Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 05.00.26i


Attachment:A

Policy #:05.00.26i

Description:ICD-10-CODING

Title:Home Prothrombin Time Monitoring


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



HOME PROTHROMBIN TIME MONITORING IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES:


D68.51 Activated protein C resistance

D68.52 Prothrombin gene mutation

D68.59 Other primary thrombophilia

D68.61 Antiphospholipid syndrome

D68.62 Lupus anticoagulant syndrome

I23.6 Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction

I26.09 Other pulmonary embolism with acute cor pulmonale

I26.90 Septic pulmonary embolism without acute cor pulmonale

I26.93 Single subsegmental pulmonary embolism without acute cor pulmonale

I26.94 Multiple subsegmental pulmonary emboli without acute cor pulmonale

I26.99 Other pulmonary embolism without acute cor pulmonale

I27.24 Chronic thromboembolic pulmonary hypertension

I27.82 Chronic pulmonary embolism

I48.0 Paroxysmal atrial fibrillation

I48.11 Longstanding persistent atrial fibrillation

I48.19 Other persistent atrial fibrillation

I48.20 Chronic atrial fibrillation, unspecified

I48.21 Permanent atrial fibrillation

I67.6 Nonpyogenic thrombosis of intracranial venous system

I80.00 Phlebitis and thrombophlebitis of superficial vessels of unspecified lower extremity

I80.01 Phlebitis and thrombophlebitis of superficial vessels of right lower extremity

I80.02 Phlebitis and thrombophlebitis of superficial vessels of left lower extremity

I80.03 Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral

I80.10 Phlebitis and thrombophlebitis of unspecified femoral vein

I80.11 Phlebitis and thrombophlebitis of right femoral vein

I80.12 Phlebitis and thrombophlebitis of left femoral vein

I80.13 Phlebitis and thrombophlebitis of femoral vein, bilateral

I80.201 Phlebitis and thrombophlebitis of unspecified deep vessels of right lower extremity

I80.202 Phlebitis and thrombophlebitis of unspecified deep vessels of left lower extremity

I80.203 Phlebitis and thrombophlebitis of unspecified deep vessels of lower extremities, bilateral

I80.209 Phlebitis and thrombophlebitis of unspecified deep vessels of unspecified lower extremity

I80.211 Phlebitis and thrombophlebitis of right iliac vein

I80.212 Phlebitis and thrombophlebitis of left iliac vein

I80.213 Phlebitis and thrombophlebitis of iliac vein, bilateral

I80.219 Phlebitis and thrombophlebitis of unspecified iliac vein

I80.221 Phlebitis and thrombophlebitis of right popliteal vein

I80.222 Phlebitis and thrombophlebitis of left popliteal vein

I80.223 Phlebitis and thrombophlebitis of popliteal vein, bilateral

I80.229 Phlebitis and thrombophlebitis of unspecified popliteal vein

I80.231 Phlebitis and thrombophlebitis of right tibial vein

I80.232 Phlebitis and thrombophlebitis of left tibial vein

I80.233 Phlebitis and thrombophlebitis of tibial vein, bilateral

I80.239 Phlebitis and thrombophlebitis of unspecified tibial vein

I80.241 Phlebitis and thrombophlebitis of right peroneal vein

I80.242 Phlebitis and thrombophlebitis of left peroneal vein

I80.243 Phlebitis and thrombophlebitis of peroneal vein, bilateral

I80.249 Phlebitis and thrombophlebitis of unspecified peroneal vein

I80.251 Phlebitis and thrombophlebitis of right calf muscular vein

I80.252 Phlebitis and thrombophlebitis of left calf muscular vein

I80.253 Phlebitis and thrombophlebitis of calf muscular vein, bilateral

I80.259 Phlebitis and thrombophlebitis of unspecified calf muscular vein

I80.291 Phlebitis and thrombophlebitis of other deep vessels of right lower extremity

I80.292 Phlebitis and thrombophlebitis of other deep vessels of left lower extremity

