BIFI6010 NONTRAUMATIC SUBARACH HEMORR UNS MID CERBRL ARTI6011 NONTRAUMATIC SUBARACH HEMORR RT MID CERBRL ARTI6012 NONTRAUMATIC SUBARACH HEMORR LT MID CERBRL ARTI6020 NONTRAUMATIC SUBARACH HEMORR UNS ANT COMM ARTI6021 NONTRAUMATIC SUBARACH HEMORR RT ANT COMM ARTI6022 NONTRAUMATIC SUBARACH HEMORR LT ANT COMM ARTI6030 NONTRAUMATIC SUBARACH HEMORR UNS POST COMM ARTI6031 NONTRAUMATIC SUBARACH HEMORR RT POST COMM ARTI6032 NONTRAUMATIC SUBARACH HEMORR LT POST COMM ARTI604 NONTRAUMATIC SUBARACH HEMORR FROM BASILAR ARTI6050 NONTRAUMATIC SUBARACH HEMORR FROM UNS VERT ARTI6051 NONTRAUMATIC SUBARACH HEMORR FROM RT VERT ARTI6052 NONTRAUMATIC SUBARACH HEMORR FROM LT VERT ARTI606 NONTRAUMATIC SUBARACH HEMORR OTH INTRACRAN ARTI607 NONTRAUMATIC SUBARACH HEMORR UNS INTRACRAN ARTI608 OTHER NONTRAUMATIC SUBARACHNOID HEMORRHAGEI609 NONTRAUMATIC SUBARACHNOID HEMORRHAGE UNSPECIFIEDI610 NONTRAUMAT INTRACEREB HEMORR HEMISPH SUBCORTICALI611 NONTRAUMAT INTRACEREB HEMORR HEMISPHERE CORTICALI612 NONTRAUMATIC INTRACEREBRAL HEMORR HEMISPHERE UNSI613 NONTRAUMATIC INTRACEREBRAL HEMORR IN BRAIN STEMI614 NONTRAUMATIC INTRACEREBRAL HEMORR IN CEREBELLUMI615 NONTRAUMATIC INTRACEREBRAL HEM INTRAVENTRICULARI616 NONTRAUMATIC INTRACEREBRAL HEMORR MULTIPLE LOCI618 OTHER NONTRAUMATIC INTRACEREBRAL HEMORRHAGE

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONI619 NONTRAUMATIC INTRACEREBRAL HEMORRHAGE UNSI6300 CEREBRAL INFARCT D/T THROMB UNS PRECEREBRAL ARTI63011 CEREBRAL INFARCT D/T THROMB RT VERTEBRAL ARTERYI63012 CEREBRAL INFARCT D/T THROMB LT VERTEBRAL ARTERYI63019 CEREBRAL INFARCT D/T THROMB UNS VERTEBRAL ARTERYI6302 CEREBRAL INFARCT D/T THROMBOSIS BASILAR ARTERYI63031 CEREBRAL INFARCT D/T THROMB RIGHT CAROTID ARTERYI63032 CEREBRAL INFARCT D/T THROMB LEFT CAROTID ARTERYI63039 CEREBRAL INFARCT D/T THROMB UNS CAROTID ARTERYI6309 CEREBRAL INFARCT D/T THROMB OTH PRECEREBRAL ARTI6310 CEREBRAL INFARCT D/T EMBOLISM UNS PRECEREBRL ARTI63111 CEREBRAL INFARCTION D/T EMBOLISM RT VERT ARTERYI63112 CEREBRAL INFARCTION D/T EMBOLISM LT VERT ARTERYI63119 CEREBRAL INFARCTION D/T EMBOLISM UNS VERT ARTERYI6312 CEREBRAL INFARCTION D/T EMBOLISM BASILAR ARTERYI63131 CEREBRAL INFARCT D/T EMBOLISM RT CAROTID ARTERYI63132 CEREBRAL INFARCT D/T EMBOLISM LT CAROTID ARTERYI63139 CEREBRAL INFARCT D/T EMBOLISM UNS CAROTID ARTERYI6319 CEREBRAL INFARCT D/T EMBOLISM OTH PRECEREBRL ARTI6320 CEREB INFARCT D/T UNS OCCL/STEN UNS PRECEREB ARTI63211 CEREBRAL INFARCT D/T UNS OCCL/STEN RT VERT ARTI63212 CEREBRAL INFARCT D/T UNS OCCL/STEN LT VERT ARTI63219 CEREBRAL INFARCT D/T UNS OCCL/STEN UNS VERT ARTI6322 CEREBRAL INFARCT D/T UNS OCCL/STEN BASILAR ARTI63231 CEREBRAL INFARCT D/T UNS OCC/STEN RT CAROTID ARTI63232 CEREBRAL INFARCT D/T UNS OCC/STEN LT CAROTID ARTI63239 CEREBRAL INFARCT D/T UNS OCC/STEN UNS CAROTD ARTI6329 CEREB INFARCT D/T UNS OCCL/STEN OTH PRECEREB ARTI6330 CEREBRAL INFARCT D/T THROMB UNS CEREBRAL ARTERYI63311 CEREBRAL INFARCT D/T THROMB RT MID CEREBRAL ARTI63312 CEREBRAL INFARCT D/T THROMB LT MID CEREBRAL ARTI63319 CEREBRAL INFARCT D/T THROMB UNS MID CERBRAL ARTI63321 CEREBRAL INFARCT D/T THROMB RT ANT CEREBRAL ARTI63322 CEREBRAL INFARCT D/T THROMB LT ANT CEREBRAL ARTI63329 CEREBRAL INFARCT D/T THROMB UNS ANT CEREBRAL ARTI63331 CEREBRAL INFARCT D/T THROMB RT POST CERBRAL ARTI63332 CEREBRAL INFARCT D/T THROMB LT POST CERBRAL ARTI63339 CEREBRAL INFARCT D/T THROMB UNS POST CERBRAL ARTI63341 CEREBRAL INFARCT D/T THROMB RT CEREBELLAR ARTERYI63342 CEREBRAL INFARCT D/T THROMB LT CEREBELLAR ARTERYI63349 CEREBRAL INFARCT D/T THROMB UNS CEREBELLAR ARTI6339 CEREBRAL INFARCT D/T THROMB OTH CEREBRAL ARTERYI6340 CEREBRAL INFARCT D/T EMBOLISM UNS CEREBRAL ARTI63411 CEREBRAL INFARCT D/T EMBOLISM RT MID CEREBRL ARTI63412 CEREBRAL INFARCT D/T EMBOLISM LT MID CEREBRL ART

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONI63419 CEREBRAL INFARCT D/T EMBOLISM UNS MID CEREB ARTI63421 CEREBRAL INFARCT D/T EMBOLISM RT ANT CEREB ARTI63422 CEREBRAL INFARCT D/T EMBOLISM LT ANT CEREB ARTI63429 CEREBRAL INFARCT D/T EMBOLISM UNS ANT CEREB ARTI63431 CEREBRAL INFARCT D/T EMBOLISM RT POST CERBRL ARTI63432 CEREBRAL INFARCT D/T EMBOLISM LT POST CERBRL ARTI63439 CEREBRAL INFARCT D/T EMBOLISM UNS POST CERB ARTI63441 CEREBRAL INFARCT D/T EMBOLISM RT CEREBELLAR ARTI63442 CEREBRAL INFARCT D/T EMBOLISM LT CEREBELLAR ARTI63449 CEREBRAL INFARCT D/T EMBOLISM UNS CEREBELLAR ARTI6349 CEREBRAL INFARCT D/T EMBOLISM OTH CEREBRAL ARTI6350 CEREBRAL INFARCT D/T UNS OCCL/STEN UNS CEREB ARTI63511 CEREBRAL INFARCTION D/T UNS OCCL/STENOSIS RT MCAI63512 CEREBRAL INFARCTION D/T UNS OCCL/STENOSIS LT MCAI63519 CEREBRAL INFARCTION D/T UNS OCCL/STEN UNS MCAI63521 CEREBRAL INFARCTION D/T UNS OCCL/STENOSIS RT ACAI63522 CEREBRAL INFARCTION D/T UNS OCCL/STENOSIS LT ACAI63529 CEREBRAL INFARCTION D/T UNS OCC/STENOSIS UNS ACAI63531 CEREBRAL INFARCTION D/T UNS OCCL/STENOSIS RT PCAI63532 CEREBRAL INFARCTION D/T UNS OCCL/STENOSIS LT PCAI63539 CEREBRAL INFARCTION D/T UNS OCCL/STEN UNS PCAI63541 CEREBRAL INFARCT UNS OCCL/STEN RT CEREBELLAR ARTI63542 CEREBRAL INFARCT UNS OCCL/STEN LT CEREBELLAR ARTI63549 CEREBRAL INFARCT UNS OCCL/STEN UNS CEREBELLR ARTI6359 CEREBRAL INFARCT UNS OCCL/STEN OTH CEREBRAL ARTI636 CEREBRAL INFARCT D/T CEREB VN THROMB NONPYOGENICI638 OTHER CEREBRAL INFARCTIONI639 CEREBRAL INFARCTION UNSPECIFIEDI6601 OCCLUSION & STENOSIS RT MIDDLE CEREBRAL ARTERYI6602 OCCLUSION & STENOSIS LEFT MIDDLE CEREBRAL ARTERYI6603 OCCLUSION & STENOSIS BILATERAL MIDDLE CERBRL ARTI6609 OCCLUSION & STENOSIS UNS MIDDLE CEREBRAL ARTERYI6611 OCCLUSION & STENOSIS RT ANTERIOR CEREBRAL ARTERYI6612 OCCLUSION & STENOSIS LT ANTERIOR CEREBRAL ARTERYI6613 OCCLUSION & STENOSIS BILATERAL ANT CEREBRAL ARTI6619 OCCLUSION & STENOSIS UNS ANT CEREBRAL ARTERYI6621 OCCLUSION & STENOSIS RT POSTERIOR CEREBRAL ARTI6622 OCCLUSION & STENOSIS LT POSTERIOR CEREBRAL ARTI6623 OCCLUSION & STENOSIS BILATERAL POST CERBRL ARTI6629 OCCLUSION & STENOSIS UNS POSTERIOR CEREBRAL ARTI663 OCCLUSION AND STENOSIS OF CEREBELLAR ARTERIESI668 OCCLUSION & STENOSIS OF OTHER CEREBRAL ARTERIESI669 OCCLUSION & STENOSIS UNSPECIFIED CEREBRAL ARTERYI67841 REVERSIBLE CEREBRVASC VASOCONSTRICTION SYNDROMEI67848 OTHER CEREBROVASCULAR VASOSPASM VASOCONSTRICTION

