LCD Reference Article Billing and Coding Article

Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing

A57077

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Source Article ID
N/A
Article ID
A57077
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing
Article Type
Billing and Coding
Original Effective Date
10/03/2018
Revision Effective Date
10/01/2024
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L36393, Controlled Substance Monitoring and Drugs of Abuse Testing. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Documentation Requirements

Note: Refer to the LCD for documentation requirements, in the patient’s medical record, of medical necessity for testing ordered on an individual patient basis by the clinician.

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. 

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Coding Information

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(379 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Labs are not to pre-populate requisition forms with diagnosis codes.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT/HCPCS codes: 80305, 80306, 80307, G0480, G0481, G0482, G0483, G0659, and 0082U.

Group 1 Codes
Code Description
E87.21 Acute metabolic acidosis
E87.22 Chronic metabolic acidosis
E87.29 Other acidosis
F10.130 Alcohol abuse with withdrawal, uncomplicated
F10.131 Alcohol abuse with withdrawal delirium
F10.132 Alcohol abuse with withdrawal with perceptual disturbance
F10.20 Alcohol dependence, uncomplicated
F11.13 Opioid abuse with withdrawal
F11.20 Opioid dependence, uncomplicated
F11.220 Opioid dependence with intoxication, uncomplicated
F11.221 Opioid dependence with intoxication delirium
F11.222 Opioid dependence with intoxication with perceptual disturbance
F11.229 Opioid dependence with intoxication, unspecified
F11.23 Opioid dependence with withdrawal
F11.24 Opioid dependence with opioid-induced mood disorder
F11.250 Opioid dependence with opioid-induced psychotic disorder with delusions
F11.251 Opioid dependence with opioid-induced psychotic disorder with hallucinations
F11.259 Opioid dependence with opioid-induced psychotic disorder, unspecified
F11.281 Opioid dependence with opioid-induced sexual dysfunction
F11.282 Opioid dependence with opioid-induced sleep disorder
F11.288 Opioid dependence with other opioid-induced disorder
F11.29 Opioid dependence with unspecified opioid-induced disorder
F12.13 Cannabis abuse with withdrawal
F13.130 Sedative, hypnotic or anxiolytic abuse with withdrawal, uncomplicated
F13.131 Sedative, hypnotic or anxiolytic abuse with withdrawal delirium
F13.132 Sedative, hypnotic or anxiolytic abuse with withdrawal with perceptual disturbance
F14.13 Cocaine abuse, unspecified with withdrawal
F14.93 Cocaine use, unspecified with withdrawal
F15.13 Other stimulant abuse with withdrawal
F18.10 Inhalant abuse, uncomplicated
F18.120 Inhalant abuse with intoxication, uncomplicated
F18.90 Inhalant use, unspecified, uncomplicated
F19.130 Other psychoactive substance abuse with withdrawal, uncomplicated
F19.131 Other psychoactive substance abuse with withdrawal delirium
F19.132 Other psychoactive substance abuse with withdrawal with perceptual disturbance
F19.20 Other psychoactive substance dependence, uncomplicated
F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.2 Catatonic schizophrenia
F20.89 Other schizophrenia
F55.0 Abuse of antacids
F55.1 Abuse of herbal or folk remedies
F55.2 Abuse of laxatives
F55.3 Abuse of steroids or hormones
F55.4 Abuse of vitamins
F55.8 Abuse of other non-psychoactive substances
G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus
G40.309 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus
G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.401 Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus
G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus
G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.901 Epilepsy, unspecified, not intractable, with status epilepticus
G40.909 Epilepsy, unspecified, not intractable, without status epilepticus
G40.911 Epilepsy, unspecified, intractable, with status epilepticus
G40.919 Epilepsy, unspecified, intractable, without status epilepticus
G89.29 Other chronic pain
G89.4 Chronic pain syndrome
I44.0 Atrioventricular block, first degree
I44.1 Atrioventricular block, second degree
I44.30 Unspecified atrioventricular block
I45.81 Long QT syndrome
I47.0 Re-entry ventricular arrhythmia
I47.11 Inappropriate sinus tachycardia, so stated
I47.19 Other supraventricular tachycardia
I47.21 Torsades de pointes
I47.29 Other ventricular tachycardia
I49.2 Junctional premature depolarization
M25.50 Pain in unspecified joint