I80.293 Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral

I80.299 Phlebitis and thrombophlebitis of other deep vessels of unspecified lower extremity

I80.8 Phlebitis and thrombophlebitis of other sites

I82.0 Budd-Chiari syndrome

I82.1 Thrombophlebitis migrans

I82.210 Acute embolism and thrombosis of superior vena cava

I82.211 Chronic embolism and thrombosis of superior vena cava

I82.220 Acute embolism and thrombosis of inferior vena cava

I82.221 Chronic embolism and thrombosis of inferior vena cava

I82.290 Acute embolism and thrombosis of other thoracic veins

I82.291 Chronic embolism and thrombosis of other thoracic veins

I82.3 Embolism and thrombosis of renal vein

I82.401 Acute embolism and thrombosis of unspecified deep veins of right lower extremity

I82.402 Acute embolism and thrombosis of unspecified deep veins of left lower extremity

I82.403 Acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral

I82.409 Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity

I82.411 Acute embolism and thrombosis of right femoral vein

I82.412 Acute embolism and thrombosis of left femoral vein

I82.413 Acute embolism and thrombosis of femoral vein, bilateral

I82.419 Acute embolism and thrombosis of unspecified femoral vein

I82.421 Acute embolism and thrombosis of right iliac vein

I82.422 Acute embolism and thrombosis of left iliac vein

I82.423 Acute embolism and thrombosis of iliac vein, bilateral

I82.429 Acute embolism and thrombosis of unspecified iliac vein

I82.431 Acute embolism and thrombosis of right popliteal vein

I82.432 Acute embolism and thrombosis of left popliteal vein

I82.433 Acute embolism and thrombosis of popliteal vein, bilateral

I82.439 Acute embolism and thrombosis of unspecified popliteal vein

I82.441 Acute embolism and thrombosis of right tibial vein

I82.442 Acute embolism and thrombosis of left tibial vein

I82.443 Acute embolism and thrombosis of tibial vein, bilateral

I82.449 Acute embolism and thrombosis of unspecified tibial vein

I82.451 Acute embolism and thrombosis of right peroneal vein

I82.452 Acute embolism and thrombosis of left peroneal vein

I82.453 Acute embolism and thrombosis of peroneal vein, bilateral

I82.459 Acute embolism and thrombosis of unspecified peroneal vein

I82.461 Acute embolism and thrombosis of right calf muscular vein

I82.462 Acute embolism and thrombosis of left calf muscular vein

I82.463 Acute embolism and thrombosis of calf muscular vein, bilateral

I82.469 Acute embolism and thrombosis of unspecified calf muscular vein

I82.491 Acute embolism and thrombosis of other specified deep vein of right lower extremity

I82.492 Acute embolism and thrombosis of other specified deep vein of left lower extremity

I82.493 Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral

I82.499 Acute embolism and thrombosis of other specified deep vein of unspecified lower extremity

I82.4Y1 Acute embolism and thrombosis of unspecified deep veins of right proximal lower extremity

I82.4Y2 Acute embolism and thrombosis of unspecified deep veins of left proximal lower extremity

I82.4Y3 Acute embolism and thrombosis of unspecified deep veins of proximal lower extremity, bilateral

I82.4Y9 Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity

I82.4Z1 Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity

I82.4Z2 Acute embolism and thrombosis of unspecified deep veins of left distal lower extremity

I82.4Z3 Acute embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral

I82.4Z9 Acute embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity

I82.501 Chronic embolism and thrombosis of unspecified deep veins of right lower extremity

I82.502 Chronic embolism and thrombosis of unspecified deep veins of left lower extremity

I82.503 Chronic embolism and thrombosis of unspecified deep veins of lower extremity, bilateral