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONI6789 OTHER CEREBROVASCULAR DISEASEI69351 HEMIPLEGIA FLW CEREBRAL INFARCT AFF RT DOM SIDEI69352 HEMIPLEGIA FLW CEREBRAL INFARCT AFF LT DOM SIDEI69353 HEMIPLEGIA FLW CEREBRAL INFARCT AFF RT NON-DOMI69354 HEMIPLEGIA FLW CEREBRAL INFARCT AFF LT NON-DOMI69359 HEMIPLEGIA FLW CEREBRAL INFARCT AFFCT UNS SIDEI701 ATHEROSCLEROSIS OF RENAL ARTERYI722 ANEURYSM OF RENAL ARTERYI7389 OTHER SPECIFIED PERIPHERAL VASCULAR DISEASESI739 PERIPHERAL VASCULAR DISEASE UNSPECIFIEDI82501 CHRONIC EMBO THROMB UNS DEEP VEINS RT LOW EXTREMI82502 CHRONIC EMBO THROMB UNS DEEP VEINS LT LOW EXTREMI82503 CHRONIC EMBO THROMB UNS DEEP VEINS LOW EXT BILI82509 CHRONIC EMBO THROMB UNS DEEP VEINS UNS LOW EXTI82511 CHRONIC EMBOLISM & THROMBOSIS RIGHT FEMORAL VEINI82512 CHRONIC EMBOLISM & THROMBOSIS LEFT FEMORAL VEINI82513 CHRONIC EMBOLISM & THROMBOSIS FEMORAL VEIN BILATI82519 CHRONIC EMBOLISM & THROMBOSIS UNS FEMORAL VEINI82521 CHRONIC EMBOLISM & THROMBOSIS RIGHT ILIAC VEINI82522 CHRONIC EMBOLISM & THROMBOSIS OF LEFT ILIAC VEINI82523 CHRONIC EMBOLISM & THROMBOSIS ILIAC VEIN BILATI82529 CHRONIC EMBOLISM & THROMBOSIS UNS ILIAC VEINI82531 CHRONIC EMBOLISM & THROMBOSIS RT POPLITEAL VEINI82532 CHRONIC EMBOLISM & THROMBOSIS LT POPLITEAL VEINI82533 CHRONIC EMBOLISM & THROMBOSIS POPLITEAL VEIN BILI82539 CHRONIC EMBOLISM & THROMBOSIS UNS POPLITEAL VEINI82541 CHRONIC EMBOLISM & THROMBOSIS RIGHT TIBIAL VEINI82542 CHRONIC EMBOLISM & THROMBOSIS LEFT TIBIAL VEINI82543 CHRONIC EMBOLISM & THROMBOSIS TIBIAL VEIN BILATI82549 CHRONIC EMBOLISM & THROMBOSIS UNS TIBIAL VEINI82591 CHRON EMB & THROMB OTH SPEC DEEP VEIN RT LOW EXTI82592 CHRON EMB & THROMB OTH SPEC DEEP VEIN LT LOW EXTI82593 CHRON EMB & THROMB OTH SPEC DEEP VEIN LW EXT BILI82599 CHRON EMB & THROMB OTH SPEC DEEP VEIN UNS LW EXTI825Y1 CHRON EMB THROMB UNS DEEP VNS RT PROX LOW EXTREMI825Y2 CHRON EMB THROMB UNS DEEP VNS LT PROX LOW EXTREMI825Y3 CHRON EMB THROMB UNS DEEP VNS PROX LW EXTREM BILI825Y9 CHRON EMB THROMB UNS DEEP VNS UNS PROX LW EXTREMI825Z1 CHRON EMB THROMB UNS DEEP VNS RT DIST LOW EXTREMI825Z2 CHRON EMB THROMB UNS DEEP VNS LT DIST LOW EXTREMI825Z3 CHRON EMB THROMB UNS DEEP VNS DIST LW EXTREM BILI825Z9 CHRON EMB THROMB UNS DEEP VNS UNS DIST LW EXTREMI97810 INTRAOP CEREBRVASCULAR INFARCT DURING CARD SURGI97811 INTRAOP CEREBRVASC INFARCTION DURING OTH SURGERYI97820 POSTPROC CEREBRVASC INFARCT DURING CARD SURGERY

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONI97821 POSTPROC CEREBRVASC INFARCT DURING OTH SURGERYJ40 BRONCHITIS NOT SPECIFIED AS ACUTE OR CHRONICJ410 SIMPLE CHRONIC BRONCHITISJ411 MUCOPURULENT CHRONIC BRONCHITISJ418 MIXED SIMPLE AND MUCOPURULENT CHRONIC BRONCHITISJ42 UNSPECIFIED CHRONIC BRONCHITISJ430 UNILATERAL PULM EMPHYSEMA MACLEODS SYNDROMEJ431 PANLOBULAR EMPHYSEMAJ432 CENTRILOBULAR EMPHYSEMAJ438 OTHER EMPHYSEMAJ439 EMPHYSEMA UNSPECIFIEDJ440 COPD WITH ACUTE LOWER RESPIRATORY INFECTIONJ441 CHRONIC OBSTRUCTIVE PULMONARY DZ W/EXACERBATIONJ449 CHRONIC OBSTRUCTIVE PULMONARY DISEASE UNSJ4520 MILD INTERMITTENT ASTHMA UNCOMPLICATEDJ4521 MILD INTERMITTENT ASTHMA WITH ACUTE EXACERBATIONJ4522 MILD INTERMITTENT ASTHMA WITH STATUS ASTHMATICUSJ4530 MILD PERSISTENT ASTHMA UNCOMPLICATEDJ4531 MILD PERSISTENT ASTHMA WITH ACUTE EXACERBATIONJ4532 MILD PERSISTENT ASTHMA WITH STATUS ASTHMATICUSJ4540 MODERATE PERSISTENT ASTHMA UNCOMPLICATEDJ4541 MODERATE PERSISTENT ASTHMA W/ACUTE EXACERBATIONJ4542 MODERATE PERSISTENT ASTHMA W/STATUS ASTHMATICUSJ4550 SEVERE PERSISTENT ASTHMA UNCOMPLICATEDJ4551 SEVERE PERSISTENT ASTHMA WITH ACUTE EXACERBATIONJ4552 SEVERE PERSISTENT ASTHMA WITH STATUS ASTHMATICUSJ45901 UNSPECIFIED ASTHMA WITH ACUTE EXACERBATIONJ45902 UNSPECIFIED ASTHMA WITH STATUS ASTHMATICUSJ45909 UNSPECIFIED ASTHMA UNCOMPLICATEDJ45990 EXERCISE INDUCED BRONCHOSPASMJ45991 COUGH VARIANT ASTHMAJ45998 OTHER ASTHMAJ470 BRONCHIECTASIS W/ACUTE LOWER RESPIRATORY INFJ471 BRONCHIECTASIS WITH ACUTE EXACERBATIONJ479 BRONCHIECTASIS UNCOMPLICATEDJ65 PNEUMOCONIOSIS ASSOCIATED WITH TUBERCULOSISK1231 ORAL MUCOSITIS ULCERATIVE D/T ANTINEOPLASTIC TXK2920 ALCOHOLIC GASTRITIS WITHOUT BLEEDINGK2921 ALCOHOLIC GASTRITIS WITH BLEEDINGK560 PARALYTIC ILEUSK700 ALCOHOLIC FATTY LIVERK7010 ALCOHOLIC HEPATITIS WITHOUT ASCITESK7011 ALCOHOLIC HEPATITIS WITH ASCITESK702 ALCOHOLIC FIBROSIS AND SCLEROSIS OF LIVERK7030 ALCOHOLIC CIRRHOSIS OF LIVER WITHOUT ASCITES