M25.59 Pain in other specified joint
M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22 Other spondylosis with radiculopathy, cervical region
M47.23 Other spondylosis with radiculopathy, cervicothoracic region
M47.26 Other spondylosis with radiculopathy, lumbar region
M47.27 Other spondylosis with radiculopathy, lumbosacral region
M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region
M47.812 Spondylosis without myelopathy or radiculopathy, cervical region
M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region
M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region
M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
M47.891 Other spondylosis, occipito-atlanto-axial region
M47.892 Other spondylosis, cervical region
M47.893 Other spondylosis, cervicothoracic region
M47.896 Other spondylosis, lumbar region
M47.897 Other spondylosis, lumbosacral region
M47.898 Other spondylosis, sacral and sacrococcygeal region
M51.14 Intervertebral disc disorders with radiculopathy, thoracic region
M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region
M51.16 Intervertebral disc disorders with radiculopathy, lumbar region
M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region
M51.360 Other intervertebral disc degeneration, lumbar region with discogenic back pain only
M51.361 Other intervertebral disc degeneration, lumbar region with lower extremity pain only
M51.362 Other intervertebral disc degeneration, lumbar region with discogenic back pain and lower extremity pain
M51.369 Other intervertebral disc degeneration, lumbar region without mention of lumbar back pain or lower extremity pain
M51.370 Other intervertebral disc degeneration, lumbosacral region with discogenic back pain only
M51.371 Other intervertebral disc degeneration, lumbosacral region with lower extremity pain only
M51.372 Other intervertebral disc degeneration, lumbosacral region with discogenic back pain and lower extremity pain
M51.379 Other intervertebral disc degeneration, lumbosacral region without mention of lumbar back pain or lower extremity pain
M54.10 Radiculopathy, site unspecified
M54.14 Radiculopathy, thoracic region
M54.15 Radiculopathy, thoracolumbar region
M54.16 Radiculopathy, lumbar region
M54.17 Radiculopathy, lumbosacral region
M54.18 Radiculopathy, sacral and sacrococcygeal region
M54.2 Cervicalgia
M54.50 Low back pain, unspecified
M54.51 Vertebrogenic low back pain
M54.59 Other low back pain
M60.811 Other myositis, right shoulder
M60.812 Other myositis, left shoulder
M60.821 Other myositis, right upper arm
M60.822 Other myositis, left upper arm
M60.831 Other myositis, right forearm
M60.832 Other myositis, left forearm
M60.841 Other myositis, right hand
M60.842 Other myositis, left hand
M60.851 Other myositis, right thigh
M60.852 Other myositis, left thigh
M60.861 Other myositis, right lower leg
M60.862 Other myositis, left lower leg
M60.871 Other myositis, right ankle and foot
M60.872 Other myositis, left ankle and foot
M60.88 Other myositis, other site
M60.89 Other myositis, multiple sites
M60.9 Myositis, unspecified
M79.11 Myalgia of mastication muscle
M79.12 Myalgia of auxiliary muscles, head and neck
M79.18 Myalgia, other site
M79.2 Neuralgia and neuritis, unspecified
M79.7 Fibromyalgia
R40.0 Somnolence
R40.1 Stupor
R40.20 Unspecified coma
R40.2110 Coma scale, eyes open, never, unspecified time
R40.2111 Coma scale, eyes open, never, in the field [EMT or ambulance]
R40.2112 Coma scale, eyes open, never, at arrival to emergency department
R40.2113 Coma scale, eyes open, never, at hospital admission
R40.2114 Coma scale, eyes open, never, 24 hours or more after hospital admission
R40.2120 Coma scale, eyes open, to pain, unspecified time
R40.2121 Coma scale, eyes open, to pain, in the field [EMT or ambulance]
R40.2122 Coma scale, eyes open, to pain, at arrival to emergency department
R40.2123 Coma scale, eyes open, to pain, at hospital admission
R40.2124 Coma scale, eyes open, to pain, 24 hours or more after hospital admission
R40.2210 Coma scale, best verbal response, none, unspecified time
R40.2211 Coma scale, best verbal response, none, in the field [EMT or ambulance]
R40.2212 Coma scale, best verbal response, none, at arrival to emergency department
R40.2213 Coma scale, best verbal response, none, at hospital admission
R40.2214 Coma scale, best verbal response, none, 24 hours or more after hospital admission
R40.2220 Coma scale, best verbal response, incomprehensible words, unspecified time
R40.2221 Coma scale, best verbal response, incomprehensible words, in the field [EMT or ambulance]
R40.2222 Coma scale, best verbal response, incomprehensible words, at arrival to emergency department