I82.509 Chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity

I82.511 Chronic embolism and thrombosis of right femoral vein

I82.512 Chronic embolism and thrombosis of left femoral vein

I82.513 Chronic embolism and thrombosis of femoral vein, bilateral

I82.519 Chronic embolism and thrombosis of unspecified femoral vein

I82.521 Chronic embolism and thrombosis of right iliac vein

I82.522 Chronic embolism and thrombosis of left iliac vein

I82.523 Chronic embolism and thrombosis of iliac vein, bilateral

I82.529 Chronic embolism and thrombosis of unspecified iliac vein

I82.531 Chronic embolism and thrombosis of right popliteal vein

I82.532 Chronic embolism and thrombosis of left popliteal vein

I82.533 Chronic embolism and thrombosis of popliteal vein, bilateral

I82.539 Chronic embolism and thrombosis of unspecified popliteal vein

I82.541 Chronic embolism and thrombosis of right tibial vein

I82.542 Chronic embolism and thrombosis of left tibial vein

I82.543 Chronic embolism and thrombosis of tibial vein, bilateral

I82.549 Chronic embolism and thrombosis of unspecified tibial vein

I82.551 Chronic embolism and thrombosis of right peroneal vein

I82.552 Chronic embolism and thrombosis of left peroneal vein

I82.553 Chronic embolism and thrombosis of peroneal vein, bilateral

I82.559 Chronic embolism and thrombosis of unspecified peroneal vein

I82.561 Chronic embolism and thrombosis of right calf muscular vein

I82.562 Chronic embolism and thrombosis of left calf muscular vein

I82.563 Chronic embolism and thrombosis of calf muscular vein, bilateral

I82.569 Chronic embolism and thrombosis of unspecified calf muscular vein

I82.591 Chronic embolism and thrombosis of other specified deep vein of right lower extremity

I82.592 Chronic embolism and thrombosis of other specified deep vein of left lower extremity

I82.593 Chronic embolism and thrombosis of other specified deep vein of lower extremity, bilateral

I82.599 Chronic embolism and thrombosis of other specified deep vein of unspecified lower extremity

I82.5Y1 Chronic embolism and thrombosis of unspecified deep veins of right proximal lower extremity

I82.5Y2 Chronic embolism and thrombosis of unspecified deep veins of left proximal lower extremity

I82.5Y3 Chronic embolism and thrombosis of unspecified deep veins of proximal lower extremity, bilateral

I82.5Y9 Chronic embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity

I82.5Z1 Chronic embolism and thrombosis of unspecified deep veins of right distal lower extremity

I82.5Z2 Chronic embolism and thrombosis of unspecified deep veins of left distal lower extremity

I82.5Z3 Chronic embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral

I82.5Z9 Chronic embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity

I82.601 Acute embolism and thrombosis of unspecified veins of right upper extremity

I82.602 Acute embolism and thrombosis of unspecified veins of left upper extremity

I82.603 Acute embolism and thrombosis of unspecified veins of upper extremity, bilateral

I82.609 Acute embolism and thrombosis of unspecified veins of unspecified upper extremity

I82.611 Acute embolism and thrombosis of superficial veins of right upper extremity

I82.612 Acute embolism and thrombosis of superficial veins of left upper extremity

I82.613 Acute embolism and thrombosis of superficial veins of upper extremity, bilateral

I82.619 Acute embolism and thrombosis of superficial veins of unspecified upper extremity

I82.621 Acute embolism and thrombosis of deep veins of right upper extremity

I82.622 Acute embolism and thrombosis of deep veins of left upper extremity

I82.623 Acute embolism and thrombosis of deep veins of upper extremity, bilateral

I82.629 Acute embolism and thrombosis of deep veins of unspecified upper extremity

I82.701 Chronic embolism and thrombosis of unspecified veins of right upper extremity

I82.702 Chronic embolism and thrombosis of unspecified veins of left upper extremity

I82.703 Chronic embolism and thrombosis of unspecified veins of upper extremity, bilateral

I82.709 Chronic embolism and thrombosis of unspecified veins of unspecified upper extremity

I82.711 Chronic embolism and thrombosis of superficial veins of right upper extremity