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONK7031 ALCOHOLIC CIRRHOSIS OF LIVER WITH ASCITESK7040 ALCOHOLIC HEPATIC FAILURE WITHOUT COMAK7041 ALCOHOLIC HEPATIC FAILURE WITH COMAK709 ALCOHOLIC LIVER DISEASE UNSPECIFIEDK740 HEPATIC FIBROSISK741 HEPATIC SCLEROSISK742 HEPATIC FIBROSIS WITH HEPATIC SCLEROSISK743 PRIMARY BILIARY CIRRHOSISK744 SECONDARY BILIARY CIRRHOSISK745 BILIARY CIRRHOSIS UNSPECIFIEDK7460 UNSPECIFIED CIRRHOSIS OF LIVERK7469 OTHER CIRRHOSIS OF LIVERK767 HEPATORENAL SYNDROMEK9420 GASTROSTOMY COMPLICATION UNSPECIFIEDK9421 GASTROSTOMY HEMORRHAGEK9422 GASTROSTOMY INFECTIONK9423 GASTROSTOMY MALFUNCTIONK9429 OTHER COMPLICATIONS OF GASTROSTOMYL1081 PARANEOPLASTIC PEMPHIGUSM1030 GOUT DUE TO RENAL IMPAIRMENT UNSPECIFIED SITEM10311 GOUT DUE TO RENAL IMPAIRMENT RIGHT SHOULDERM10312 GOUT DUE TO RENAL IMPAIRMENT LEFT SHOULDERM10319 GOUT DUE TO RENAL IMPAIRMENT UNS SHOULDERM10321 GOUT DUE TO RENAL IMPAIRMENT RIGHT ELBOWM10322 GOUT DUE TO RENAL IMPAIRMENT LEFT ELBOWM10329 GOUT DUE TO RENAL IMPAIRMENT UNSPECIFIED ELBOWM10331 GOUT DUE TO RENAL IMPAIRMENT RIGHT WRISTM10332 GOUT DUE TO RENAL IMPAIRMENT LEFT WRISTM10339 GOUT DUE TO RENAL IMPAIRMENT UNSPECIFIED WRISTM10341 GOUT DUE TO RENAL IMPAIRMENT RIGHT HANDM10342 GOUT DUE TO RENAL IMPAIRMENT LEFT HANDM10349 GOUT DUE TO RENAL IMPAIRMENT UNSPECIFIED HANDM10351 GOUT DUE TO RENAL IMPAIRMENT RIGHT HIPM10352 GOUT DUE TO RENAL IMPAIRMENT LEFT HIPM10359 GOUT DUE TO RENAL IMPAIRMENT UNSPECIFIED HIPM10361 GOUT DUE TO RENAL IMPAIRMENT RIGHT KNEEM10362 GOUT DUE TO RENAL IMPAIRMENT LEFT KNEEM10369 GOUT DUE TO RENAL IMPAIRMENT UNSPECIFIED KNEEM10371 GOUT DUE TO RENAL IMPAIRMENT RIGHT ANKLE & FOOTM10372 GOUT DUE TO RENAL IMPAIRMENT LEFT ANKLE AND FOOTM10379 GOUT DUE TO RENAL IMPAIRMENT UNS ANKLE & FOOTM1038 GOUT DUE TO RENAL IMPAIRMENT VERTEBRAEM1039 GOUT DUE TO RENAL IMPAIRMENT MULTIPLE SITESM3214 GLOMERULAR DISEASE IN SYS LUPUS ERYTHEMATOSUSM3215 TUBULO-INTRST NEPHROPATH SYS LUPUS ERYTHEMATOSUS

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONM360 DERMATOPOLYMYOSITIS IN NEOPLASTIC DISEASEM361 ARTHROPATHY IN NEOPLASTIC DISEASEM623 IMMOBILITY SYNDROME PARAPLEGICM8450XA PATH FX NEOPLASTIC DZ UNS SITE INIT ENC FXM8450XD PATH FX NEOPLASTIC DZ UNS SITE SUB ENC RTN HEALM8450XG PATH FX NEOPLASTIC DZ UNS SITE SUB ENC DLAY HEALM8450XK PATH FX NEOPLASTIC DZ UNS SITE SUB ENC NONUNIONM8450XP PATH FX NEOPLASTIC DZ UNS SITE SUB ENC MALUNIONM8450XS PATHOLOGICAL FX NEOPLASTIC DISEASE UNS SITE SEQM84511A PATH FX NEOPLASTIC DZ RT SHOULDER INIT ENCM84511D PATH FX NEOPLASTIC DZ RT SHLDR SUB ENC RTN HEALM84511G PATH FX NEOPLASTIC DZ RT SHLDR SUB ENC DLAY HEALM84511K PATH FX NEOPLASTIC DZ RT SHLDR SUB ENC NONUNIONM84511P PATH FX NEOPLASTIC DZ RT SHLDR SUB ENC MALUNIONM84511S PATHOLOGICAL FX NEOPLASTIC DZ RT SHOULDER SEQM84512A PATH FX NEOPLASTIC DZ LT SHOULDER INIT ENCM84512D PATH FX NEOPLASTIC DZ LT SHLDR SUB ENC RTN HEALM84512G PATH FX NEOPLASTIC DZ LT SHLDR SUB ENC DLAY HEALM84512K PATH FX NEOPLASTIC DZ LT SHLDR SUB ENC NONUNIONM84512P PATH FX NEOPLASTIC DZ LT SHLDR SUB ENC MALUNIONM84512S PATHOLOGICAL FX NEOPLASTIC DZ LT SHOULDER SEQM84519A PATH FX NEOPLASTIC DZ UNS SHOULDER INIT ENCM84519D PATH FX NEOPLASTIC DZ UNS SHLDR SUB ENC RTN HEALM84519G PATH FX NEOPLASTIC DZ UNS SHLDR SUB DLAY HEALM84519K PATH FX NEOPLASTIC DZ UNS SHLDR SUB ENC NONUNIONM84519P PATH FX NEOPLASTIC DZ UNS SHLDR SUB ENC MALUNIONM84519S PATHOLOGICAL FX NEOPLASTIC DZ UNS SHOULDER SEQM84521A PATH FX NEOPLASTIC DZ RT HUMERUS INIT ENC FXM84521D PATH FX NEOPLASTIC DZ RT HUMERUS SUB ENC RTN HLM84521G PATH FX NEOPLASTIC DZ RT HUMERUS SUB ENC DLAY HLM84521K PATH FX NEOPLASTIC DZ RT HUMERUS SUB ENC NONUNM84521P PATH FX NEOPLASTIC DZ RT HUMERUS SUB ENC MALUNM84521S PATHOLOGICAL FX NEOPLASTIC DISEASE RT HUM SEQM84522A PATH FX NEOPLASTIC DZ LT HUMERUS INIT ENC FXM84522D PATH FX NEOPLASTIC DZ LT HUMERUS SUB ENC RTN HLM84522G PATH FX NEOPLASTIC DZ LT HUMERUS SUB ENC DLAY HLM84522K PATH FX NEOPLASTIC DZ LT HUMERUS SUB ENC NONUNM84522P PATH FX NEOPLASTIC DZ LT HUMERUS SUB ENC MALUNM84522S PATHOLOGICAL FX NEOPLASTIC DZ LT HUMERUS SEQM84529A PATH FX NEOPLASTIC DZ UNS HUMERUS INIT ENC FXM84529D PATH FX NEOPLASTIC DZ UNS HUMERUS SUB ENC RTNM84529G PATH FX NEOPLASTIC DZ UNS HUMERUS SUB ENC DLAYM84529K PATH FX NEOPLASTIC DZ UNS HUMERUS SUB ENC NONUNM84529P PATH FX NEOPLASTIC DZ UNS HUMERUS SUB ENC MALUNM84529S PATHOLOGICAL FX NEOPLASTIC DZ UNS HUMERUS SEQ

