(Reproduced by permission from Medicare Focus, August, 1998, pp. 9 - 15.)

Medicare Part A - Revised
Local Medical Review Policy
Thyroid Testing Including TSH

Policy Number: A98-49

Description

Thyroid function studies are used to delineate the presence or absence of hormonal abnormalities of the thyroid. These abnormalities may be either primary or secondary and usually accompany clinically well defined signs and symptoms indicative of thyroid dysfunction.

Serum levels of thyroid hormone are useful to confirm clinical hyperfunction, hypofunction or euthyroidism of the thyroid gland. Thyroid function levels do not determine the etiology of thyroid disease.

Laboratory analysis to detect thyroid function has become more scientifically defined. Tests can be done with increased specificity, thereby reducing the number of tests needed to diagnose and follow treatment of most thyroid disease. The American Thyroid Association recommends the measurement of serum sensitive thyroid-stimulating hormone (sTSH) levels complemented by an appropriate free thyroxine (FT4) estimate. These tests represent the best and most efficient combination of blood tests for diagnosis and follow-up of most patients with thyroid disorders. This is true for most ambulatory patients. It is not meant to be used for certain complex diagnostic problems or on an inpatient basis, where many circumstances can skew test results.

Type of Bill

12X, 13X, 14X, 22X, 23X, 71X, 74X, 75X,

Revenue Code

300 - 319

Indications and Limitations

1.

Thyroid function levels do not determine the etiology of thyroid disease but are necessary to define hyperfunction, euthyroidism, or hypofunction of thyroid disease. Screening testing using thyroid function tests is excluded from Medicare coverage by statutory exclusion.

2.

Thyroid testing is used to:

 

·

Distinguish between primary and secondary hypothyroidism;

 

·

Confirm or rule out primary hypothyroidism;

 

·

Monitor drug therapy in patients with primary hypothyroidism, and;

 

·

Confirm or rule out primary hyperthyroidism.

HCPCS Codes

84436

Thyroxine, total

84439

Thyroxine, free

84443

Thyroid stimulating hormone (TSH)

84479

Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR)

80091

Thyroid panel, includes Thyroxine; total (84436) and thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) (84479).

80092

Thyroid panel with thyroid stimulating hormone (TSH) (84443) and includes (84436, 84479).

   

Diagnosis Codes For Coverage

One of the following covered ICD-9-CM diagnosis code(s) must be linked to the appropriate procedure.

Diagnosis Definition

Other Diseases Due to Viruses and Chlamydiae
078.2
Malignant Neoplasm of Other and Unspecified Sites
193
198.89
Benign Neoplasms
226
227.3
Carcinoma in Situ
234.8
Neoplasms of Uncertain Behavior
237.4
Neoplasms of Unspecified Nature
239.7
Disorders of Thyroid Gland
240.0-240.9
241.0-241.1
241.9
242.0-242.01
242.1-242.11
242.2-242.21
242.3-242.31
242.4-242.41
242.8-242.81
242.9-242.91
243
244.0
244.1-244.3
244.8-244.9
245.0-245.9
246.1-246.2
246.3
246.8
Diseases of Other Endocrine Glands
252.1
253.1
253.2
253.3-253.4
253.7
255.2
255.4
258.0-258.9
Nutritional Deficiencies
266.0
Other Metabolic and Immunity Disorders
272.0
272.4
275.40-275.49 Revised per Medicare Focus January, 2001
276.1
278.00
278.01
Diseases of the Blood and Blood-Forming Organs
281.0 Revised per Medicare Focus April, 2001
Organic Psychotic Conditions
290.00
290.10-290.13
290.20-290.21
290.3
293.1
Other Psychoses
297.1
298.9
Neurotic Disorders, Personality Disorders, and Other Nonpsychotic Mental Disorders
300.00-300.02
300.16
310.1
311
Hereditary and Degenerative Diseases of the Central Nervous System
331.0-331.2
333.1
Other Diseases of the Central Nervous System
344.9
Disorders of the Peripheral Nervous System
354.0
356.9
358.1
359.3
359.5
359.9
Disorders of the Eye and Adnexa
368.2
374.3
374.41
376.21
376.22
376.30-376.31
376.33-376.35
Other Forms of Heart Disease
423.9
425.7
425.9
427.0
427.2
427.31
427.89
427.9
428.0
428.1
429.3
Other Diseases of Intestines and Peritoneum
560.1
564.0-564.9 Revised per Medicare Focus December, 2001
564.7
Other Disorders of Female Genital Tract
625.3
626.0-626.2
Complications Mainly Related to Pregnancy
648.1-648.14
Complications of the Puerperium
676.20-676.24
Other Diseases of Skin and Subcutaneous Tissue
701.1
703.8
704.00
Arthropathies and Related Disorders
710.9 Revised per Medicare Focus April, 2001
712.10 - 712.39 Revised per Medicare Focus April, 2001
716.90 - 716.99 Revised per Medicare Focus April, 2001
Rheumatism, Excluding the Back
725 Revised per Medicare Focus April, 2001
729.0 Revised per Medicare Focus April, 2001
729.1
729.82
Osteopathies, Chondropathies, and Acquired Musculoskeletal Deformities
733.00 Revised per Medicare Focus April, 2001
733.09
Congenital Anomalies
750.15
759.2
Other Conditions Originating in the Perinatal Period
775.3
Symptoms
780.09
780.57
780.71-780.79 Revised per Medicare Focus September, 1999
780.8
781.0
781.3
782.8
783.1
783.21 Revised per Medicare Focus December, 2000
784.1
784.49
784.69
785.0
785.1
787.2
787.91
789.5
Nonspecific Abnormal Findings
790.6
793.2
794.31
794.5
Ill-Defined and Unknown Causes of Morbidity and Mortality
799.2
Other and Unspecified Effects of External Causes
992.9
Persons Encountering Health Services for Specific Procedures and Aftercare
V58.69