I82.712 Chronic embolism and thrombosis of superficial veins of left upper extremity

I82.713 Chronic embolism and thrombosis of superficial veins of upper extremity, bilateral

I82.719 Chronic embolism and thrombosis of superficial veins of unspecified upper extremity

I82.721 Chronic embolism and thrombosis of deep veins of right upper extremity

I82.722 Chronic embolism and thrombosis of deep veins of left upper extremity

I82.723 Chronic embolism and thrombosis of deep veins of upper extremity, bilateral

I82.729 Chronic embolism and thrombosis of deep veins of unspecified upper extremity

I82.811 Embolism and thrombosis of superficial veins of right lower extremity

I82.812 Embolism and thrombosis of superficial veins of left lower extremity

I82.813 Embolism and thrombosis of superficial veins of lower extremities, bilateral

I82.819 Embolism and thrombosis of superficial veins of unspecified lower extremity

I82.890 Acute embolism and thrombosis of other specified veins

I82.891 Chronic embolism and thrombosis of other specified veins

I82.90 Acute embolism and thrombosis of unspecified vein

I82.91 Chronic embolism and thrombosis of unspecified vein

I82.A11 Acute embolism and thrombosis of right axillary vein

I82.A12 Acute embolism and thrombosis of left axillary vein

I82.A13 Acute embolism and thrombosis of axillary vein, bilateral

I82.A19 Acute embolism and thrombosis of unspecified axillary vein

I82.A21 Chronic embolism and thrombosis of right axillary vein

I82.A22 Chronic embolism and thrombosis of left axillary vein

I82.A23 Chronic embolism and thrombosis of axillary vein, bilateral

I82.A29 Chronic embolism and thrombosis of unspecified axillary vein

I82.B11 Acute embolism and thrombosis of right subclavian vein

I82.B12 Acute embolism and thrombosis of left subclavian vein

I82.B13 Acute embolism and thrombosis of subclavian vein, bilateral

I82.B19 Acute embolism and thrombosis of unspecified subclavian vein

I82.B21 Chronic embolism and thrombosis of right subclavian vein

I82.B22 Chronic embolism and thrombosis of left subclavian vein

I82.B23 Chronic embolism and thrombosis of subclavian vein, bilateral

I82.B29 Chronic embolism and thrombosis of unspecified subclavian vein

I82.C11 Acute embolism and thrombosis of right internal jugular vein

I82.C12 Acute embolism and thrombosis of left internal jugular vein

I82.C13 Acute embolism and thrombosis of internal jugular vein, bilateral

I82.C19 Acute embolism and thrombosis of unspecified internal jugular vein

I82.C21 Chronic embolism and thrombosis of right internal jugular vein

I82.C22 Chronic embolism and thrombosis of left internal jugular vein

I82.C23 Chronic embolism and thrombosis of internal jugular vein, bilateral

I82.C29 Chronic embolism and thrombosis of unspecified internal jugular vein

O22.51 Cerebral venous thrombosis in pregnancy, first trimester

O22.52 Cerebral venous thrombosis in pregnancy, second trimester

O22.53 Cerebral venous thrombosis in pregnancy, third trimester

O87.3 Cerebral venous thrombosis in the puerperium

T82.817A Embolism due to cardiac prosthetic devices, implants and grafts, initial encounter

T82.817D Embolism due to cardiac prosthetic devices, implants and grafts, subsequent encounter

T82.817S Embolism due to cardiac prosthetic devices, implants and grafts, sequela

T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounter

T82.818D Embolism due to vascular prosthetic devices, implants and grafts, subsequent encounter

T82.818S Embolism due to vascular prosthetic devices, implants and grafts, sequela

Z79.01 Long term (current) use of anticoagulants

Z86.718 Personal history of other venous thrombosis and embolism

Z95.2 Presence of prosthetic heart valve

Z95.4 Presence of other heart-valve replacement

Version Effective Date: 11/04/2019
Version Issued Date: 11/04/2019
Version Reissued Date:

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