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONM84531A PATH FX NEOPLASTIC DZ RT ULNA INIT ENCOUNTER FXM84531D PATH FX NEOPLASTIC DZ RT ULNA SUB ENC RTN HEALM84531G PATH FX NEOPLASTIC DZ RT ULNA SUB ENC DLAY HEALM84531K PATH FX NEOPLASTIC DZ RT ULNA SUB ENC NONUNIONM84531P PATH FX NEOPLASTIC DZ RT ULNA SUB ENC MALUNIONM84531S PATHOLOGICAL FX NEOPLASTIC DISEASE RT ULNA SEQM84532A PATH FX NEOPLASTIC DZ LT ULNA INIT ENCOUNTER FXM84532D PATH FX NEOPLASTIC DZ LT ULNA SUB ENC RTN HEALM84532G PATH FX NEOPLASTIC DZ LT ULNA SUB ENC DLAY HEALM84532K PATH FX NEOPLASTIC DZ LT ULNA SUB ENC NONUNIONM84532P PATH FX NEOPLASTIC DZ LT ULNA SUB ENC MALUNIONM84532S PATH FX NEOPLASTIC DISEASE LT ULNA SEQUELAM84533A PATH FX NEOPLASTIC DZ RT RADIUS INIT ENCOUNTR FXM84533D PATH FX NEOPLASTIC DZ RT RADIUS SUB ENC RTN HEALM84533G PATH FX NEOPLASTIC DZ RT RADIUS SUB ENC DLAY HLM84533K PATH FX NEOPLASTIC DZ RT RADIUS SUB ENC NONUNM84533P PATH FX NEOPLASTIC DZ RT RADIUS SUB ENC MALUNM84533S PATHOLOGICAL FX NEOPLASTIC DISEASE RT RADIUS SEQM84534A PATH FX NEOPLASTIC DZ LT RADIUS INIT ENCOUNTR FXM84534D PATH FX NEOPLASTIC DZ LT RADIUS SUB ENC RTN HEALM84534G PATH FX NEOPLASTIC DZ LT RADIUS SUB ENC DLAY HLM84534K PATH FX NEOPLASTIC DZ LT RADIUS SUB ENC NONUNM84534P PATH FX NEOPLASTIC DZ LT RADIUS SUB ENC MALUNM84534S PATHOLOGICAL FX NEOPLASTIC DISEASE LT RADIUS SEQM84539A PATH FX NEOPLASTIC DZ UNS ULNA RADIUS INIT ENCM84539D PATH FX NEOPLASTIC DZ UNS ULNA RADIUS SUB RTNM84539G PATH FX NEOPLASTIC DZ UNS ULNA RADIUS SUB DLAYM84539K PATH FX NEOPLASTIC DZ UNS ULNA RADIUS SUB NONUNM84539P PATH FX NEOPLASTIC DZ UNS ULNA RADIUS SUB MALUNM84539S PATHOLOGICAL FX NEOPLASTIC DZ UNS ULN RADIUS SEQM84541A PATH FX NEOPLASTIC DZ RT HAND INIT ENCOUNTER FXM84541D PATH FX NEOPLASTIC DZ RT HAND SUB ENC RTN HEALM84541G PATH FX NEOPLASTIC DZ RT HAND SUB ENC DLAY HEALM84541K PATH FX NEOPLASTIC DZ RT HAND SUB ENC NONUNIONM84541P PATH FX NEOPLASTIC DZ RT HAND SUB ENC MALUNIONM84541S PATHOLOGICAL FX NEOPLASTIC DISEASE RT HAND SEQM84542A PATH FX NEOPLASTIC DZ LT HAND INIT ENCOUNTER FXM84542D PATH FX NEOPLASTIC DZ LT HAND SUB ENC RTN HEALM84542G PATH FX NEOPLASTIC DZ LT HAND SUB ENC DLAY HEALM84542K PATH FX NEOPLASTIC DZ LT HAND SUB ENC NONUNIONM84542P PATH FX NEOPLASTIC DZ LT HAND SUB ENC MALUNIONM84542S PATHOLOGICAL FX NEOPLASTIC DISEASE LT HAND SEQM84549A PATH FX NEOPLASTIC DZ UNS HAND INIT ENCOUNTER FXM84549D PATH FX NEOPLASTIC DZ UNS HAND SUB ENC RTN HEALM84549G PATH FX NEOPLASTIC DZ UNS HAND SUB ENC DLAY HEAL

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONM84549K PATH FX NEOPLASTIC DZ UNS HAND SUB ENC NONUNIONM84549P PATH FX NEOPLASTIC DZ UNS HAND SUB ENC MALUNIONM84549S PATHOLOGICAL FX NEOPLASTIC DISEASE UNS HAND SEQM84550A PATHOLOGICAL FX NEOPLASTIC DZ PELVIS INIT ENC FXM84550D PATH FX NEOPLASTIC DZ PELVIS SUB ENC FX RTN HEALM84550G PATH FX NEOPLASTIC DZ PELVIS SUB ENC DELAY HEALM84550K PATH FX NEOPLASTIC DZ PELVIS SUB ENC FX NONUNIONM84550P PATH FX NEOPLASTIC DZ PELVIS SUB ENC FX MALUNIONM84550S PATHL FX NEOPLASTIC DISEASE PELVIS SEQUELAM84551A PATHOLOGICAL FX NEOPLASTIC DZ RT FEMUR INIT ENCM84551D PATH FX NEOPLASTIC DZ RT FEMUR SUB ENC RTN HEALM84551G PATH FX NEOPLASTIC DZ RT FEMUR SUB ENC DLAY HEALM84551K PATH FX NEOPLASTIC DZ RT FEMUR SUB ENC NONUNIONM84551P PATH FX NEOPLASTIC DZ RT FEMUR SUB ENC MALUNIONM84551S PATHOLOGICAL FX NEOPLASTIC DISEASE RT FEMUR SEQM84552A PATHOLOGICAL FX NEOPLASTIC DZ LT FEMUR INIT ENCM84552D PATH FX NEOPLASTIC DZ LT FEMUR SUB ENC RTN HEALM84552G PATH FX NEOPLASTIC DZ LT FEMUR SUB ENC DLAY HEALM84552K PATH FX NEOPLASTIC DZ LT FEMUR SUB ENC NONUNIONM84552P PATH FX NEOPLASTIC DZ LT FEMUR SUB ENCMALUNIONM84552S PATHOLOGICAL FX NEOPLASTIC DISEASE LT FEMUR SEQM84553A PATH FX NEOPLASTIC DZ UNS FEMUR INIT ENCOUNTERM84553D PATH FX NEOPLASTIC DZ UNS FEMUR SUB ENC RTN HEALM84553G PATH FX NEOPLASTIC DZ UNS FEMUR SUB ENC DELAYM84553K PATH FX NEOPLASTIC DZ UNS FEMUR SUB ENC NONUNIONM84553P PATH FX NEOPLASTIC DZ UNS FEMUR SUB ENC MALUNIONM84553S PATHOLOGICAL FX NEOPLASTIC DISEASE UNS FEMUR SEQM84559A PATH FX NEOPLASTIC DZ HIP UNS INIT ENCOUNTER FXM84559D PATH FX NEOPLASTIC DZ HIP UNS SUB ENC RTN HEALM84559G PATH FX NEOPLASTIC DZ HIP UNS SUB ENC DELAY HEALM84559K PATH FX NEOPLASTIC DZ HIP UNS SUB ENC NONUNIONM84559P PATH FX NEOPLASTIC DZ HIP UNS SUB ENC MALUNIONM84559S PATHOLOGICAL FX NEOPLASTIC DISEASE HIP UNS SEQM84561A PATH FX NEOPLASTIC DZ RT TIBIA INIT ENCOUNTER FXM84561D PATH FX NEOPLASTIC DZ RT TIBIA SUB ENC RTN HEALM84561G PATH FX NEOPLASTIC DZ RT TIBIA SUB ENC DLAY HEALM84561K PATH FX NEOPLASTIC DZ RT TIBIA SUB ENC NONUNIONM84561P PATH FX NEOPLASTIC DZ RT TIBIA SUB ENC MALUNIONM84561S PATHOLOGICAL FX NEOPLASTIC DISEASE RT TIBIA SEQM84562A PATH FX NEOPLASTIC DZ LT TIBIA INIT ENC FXM84562D PATH FX NEOPLASTIC DZ LT TIBIA SUB ENC RTN HEALM84562G PATH FX NEOPLASTIC DZ LT TIBIA SUB ENC DLAY HEALM84562K PATH FX NEOPLASTIC DZ LT TIBIA SUB ENC NONUNIONM84562P PATH FX NEOPLASTIC DZ LT TIBIA SUB ENC MALUNIONM84562S PATHOLOGICAL FX NEOPLASTIC DISEASE LT TIBIA SEQ