Category

Pathology and Laboratory

HCFA National Policy

Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.

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

Reason For Denial

When the test is considered to be medically unnecessary
When performed as a screening test, which is statutorily excluded by Medicare

Non-Covered Diagnosis Codes

Any that are not listed as covered diagnosis codes in the "Diagnosis Codes for Coverage" section in this policy.

Sources of Information

The American Thyroid Association
Common Diagnosis Tests, Use and Interpretation
The Merck Manual
CMD Clinical Laboratory Workgroup

Coding Guides

1.

ICD-9 code V82.9, (special screening of other conditions, unspecified condition), or comparable narratives should be used to indicate screening tests performed in the absence of a specific sign, symptom, or complaint. Use of V82.9 or comparable narrative will result in the denial of claims as non covered screening services.

2.

Only the test or combination of tests which best addresses the clinical thyroid condition will be covered. Following are examples of which test or possible combination of tests would be indicated:

Hyperthyroidism:

84436 (T4) and/or 84439 (freeT4)

Hypothyroidism:

84436 (T4) and/or 84443 (TSH)

Thyroid binding abnormality:

80091 (thyroid panel, including T4 total and T3 Resin Uptake) or 80092 (thyroid panel, including T4 total, T3 Resin Uptake, and TSH)

3.

If procedure code 84436 (thyroxine, total) and 84479 (Thyroid hormone T3 or T4 or Thyroidbinding Ratio), resin uptake are performed on the same day of service as 80091, the individual components will be combined and paid as code 80091.4

4.

If procedure codes 84436, 84479, and 84443 (TSH) are performed on the same day of service as 80092, the individual components will be combined and paid code 80092.

5.

The claim must be submitted with one of the covered ICD-9 diagnosis codes. Failure to do so may result in denial or delay in processing the claim.

Reconsiderations and Appeals - Claims resubmitted with a different diagnosis code must include medical record documentation to justify the diagnosis code change. Submission with diagnoses other than those listed as "Covered Codes" will be individually reviewed by this Intermediary for medical necessity.

Documentation Required

ICD-9-CM diagnosis codes are required on claim.

Medical Records must clearly document the medical necessity for the test and the frequency of the test.

If documentation is requested for review, submit the following:

·

History and Physical

·

Physician orders/progress notes

·

Diagnosis/reason for test

·

Test results

·

Itemization of charges

Comments

This policy is a revision of and supersedes all previously published thyroid policies (96-14, 96-15, 96-16, 96-17, 97-13) and is being republished for diagnosis clarification purposes.

This policy should be interpreted to incorporate future changes in the ICD-9 -CM or CPT/HCPCS coding systems such that its original intent and scope will not be substantively changed.

Approval Dates

Date of Notice and Comments:

June 1996

Notice Period Date:

October 1996 Revision: July 1, 1997

Effective Date of Policy:

November 1, 1996

Revised Effective Date:

August 1, 1997 (97-13)

Revision History:

August 1998

Approval

This policy does not reflect the sole opinion of the Intermediary/Medical Director.