LCD for Syphilis Test (L1669)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L1669 

 

LCD Title 

Syphilis Test 

 

Contractor's Determination Number 

1669 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  

 

CMS National Coverage Policy 

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.
 

 

Primary Geographic Jurisdiction 

New Jersey
Tennessee
 

 

Secondary Geographic Jurisdiction 

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 10/16/1997  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 12/08/2005  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

The Venereal Disease Research Laboratory (VDRL) test and its analogues, Rapid Plasma Reagin (RPR) and Automated Reagin Test (ART), are the standard laboratory tests used for syphilis screening and nonspecific confirmation of syphilitic infection. Based on hemagglutination of sheep red blood cells, these tests demonstrate the presence of antibodies frequently present in syphilis-infected patients but nonspecific to syphilis confirmation of treponemal disease (syphilis, yaws, bejel, pinta) or false postive reactor to these reagin tests is then determined by Treponema Pallidium Immobilization (TPI).

Medicare covered qualitative syphilis testing (e.g. VDRL. PIPR, ART) is indicated only when there are clinical findings of the skin, eyes, teeth, cardiovasular system, or central nervous system that suggest syphilitic infection. Quantitative syphilis testing is indicated only when there has been previous positive results of either qualitated or treponema pallidum confirmatory test, leg, FTA abs but is never indicated when qualitative syphilis testing is negative. Confirmatory and specific treponemal testing is indicated only when there has been a previous positive test result of qualitative syphilis testing and very rarely when clinical disease, particularly in the central nervous system, suggests a tertiary syphilic disease of meningoencephalitis, tabes dorsalis, or general paresis, despite a negative qualitative test for syphilis previous positive testing at periodic intervals not to exceed semiannually until seronegativity occurs. 

 

Coverage Topic 

Lab Services
 

 

Coding Information

Bill Type Codes: 

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12x

Hospital-inpatient or home health visits (Part B only)

13x

Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)

14x

Non-Patient Laboratory Specimens

 

 

Revenue Codes: 

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

030X

Laboratory-general classification

031X

Laboratory pathological-general classification

039X

Blood storage and processing-general classification

 

 

CPT/HCPCS Codes 

 

86592

SYPHILIS TEST; QUALITATIVE (EG, VDRL, RPR, ART)

86593

SYPHILIS TEST; QUANTITATIVE

86781

ANTIBODY; TREPONEMA PALLIDUM, CONFIRMATORY TEST (EG, FTA-ABS)

 

 

ICD-9 Codes that Support Medical Necessity 

 