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONM84563A PATHL FX NEOPLASTIC DZ RT FIBULA INIT ENC FXM84563D PATH FX NEOPLASTIC DZ RT FIBULA SUB ENC RTN HEALM84563G PATH FX NEOPLASTIC DZ RT FIBULA SUB ENC DLAY HEAM84563K PATH FX NEOPLASTIC DZ RT FIBULA SUB ENC NONUNIONM84563P PATH FX NEOPLASTIC DZ RT FIBULA SUB ENC MALUNIONM84563S PATHOLOGICAL FX NEOPLASTIC DZ RT FIBULA SEQM84564A PATH FX NEOPLASTIC DZ LT FIBULA INIT ENC FXM84564D PATH FX NEOPLASTIC DZ LT FIBULA SUB ENC RTN HEALM84564G PATH FX NEOPLASTIC DZ LT FIBULA SUB ENC DELAYM84564K PATH FX NEOPLASTIC DZ LT FIBULA SUB ENC NONUNIONM84564P PATH FX NEOPLASTIC DZ LT FIBULA SUB ENC MALUNIONM84564S PATHOLOGICAL FX NEOPLASTIC DZ LT FIBULA SEQM84569A PATH FX NEOPLASTIC DZ UNS TIB FIB INIT ENC FXM84569D PATH FX NEOPLASTIC DZ UNS TIB FIB SUB ENC RTNM84569G PATH FX NEOPLASTIC DZ UNS TIB FIB SUB ENC DELAYM84569K PATH FX NEOPLASTIC DZ UNS TIB FIB SUB ENC NONUNM84569P PATH FX NEOPLASTIC DZ UNS TIB FIB SUB ENC MALUNM84569S PATH FX NEOPLASTIC DZ UNS TIBIA FIBULA SEQUELAM84571A PATH FX NEOPLASTIC DZ RT ANKLE INIT ENC FXM84571D PATH FX NEOPLASTIC DZ RT ANKLE SUB ENC RTN HEALM84571G PATH FX NEOPLASTIC DZ RT ANKLE SUB ENC DLAY HEALM84571K PATH FX NEOPLASTIC DZ RT ANKLE SUB ENC NONUNIONM84571P PATH FX NEOPLASTIC DZ RT ANKLE SUB ENC MALUNIONM84571S PATHOLOGICAL FX NEOPLASTIC DZ RT ANKLE SEQM84572A PATH FX NEOPLASTIC DZ LT ANKLE INIT ENC FXM84572D PATH FX NEOPLASTIC DZ LT ANKLE SUB ENC RTN HEALM84572G PATH FX NEOPLASTIC DZ LT ANKLE SUB ENC DLAY HEALM84572K PATH FX NEOPLASTIC DZ LT ANKLE SUB ENC NONUNIONM84572P PATH FX NEOPLASTIC DZ LT ANKLE SUB ENC MALUNIONM84572S PATH FX NEOPLASTIC DISEASE LT ANKLE SEQUELAM84573A PATH FX NEOPLASTIC DZ UNS ANKLE INIT ENC FXM84573D PATH FX NEOPLASTIC DZ UNS ANKLE SUB ENC RTN HEALM84573G PATH FX NEOPLASTIC DZ UNS ANKLE SUB ENC DELAYM84573K PATH FX NEOPLASTIC DZ UNS ANKLE SUB ENC NONUNIONM84573P PATH FX NEOPLASTIC DZ UNS ANKLE SUB ENC MALUNIONM84573S PATH FX NEOPLASTIC DISEASE UNS ANKLE SEQUELAM84574A PATHOLOGICAL FX NEOPLASTIC DZ RT FOOT INIT ENCM84574D PATH FX NEOPLASTIC DZ RT FOOT SUB ENC RTN HEALM84574G PATH FX NEOPLASTIC DZ RT FOOT SUB ENC DLAY HEALM84574K PATH FX NEOPLASTIC DZ RT FOOT SUB ENC NONUNIONM84574P PATH FX NEOPLASTIC DZ RT FOOT SUB ENC MALUNIONM84574S PATH FX NEOPLASTIC DISEASE RT FOOT SEQUELAM84575A PATHOLOGICAL FX NEOPLASTIC DZ LT FOOT INIT ENCM84575D PATH FX NEOPLASTIC DZ LT FOOT SUB ENC RTN HEALM84575G PATH FX NEOPLASTIC DZ LT FOOT SUB ENC DLAY HEAL

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONM84575K PATH FX NEOPLASTIC DZ LT FOOT SUB ENC NONUNIONM84575P PATH FX NEOPLASTIC DZ LT FOOT SUB ENC MALUNIONM84575S PATH FX NEOPLASTIC DISEASE LT FOOT SEQUELAM84576A PATHOLOGICAL FX NEOPLASTIC DZ UNS FOOT INIT ENCM84576D PATH FX NEOPLASTIC DZ UNS FOOT SUB ENC RTN HEALM84576G PATH FX NEOPLASTIC DZ UNS FOOT SUB ENC DLAY HEALM84576K PATH FX NEOPLASTIC DZ UNS FOOT SUB ENC NONUNIONM84576P PATH FX NEOPLASTIC DZ UNS FOOT SUB ENC MALUNIONM84576S PATH FX NEOPLASTIC DISEASE UNS FOOT SEQUELAM8458XA PATH FX NEOPLASTIC DZ OTHER SPEC INIT ENC FXM8458XD PATH FX NEOPLASTIC DZ OTH SPEC SUB ENC RTN HEALM8458XG PATH FX NEOPLASTIC DZ OTH SPEC SUB ENC DLAY HEALM8458XK PATH FX NEOPLASTIC DZ OTH SPEC SUB ENC NONUNIONM8458XP PATH FX NEOPLASTIC DZ OTH SPEC SUB ENC MALUNIONM8458XS PATHOLOGICAL FX NEOPLASTIC DISEASE OTH SPEC SEQM8630 CHRONIC MULTIFOCAL OSTEOMYELITIS UNS SITEM86311 CHRONIC MULTIFOCAL OSTEOMYELITIS RIGHT SHOULDERM86312 CHRONIC MULTIFOCAL OSTEOMYELITIS LEFT SHOULDERM86319 CHRONIC MULTIFOCAL OSTEOMYELITIS UNS SHOULDERM86321 CHRONIC MULTIFOCAL OSTEOMYELITIS RIGHT HUMERUSM86322 CHRONIC MULTIFOCAL OSTEOMYELITIS LEFT HUMERUSM86329 CHRONIC MULTIFOCAL OSTEOMYELITIS UNS HUMERUSM86331 CHRONIC MULTIFOCAL OSTEOMYELITIS RT RADIUS ULNAM86332 CHRONIC MULTIFOCAL OSTEOMYELITIS LT RADIUS ULNAM86339 CHRONIC MULTIFOCAL OSTEOMYELITIS UNS RADIUS ULNAM86341 CHRONIC MULTIFOCAL OSTEOMYELITIS RIGHT HANDM86342 CHRONIC MULTIFOCAL OSTEOMYELITIS LEFT HANDM86349 CHRONIC MULTIFOCAL OSTEOMYELITIS UNS HANDM86351 CHRONIC MULTIFOCAL OSTEOMYELITIS RIGHT FEMURM86352 CHRONIC MULTIFOCAL OSTEOMYELITIS LEFT FEMURM86359 CHRONIC MULTIFOCAL OSTEOMYELITIS UNS FEMURM86361 CHRONIC MULTIFOCAL OSTEOMYELITIS RT TIBIA FIBULAM86362 CHRONIC MULTIFOCAL OSTEOMYELITIS LT TIBIA FIBULAM86369 CHRONIC MULTIFOCAL OSTEOMYELITIS UNS TIBIA FIBM86371 CHRONIC MULTIFOCAL OSTEOMYELITIS RT ANKLE & FOOTM86372 CHRONIC MULTIFOCAL OSTEOMYELITIS LT ANKLE & FOOTM86379 CHRONIC MULTIFOCAL OSTEOMYELITIS UNS ANKLE FOOTM8638 CHRONIC MULTIFOCAL OSTEOMYELITIS OTHER SITEM8639 CHRONIC MULTIFOCAL OSTEOMYELITIS MULTIPLE SITESM8640 CHRONIC OSTEOMYELITIS W/DRAINING SINUS UNS SITEM86411 CHRONIC OSTEOMYELITIS DRAINING SINUS RT SHOULDERM86412 CHRONIC OSTEOMYELITIS DRAINING SINUS LT SHOULDERM86419 CHRONIC OSTEOMYELITIS DRAINING SINUS UNS SHOULDRM86421 CHRONIC OSTEOMYELITIS DRAINING SINUS RT HUMERUSM86422 CHRONIC OSTEOMYELITIS DRAINING SINUS LT HUMERUS

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONM86429 CHRONIC OSTEOMYELITIS DRAINING SINUS UNS HUMERUSM86431 CHRONIC OSTEOMYELITIS DRAIN SINUS RT RAD & ULNAM86432 CHRONIC OSTEOMYELITIS DRAIN SINUS LT RAD & ULNAM86439 CHRONIC OSTEOMYELITIS DRAIN SINUS UNS RAD & ULNAM86441 CHRONIC OSTEOMYELITIS W/DRAINING SINUS RT HANDM86442 CHRONIC OSTEOMYELITIS W/DRAINING SINUS LT HANDM86449 CHRONIC OSTEOMYELITIS W/DRAINING SINUS UNS HANDM86451 CHRONIC OSTEOMYELITIS W/DRAINING SINUS RT FEMURM86452 CHRONIC OSTEOMYELITIS W/DRAINING SINUS LT FEMURM86459 CHRONIC OSTEOMYELITIS W/DRAINING SINUS UNS FEMURM86461 CHRONIC OSTEOMYELITIS DRAIN SINUS RT TIB & FIBM86462 CHRONIC OSTEOMYELITIS DRAIN SINUS LT TIB & FIBM86469 CHRONIC OSTEOMYELITIS DRAIN SINUS UNS TIB & FIBM86471 CHRONIC OSTEOMYELITIS DRAIN SINUS RT ANK & FOOTM86472 CHRONIC OSTEOMYELITIS DRAIN SINUS LT ANK & FOOTM86479 CHRONIC OSTEOMYELITIS DRAIN SINUS UNS ANK & FOOTM8648 CHRONIC OSTEOMYELITIS W/DRAINING SINUS OTH SITEM8649 CHRONIC OSTEOMYELITIS W/DRAINING SINUS MX SITESM8650 OTH CHRONIC HEMATOGENOUS OSTEOMYELITIS UNS SITEM86511 OTH CHRONIC HEMATOGENOUS OSTEOMYEL RT SHOULDERM86512 OTH CHRONIC HEMATOGENOUS OSTEOMYEL LT SHOULDERM86519 OTH CHRONIC HEMATOGENOUS OSTEOMYEL UNS SHOULDERM86521 OTH CHRONIC HEMATOGENOUS OSTEOMYELITIS RT HUMM86522 OTH CHRONIC HEMATOGENOUS OSTEOMYELITIS LT HUMM86529 OTH CHRONIC HEMATOGENOUS OSTEOMYELITIS UNS HUMM86531 OTHER CHRON HEMATOGENOUS OSTEOMYEL RT RAD & ULNAM86532 OTHER CHRON HEMATOGENOUS OSTEOMYEL LT RAD & ULNAM86539 OTH CHRON HEMATOGENOUS OSTEOMYEL UNS RAD & ULNAM86541 OTHER CHRONIC HEMATOGENOUS OSTEOMYELITIS RT HANDM86542 OTHER CHRONIC HEMATOGENOUS OSTEOMYELITIS LT HANDM86549 OTH CHRONIC HEMATOGENOUS OSTEOMYELITIS UNS HANDM86551 OTH CHRONIC HEMATOGENOUS OSTEOMYELITIS RT FEMURM86552 OTH CHRONIC HEMATOGENOUS OSTEOMYELITIS LT FEMURM86559 OTH CHRONIC HEMATOGENOUS OSTEOMYELITIS UNS FEMURM86561 OTH CHRON HEMATOGEN OSTEOMYEL RT TIBIA & FIBULAM86562 OTH CHRON HEMATOGEN OSTEOMYEL LT TIBIA & FIBULAM86569 OTH CHRN HEMATOGEN OSTEOMYEL UNS TIBIA & FIBULAM86571 OTH CHRONIC HEMATOGENOUS OSTEOMYEL RT ANK FOOTM86572 OTH CHRONIC HEMATOGENOUS OSTEOMYEL LT ANK FOOTM86579 OTH CHRONIC HEMATOGENOUS OSTEOMYEL UNS ANK FTM8658 OTH CHRONIC HEMATOGENOUS OSTEOMYELITIS OTH SITEM8659 OTH CHRONIC HEMATOGENOUS OSTEOMYELITIS MX SITESM8660 OTHER CHRONIC OSTEOMYELITIS UNSPECIFIED SITEM86611 OTHER CHRONIC OSTEOMYELITIS RIGHT SHOULDERM86612 OTHER CHRONIC OSTEOMYELITIS LEFT SHOULDER

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONM86619 OTHER CHRONIC OSTEOMYELITIS UNSPECIFIED SHOULDERM86621 OTHER CHRONIC OSTEOMYELITIS RIGHT HUMERUSM86622 OTHER CHRONIC OSTEOMYELITIS LEFT HUMERUSM86629 OTHER CHRONIC OSTEOMYELITIS UNSPECIFIED HUMERUSM86631 OTHER CHRONIC OSTEOMYELITIS RIGHT RADIUS & ULNAM86632 OTHER CHRONIC OSTEOMYELITIS LEFT RADIUS AND ULNAM86639 OTHER CHRONIC OSTEOMYELITIS UNS RADIUS AND ULNAM86641 OTHER CHRONIC OSTEOMYELITIS RIGHT HANDM86642 OTHER CHRONIC OSTEOMYELITIS LEFT HANDM86649 OTHER CHRONIC OSTEOMYELITIS UNSPECIFIED HANDM86651 OTHER CHRONIC OSTEOMYELITIS RIGHT THIGHM86652 OTHER CHRONIC OSTEOMYELITIS LEFT THIGHM86659 OTHER CHRONIC OSTEOMYELITIS UNSPECIFIED THIGHM86661 OTHER CHRONIC OSTEOMYELITIS RIGHT TIBIA & FIBULAM86662 OTHER CHRONIC OSTEOMYELITIS LEFT TIBIA & FIBULAM86669 OTHER CHRONIC OSTEOMYELITIS UNS TIBIA & FIBULAM86671 OTHER CHRONIC OSTEOMYELITIS RIGHT ANKLE AND FOOTM86672 OTHER CHRONIC OSTEOMYELITIS LEFT ANKLE AND FOOTM86679 OTHER CHRONIC OSTEOMYELITIS UNS ANKLE & FOOTM8668 OTHER CHRONIC OSTEOMYELITIS OTHER SITEM8669 OTHER CHRONIC OSTEOMYELITIS MULTIPLE SITESM9060 OSTEITIS DEFORMANS NEOPLASTIC DISEASES UNS SITEM90611 OSTEITIS DEFORMANS NEOPLASTIC DZ RT SHOULDERM90612 OSTEITIS DEFORMANS NEOPLASTIC DZ LT SHOULDERM90619 OSTEITIS DEFORMANS NEOPLASTIC DZ UNS SHOULDERM90621 OSTEITIS DEFORMANS NEOPLASTIC DZ RT UPPER ARMM90622 OSTEITIS DEFORMANS NEOPLASTIC DZ LT UPPER ARMM90629 OSTEITIS DEFORMANS NEOPLASTIC DZ UNS UPPER ARMM90631 OSTEITIS DEFORMANS NEOPLASTIC DZ RT FOREARMM90632 OSTEITIS DEFORMANS NEOPLASTIC DZ LT FOREARMM90639 OSTEITIS DEFORMANS NEOPLASTIC DZ UNS FOREARMM90641 OSTEITIS DEFORMANS NEOPLASTIC DISEASES RT HANDM90642 OSTEITIS DEFORMANS NEOPLASTIC DISEASES LEFT HANDM90649 OSTEITIS DEFORMANS NEOPLASTIC DISEASES UNS HANDM90651 OSTEITIS DEFORMANS NEOPLASTIC DISEASES RT THIGHM90652 OSTEITIS DEFORMANS NEOPLASTIC DISEASES LT THIGHM90659 OSTEITIS DEFORMANS NEOPLASTIC DISEASES UNS THIGHM90661 OSTEITIS DEFORMANS NEOPLASTIC DZ RT LOWER LEGM90662 OSTEITIS DEFORMANS NEOPLASTIC DZ LT LOWER LEGM90669 OSTEITIS DEFORMANS NEOPLASTIC DZ UNS LOWER LEGM90671 OSTEITIS DEFORMANS NEOPLASTIC DZ RT ANK FOOTM90672 OSTEITIS DEFORMANS NEOPLASTIC DZ LT ANK FOOTM90679 OSTEITIS DEFORMANS NEOPLASTIC DZ UNS ANK FOOTM9068 OSTEITIS DEFORMANS NEOPLASTIC DISEASES OTH SITEM9069 OSTEITIS DEFORMANS NEOPLASTIC DZ MULTIPLE SITES