042

HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE

054.10 - 054.19

GENITAL HERPES UNSPECIFIED - OTHER GENITAL HERPES

078.0 - 078.19

MOLLUSCUM CONTAGIOSUM - OTHER SPECIFIED VIRAL WARTS

090.3 - 093.24

SYPHILITIC INTERSTITIAL KERATITIS - SYPHILITIC ENDOCARDITIS OF PULMONARY VALVE

093.81 - 094.3

SYPHILITIC PERICARDITIS - ASYMPTOMATIC NEUROSYPHILIS

094.81 - 099.59

SYPHILITIC ENCEPHALITIS - OTHER VENEREAL DISEASES DUE TO CHLAMYDIA TRACHOMATIS OTHER SPECIFIED SITE

099.8

OTHER SPECIFIED VENEREAL DISEASES

099.9

VENEREAL DISEASE UNSPECIFIED

104.0

NONVENEREAL ENDEMIC SYPHILIS

131.00 - 131.09

UROGENITAL TRICHOMONIASIS UNSPECIFIED - OTHER UROGENITAL TRICHOMONIASIS

283.0

AUTOIMMUNE HEMOLYTIC ANEMIAS

286.5

HEMORRHAGIC DISORDER DUE TO INTRINSIC CIRCULATING ANTICOAGULANTS

290.0

SENILE DEMENTIA UNCOMPLICATED

290.10 - 290.13

PRESENILE DEMENTIA UNCOMPLICATED - PRESENILE DEMENTIA WITH DEPRESSIVE FEATURES

290.20 - 290.21

SENILE DEMENTIA WITH DELUSIONAL FEATURES - SENILE DEMENTIA WITH DEPRESSIVE FEATURES

290.3 - 290.43

SENILE DEMENTIA WITH DELIRIUM - VASCULAR DEMENTIA, WITH DEPRESSED MOOD

290.8

OTHER SPECIFIED SENILE PSYCHOTIC CONDITIONS

290.9

UNSPECIFIED SENILE PSYCHOTIC CONDITION

331.0

ALZHEIMER'S DISEASE

331.2

SENILE DEGENERATION OF BRAIN

356.0

HEREDITARY PERIPHERAL NEUROPATHY

356.9

UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

580.9

ACUTE GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

582.9

CHRONIC GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

614.0 - 614.9

ACUTE SALPINGITIS AND OOPHORITIS - UNSPECIFIED INFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS AND TISSUES

615.0 - 615.9

ACUTE INFLAMMATORY DISEASES OF UTERUS EXCEPT CERVIX - UNSPECIFIED INFLAMMATORY DISEASE OF UTERUS

616.0 - 616.9

CERVICITIS AND ENDOCERVICITIS - UNSPECIFIED INFLAMMATORY DISEASE OF CERVIX VAGINA AND VULVA

710.0

SYSTEMIC LUPUS ERYTHEMATOSUS

714.1

FELTY'S SYNDROME

760.2

MATERNAL INFECTIONS AFFECTING FETUS OR NEWBORN

791.0

PROTEINURIA

V01.6

CONTACT WITH OR EXPOSURE TO VENEREAL DISEASES

 

 

Diagnoses that Support Medical Necessity 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity 

 

 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 

 

 

Diagnoses that DO NOT Support Medical Necessity 

 

 

General Information

Documentation Requirements 

Documentation supporting medical necessity of this test, such as ICD-9 codes, must be submitted with each claim. Claims without such evidence will be denied. 

 

Appendices 

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:

Frequently Asked Questions


 

 

Utilization Guidelines 

 

 

Sources of Information and Basis for Decision 

Carrier Policy 

 

Advisory Committee Meeting Notes 

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives. 

 

Start Date of Comment Period 

08/01/1997 

 

End Date of Comment Period 

 

 

Start Date of Notice Period 

09/15/1997 

 

Revision History Number 

050-97h 

 

Revision History Explanation 

01/10/2003 Added 12x to Type of Bill Code

07/24/2002 Formatted

02/23/2001 Updated codes with ICD-9 and CPT code books

09/04/2004 - This policy was updated by the ICD-9 Code Annual Update for 2004-2005.

This LCD was converted from an LMRP on 12/7/2005

7/2/2006 - The description for Bill code 14 was changed

09/04/2006 - This policy was updated by the ICD-9 2006-2007 Annual Update.

10/30/2007 - Frequently Asked Question restored to Appendices 

 

Reason for Change 

Other
 

Last Reviewed On Date 

10/30/2007 

 

Related Documents 

Article(s)
A37893 - Syphilis Test

 

LCD Attachments 

FAQ - Comment and Response (912 bytes)

 

Other Versions 

Updated on 10/30/2007 with effective dates 12/08/2005 - N/A

Updated on 09/05/2006 with effective dates 12/08/2005 - N/A

Updated on 07/02/2006 with effective dates 12/08/2005 - N/A

Updated on 12/07/2005 with effective dates 12/08/2005 - N/A

Updated on 12/07/2005 with effective dates 01/10/2003 - 12/07/2005

Updated on 09/04/2004 with effective dates 01/10/2003 - N/A

Updated on 10/09/2003 with effective dates 01/10/2003 - N/A

Updated on 09/09/2003 with effective dates 01/10/2003 - N/A

Updated on 03/11/2003 with effective dates 01/10/2003 - N/A

Updated on 02/15/2003 with effective dates 01/10/2003 - N/A

Updated on 01/09/2003 with effective dates 01/10/2003 - N/A

Updated on 10/04/2002 with effective dates 07/24/2002 - 01/09/2003