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONN000 ACUTE NEPHRITIC SYND W/MINOR GLOMERULAR ABNORMN001 ACUTE NEPHRITIC SYND W/FOCL & SEG GLOMERULAR LESN002 ACUTE NEPHRITIC SYNDROME W/DIFFUSE MEMBRANOUS GNN003 AC NEPHRITIC SYND W/DIFFUSE MESANGIAL PROLIF GNN004 AC NEPHRITIC SYND W/DIFFUSE ENDOCAP PROLIF GNN005 AC NEPHRITIC SYND W/DIFFUSE MESANGIOCAPILLARY GNN006 ACUTE NEPHRITIC SYND W/DENSE DEPOSIT DISEASEN007 ACUTE NEPHRITIC SYND W/DIFFUSE CRESCENTIC GNN008 ACUTE NEPHRITIC SYND W/OTH MORPHOLOGIC CHANGESN009 ACUTE NEPHRITIC SYND W/UNS MORPHOLOGIC CHANGESN010 RAPID PROGS NEPHRITIC SYND MINOR GLOMERULAR ABNN011 RAPID PROGS NEPHRIT SYND FOCL&SEG GLOMERULAR LESN012 RAPID PROGS NEPHRITIC SYND DIFFUSE MEMBRANOUS GNN013 RAPID PROG NEPHRIT SYND DIFF MESANGIAL PROLIF GNN014 RAPID PROGS NEPHRIT SYND DIFF ENDOCAP PROLIF GNN015 RAPID PROGS NEPHRITIC SYND DIFF MESANGIOCAP GNN016 RAPID PROGS NEPHRITIC SYND DENSE DEPOSIT DISEASEN017 RAPID PROGS NEPHRITIC SYND DIFFUSE CRESCENTIC GNN018 RAPID PROGS NEPHRITIC SYND OTH MORPHOLOG CHANGESN019 RAPID PROGS NEPHRITIC SYND UNS MORPHOLOG CHANGESN020 RECUR & PERSIST HEMATURIA W/MINOR GLOMERULAR ABNN021 RECUR & PERSIST HEMATUR FOCL&SEG GLOMERULAR LESN022 RECURRENT & PERSIST HEMATURIA W/DIFFUSE MEMB GNN023 RECUR & PERSIST HEMATUR DIFF MESANGIAL PROLIF GNN024 RECUR & PERSIST HEMATURIA DIFF ENDOCAP PROLIF GNN025 RECUR & PERSIST HEMATURIA DIFFUSE MESANGIOCAP GNN026 RECUR & PERSIST HEMATURIA DENSE DEPOSIT DISEASEN027 RECUR & PERSIST HEMATURIA DIFFUSE CRESCENTIC GNN028 RECUR & PERSIST HEMATURIA OTH MORPHOLOG CHANGESN029 RECUR & PERSIST HEMATURIA UNS MORPHOLOG CHANGESN030 CHRONIC NEPHRITIC SYND W/MINOR GLOMERULAR ABNORMN031 CHRONIC NEPHRITIC SYND FOCL & SEG GLOMERULAR LESN032 CHRONIC NEPHRITIC SYNDROME DIFFUSE MEMBRANOUS GNN033 CHRON NEPHRITIC SYND DIFFUSE MESANGIAL PROLIF GNN034 CHRON NEPHRITIC SYND W/DIFFUSE ENDOCAP PROLIF GNN035 CHRONIC NEPHRITIC SYND W/DIFFUSE MESANGIOCAP GNN036 CHRONIC NEPHRITIC SYND W/DENSE DEPOSIT DISEASEN037 CHRONIC NEPHRITIC SYND W/DIFFUSE CRESCENTIC GNN038 CHRONIC NEPHRITIC SYND W/OTH MORPHOLOGIC CHANGESN039 CHRONIC NEPHRITIC SYND W/UNS MORPHOLOGIC CHANGESN040 NEPHROTIC SYNDROME W/MINOR GLOMERULAR ABNORMN041 NEPHROTIC SYNDROME W/FOCL & SEG GLOMERULAR LESN042 NEPHROTIC SYNDROME W/DIFFUSE MEMBRANOUS GNN043 NEPHROTIC SYND W/DIFFUSE MESANGIAL PROLIF GNN044 NEPHROTIC SYND W/DIFFUSE ENDOCAPILLARY PROLIF GN

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONN045 NEPHROTIC SYND W/DIFFUSE MESANGIOCAPILLARY GNN046 NEPHROTIC SYNDROME WITH DENSE DEPOSIT DISEASEN047 NEPHROTIC SYNDROME W/DIFFUSE CRESCENTIC GNN048 NEPHROTIC SYNDROME W/ OTHER MORPHOLOGIC CHANGESN049 NEPHROTIC SYNDROME W/UNS MORPHOLOGIC CHANGESN050 UNS NEPHRITIC SYNDROME W/MINOR GLOMERULAR ABNORMN051 UNS NEPHRITIC SYND W/FOCL & SEG GLOMERULAR LESN052 UNS NEPHRITIC SYNDROME W/DIFFUSE MEMBRANOUS GNN053 UNS NEPHRITIC SYND W/DIFFUSE MESANGIAL PROLIF GNN054 UNS NEPHRITIC SYND W/DIFFUSE ENDOCAP PROLIF GNN055 UNS NEPHRITIC SYND W/DIFFUSE MESANGIOCAPILLRY GNN056 UNS NEPHRITIC SYNDROME W/DENSE DEPOSIT DISEASEN057 UNS NEPHRITIC SYNDROME W/DIFFUSE CRESCENTIC GNN058 UNS NEPHRITIC SYNDROME W/OTH MORPHOLOGIC CHANGESN059 UNS NEPHRITIC SYNDROME W/UNS MORPHOLOGIC CHANGESN060 ISOLATED PROTEINURIA W/MINOR GLOMERULAR ABNORMN061 ISOLATED PROTEINURIA W/FOCL & SEG GLOMERULAR LESN062 ISOLATED PROTEINURIA W/DIFFUSE MEMBRANOUS GNN063 ISOLATED PROTEINURIA W/DIFF MESANGIAL PROLIF GNN064 ISOLATED PROTEINURIA W/DIFFUSE ENDOCAP PROLIF GNN065 ISOLATED PROTEINURIA W/DIFFUSE MESANGIOCAP GNN066 ISOLATED PROTEINURIA WITH DENSE DEPOSIT DISEASEN067 ISOLATED PROTEINURIA W/DIFFUSE CRESCENTIC GNN068 ISOLATED PROTEINURIA W/ OTHER MORPHOLOGIC LESIONN069 ISOLATED PROTEINURIA W/UNS MORPHOLOGIC LESIONN070 HEREDIT NEPHROPATHY NEC W/MINOR GLOMERULAR ABNN071 HEREDIT NEPHROPATHY NEC FOCL&SEG GLOMERULAR LESN072 HEREDIT NEPHROPATHY NEC W/DIFFUSE MEMBRANOUS GNN073 HEREDIT NEPHROPATHY NEC DIFF MESANGIAL PROLIF GNN074 HEREDIT NEPHROPATHY NEC W/DIFF ENDOCAP PROLIF GNN075 HEREDIT NEPHROPATHY NEC W/DIFFUSE MESANGIOCAP GNN076 HEREDIT NEPHROPATHY NEC W/DENSE DEPOSIT DISEASEN077 HEREDIT NEPHROPATHY NEC W/DIFFUSE CRESCENTIC GNN078 HEREDITARY NEPHROPATHY NEC W/OTH MORPHOLOGIC LESN079 HEREDITARY NEPHROPATHY NEC W/UNS MORPHOLOGIC LESN08 GLOMERULAR DISORDERS IN DISEASES CLASSIFIED ELSWN131 HYDRONEPHROSIS WITH URETERAL STRICTURE NECN132 HYDRONEPHROSIS W/RENAL & URETRL CALCULOUS OBSTN1330 UNSPECIFIED HYDRONEPHROSISN1339 OTHER HYDRONEPHROSISN134 HYDROURETERN135 CROSSING VES & STRICT URETER W/O HYDRONEPHROSISN136 PYONEPHROSISN1370 VESICOURETERAL-REFLUX UNSPECIFIEDN1371 VESICOURETERAL-REFLUX WITHOUT REFLUX NEPHROPATHY

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONN13721 VESICOURETERAL-REFLUX W/RN W/O HYDROURETER UNIN13722 VESICOURETERAL-REFLUX W/RN W/O HYDROURETER BILN13729 VESICOURETERAL-REFLUX W/RN W/O HYDROURETER UNSN13731 VESICOURETERAL-REFLUX W/RN W/HYDROURETER UNIN13732 VESICOURETERAL-REFLUX W/RN W/HYDROURETER BILN13739 VESICOURETERAL-REFLUX W/RN W/HYDROURETER UNSN138 OTHER OBSTRUCTIVE AND REFLUX UROPATHYN139 OBSTRUCTIVE AND REFLUX UROPATHY UNSPECIFIEDN140 ANALGESIC NEPHROPATHYN141 NEPHROPATHY INDUCED BY OTH RX MEDS & BIOL SBSTNCN142 NEPHROPATHY INDUCED BY UNS RX MED OR BIOL SBSTNCN143 NEPHROPATHY INDUCED BY HEAVY METALSN144 TOXIC NEPHROPATHY NOT ELSEWHERE CLASSIFIEDN150 BALKAN NEPHROPATHYN151 RENAL AND PERINEPHRIC ABSCESSN158 OTHER SPEC RENAL TUBULO-INTERSTITIAL DISEASESN159 RENAL TUBULO-INTERSTITIAL DISEASE UNSPECIFIEDN16 RENAL TUBULO-INTERSTITIAL D/O IN DZ CLASS ELSWN170 ACUTE RENAL FAILURE WITH TUBULAR NECROSISN171 ACUTE KIDNEY FAILURE W/ ACUTE CORTICAL NECROSISN172 ACUTE KIDNEY FAILURE WITH MEDULLARY NECROSISN178 OTHER ACUTE KIDNEY FAILUREN179 ACUTE KIDNEY FAILURE UNSPECIFIEDN181 CHRONIC KIDNEY DISEASE STAGE 1N182 CHRONIC KIDNEY DISEASE STAGE 2 MILDN183 CHRONIC KIDNEY DISEASE STAGE 3 MODERATEN184 CHRONIC KIDNEY DISEASE STAGE 4 SEVEREN185 CHRONIC KIDNEY DISEASE STAGE 5N186 END STAGE RENAL DISEASEN189 CHRONIC KIDNEY DISEASE UNSPECIFIEDN19 UNSPECIFIED KIDNEY FAILUREN250 RENAL OSTEODYSTROPHYN251 NEPHROGENIC DIABETES INSIPIDUSN2581 SECONDARY HYPERPARATHYROIDISM OF RENAL ORIGINN2589 OTH D/O RESULT FROM IMPAIRED RENAL TUBULAR FUNCTN259 D/O RESULT FROM IMPAIRED RENAL TUBULAR FUNCT UNSN261 ATROPHY OF KIDNEY TERMINALN269 RENAL SCLEROSIS UNSPECIFIEDN310 UNINHIBITED NEUROPATHIC BLADDER NECN311 REFLEX NEUROPATHIC BLADDER NECN312 FLACCID NEUROPATHIC BLADDER NECN318 OTHER NEUROMUSCULAR DYSFUNCTION OF BLADDERN319 NEUROMUSCULAR DYSFUNCTION OF BLADDER UNSPECIFIEDN8502 ENDOMETRIAL INTRAEPITHELIAL NEOPLASIAO98011 TUBERCULOSIS COMP PREGNANCY FIRST TRIMESTER

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONO98012 TUBERCULOSIS COMP PREGNANCY SECOND TRIMESTERO98013 TUBERCULOSIS COMP PREGNANCY THIRD TRIMESTERO98019 TUBERCULOSIS COMP PREGNANCY UNS TRIMESTERO9802 TUBERCULOSIS COMPLICATING CHILDBIRTHO9803 TUBERCULOSIS COMPLICATING THE PUERPERIUMO9A111 MALIGNANT NEOPLASM COMP PREGNANCY 1ST TRIMESTERO9A112 MALIGNANT NEOPLASM COMP PREGNANCY 2ND TRIMESTERO9A113 MALIGNANT NEOPLASM COMP PREGNANCY 3RD TRIMESTERO9A119 MALIGNANT NEOPLASM COMP PREGNANCY UNS TRIMESTERO9A12 MALIGNANT NEOPLASM COMPLICATING CHILDBIRTHO9A13 MALIGNANT NEOPLASM COMPLICATING THE PUERPERIUMP370 CONGENITAL TUBERCULOSISQ050 CERVICAL SPINA BIFIDA WITH HYDROCEPHALUSQ051 THORACIC SPINA BIFIDA WITH HYDROCEPHALUSQ052 LUMBAR SPINA BIFIDA WITH HYDROCEPHALUSQ053 SACRAL SPINA BIFIDA WITH HYDROCEPHALUSQ054 UNSPECIFIED SPINA BIFIDA WITH HYDROCEPHALUSQ055 CERVICAL SPINA BIFIDA WITHOUT HYDROCEPHALUSQ056 THORACIC SPINA BIFIDA WITHOUT HYDROCEPHALUSQ057 LUMBAR SPINA BIFIDA WITHOUT HYDROCEPHALUSQ058 SACRAL SPINA BIFIDA WITHOUT HYDROCEPHALUSQ059 SPINA BIFIDA UNSPECIFIEDQ6102 CONGENITAL MULTIPLE RENAL CYSTSQ6111 CYSTIC DILATATION OF COLLECTING DUCTSQ6119 OTHER POLYCYSTIC KIDNEY INFANTILE TYPEQ612 POLYCYSTIC KIDNEY ADULT TYPEQ613 POLYCYSTIC KIDNEY UNSPECIFIEDQ614 RENAL DYSPLASIAQ615 MEDULLARY CYSTIC KIDNEYQ618 OTHER CYSTIC KIDNEY DISEASESQ620 CONGENITAL HYDRONEPHROSISQ6210 CONGENITAL OCCLUSION OF URETER UNSPECIFIEDQ6211 CONGENITAL OCCLUSION OF URETEROPELVIC JUNCTIONQ6212 CONGENITAL OCCLUSION OF URETEROVESICAL ORIFICEQ622 CONGENITAL MEGAURETERQ6231 CONGENITAL URETEROCELE ORTHOTOPICQ6232 CECOURETEROCELEQ6239 OTHER OBSTRUCTIVE DEFECTS RENAL PELVIS & URETERQ871 Congenital malformation syndromes predominantly associated with short statureQ900 Trisomy 21, nonmosaicism (meiotic nondisjunction)Q901 Trisomy 21, mosaicism (mitotic nondisjunction)Q902 Trisomy 21, translocationQ909 Down syndrome, unspecifiedQ910 Trisomy 18, nonmosaicism (meiotic nondisjunction)Q911 Trisomy 18, mosaicism (mitotic nondisjunction)

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONQ912 Trisomy 18, translocationQ913 Trisomy 18, unspecifiedQ914 Trisomy 13, nonmosaicism (meiotic nondisjunction)Q915 Trisomy 13, mosaicism (mitotic nondisjunction)Q916 Trisomy 13, translocationQ917 Trisomy 13, unspecifiedQ920 Whole chromosome trisomy, nonmosaicism (meiotic nondisjunction)Q921 Whole chromosome trisomy, mosaicism (mitotic nondisjunction)Q922 Partial trisomyQ925 Duplications with other complex rearrangementsQ9261 Marker chromosomes in normal individualQ9262 Marker chromosomes in abnormal individualQ927 Triploidy and polyploidyQ928 Other specified trisomies and partial trisomies of autosomesQ929 Trisomy and partial trisomy of autosomes, unspecifiedQ930 Whole chromosome monosomy, nonmosaicism (meiotic nondisjunction)Q931 Whole chromosome monosomy, mosaicism (mitotic nondisjunction)Q932 Chromosome replaced with ring, dicentric or isochromosomeQ937 Deletions with other complex rearrangementsQ9381 Velo-cardio-facial syndromeQ9388 Other microdeletionsQ9389 Other deletions from the autosomesQ939 Deletion from autosomes, unspecifiedQ952 Balanced autosomal rearrangement in abnormal individualQ953 Balanced sex/autosomal rearrangement in abnormal individualQ992 Fragile X chromosomeR532 FUNCTIONAL QUADRIPLEGIAZ21 ASYMPTOMATIC HIV INFECTION STATUSZ510 ENCOUNTER FOR ANTINEOPLASTIC RADIATION THERAPYZ5111 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPYZ5112 ENCOUNTER FOR ANTINEOPLASTIC IMMUNOTHERAPYZ7682 AWAITING ORGAN TRANSPLANT STATUSZ8611 PERSONAL HISTORY OF TUBERCULOSISZ940 KIDNEY TRANSPLANT STATUSZ941 HEART TRANSPLANT STATUSZ942 LUNG TRANSPLANT STATUSZ943 HEART AND LUNGS TRANSPLANT STATUSZ944 LIVER TRANSPLANT STATUSZ945 SKIN TRANSPLANT STATUSZ946 BONE TRANSPLANT STATUSZ947 CORNEAL TRANSPLANT STATUSZ9481 BONE MARROW TRANSPLANT STATUSZ9482 INTESTINE TRANSPLANT STATUSZ9483 PANCREAS TRANSPLANT STATUSZ9484 STEM CELLS TRANSPLANT STATUS

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval

CODE DESCRIPTIONZ9489 OTHER TRANSPLANTED ORGAN AND TISSUE STATUSZ949 TRANSPLANTED ORGAN AND TISSUE STATUS UNSPECIFIEDZ9911 DEPENDENCE ON RESPIRATOR VENTILATOR STATUSZ9981 DEPENDENCE ON SUPPLEMENTAL OXYGEN

This protocol was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 29, 2017 and is subject to CMS approval