R40.2223 Coma scale, best verbal response, incomprehensible words, at hospital admission
R40.2224 Coma scale, best verbal response, incomprehensible words, 24 hours or more after hospital admission
R40.2310 Coma scale, best motor response, none, unspecified time
R40.2311 Coma scale, best motor response, none, in the field [EMT or ambulance]
R40.2312 Coma scale, best motor response, none, at arrival to emergency department
R40.2313 Coma scale, best motor response, none, at hospital admission
R40.2314 Coma scale, best motor response, none, 24 hours or more after hospital admission
R40.2320 Coma scale, best motor response, extension, unspecified time
R40.2321 Coma scale, best motor response, extension, in the field [EMT or ambulance]
R40.2322 Coma scale, best motor response, extension, at arrival to emergency department
R40.2323 Coma scale, best motor response, extension, at hospital admission
R40.2324 Coma scale, best motor response, extension, 24 hours or more after hospital admission
R40.2340 Coma scale, best motor response, flexion withdrawal, unspecified time
R40.2341 Coma scale, best motor response, flexion withdrawal, in the field [EMT or ambulance]
R40.2342 Coma scale, best motor response, flexion withdrawal, at arrival to emergency department
R40.2343 Coma scale, best motor response, flexion withdrawal, at hospital admission
R40.2344 Coma scale, best motor response, flexion withdrawal, 24 hours or more after hospital admission
R40.2A Nontraumatic coma due to underlying condition
R44.0 Auditory hallucinations
R44.2 Other hallucinations
R44.3 Hallucinations, unspecified
R56.9 Unspecified convulsions
T39.011A Poisoning by aspirin, accidental (unintentional), initial encounter
T39.012A Poisoning by aspirin, intentional self-harm, initial encounter
T39.013A Poisoning by aspirin, assault, initial encounter
T39.014A Poisoning by aspirin, undetermined, initial encounter
T39.091A Poisoning by salicylates, accidental (unintentional), initial encounter
T39.092A Poisoning by salicylates, intentional self-harm, initial encounter
T39.093A Poisoning by salicylates, assault, initial encounter
T39.094A Poisoning by salicylates, undetermined, initial encounter
T39.1X1A Poisoning by 4-Aminophenol derivatives, accidental (unintentional), initial encounter
T39.1X2A Poisoning by 4-Aminophenol derivatives, intentional self-harm, initial encounter
T39.1X3A Poisoning by 4-Aminophenol derivatives, assault, initial encounter
T39.1X4A Poisoning by 4-Aminophenol derivatives, undetermined, initial encounter
T39.2X1A Poisoning by pyrazolone derivatives, accidental (unintentional), initial encounter
T39.2X2A Poisoning by pyrazolone derivatives, intentional self-harm, initial encounter
T39.2X3A Poisoning by pyrazolone derivatives, assault, initial encounter
T39.2X4A Poisoning by pyrazolone derivatives, undetermined, initial encounter
T39.311A Poisoning by propionic acid derivatives, accidental (unintentional), initial encounter
T39.312A Poisoning by propionic acid derivatives, intentional self-harm, initial encounter
T39.313A Poisoning by propionic acid derivatives, assault, initial encounter
T39.314A Poisoning by propionic acid derivatives, undetermined, initial encounter
T39.391A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], accidental (unintentional), initial encounter
T39.392A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], intentional self-harm, initial encounter
T39.393A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], assault, initial encounter
T39.394A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], undetermined, initial encounter
T40.0X1A Poisoning by opium, accidental (unintentional), initial encounter
T40.0X2A Poisoning by opium, intentional self-harm, initial encounter
T40.0X3A Poisoning by opium, assault, initial encounter
T40.0X4A Poisoning by opium, undetermined, initial encounter
T40.1X1A Poisoning by heroin, accidental (unintentional), initial encounter
T40.1X2A Poisoning by heroin, intentional self-harm, initial encounter
T40.1X3A Poisoning by heroin, assault, initial encounter
T40.1X4A Poisoning by heroin, undetermined, initial encounter
T40.2X1A Poisoning by other opioids, accidental (unintentional), initial encounter
T40.2X2A Poisoning by other opioids, intentional self-harm, initial encounter
T40.2X3A Poisoning by other opioids, assault, initial encounter
T40.2X4A Poisoning by other opioids, undetermined, initial encounter
T40.3X1A Poisoning by methadone, accidental (unintentional), initial encounter
T40.3X2A Poisoning by methadone, intentional self-harm, initial encounter
T40.3X3A Poisoning by methadone, assault, initial encounter
T40.3X4A Poisoning by methadone, undetermined, initial encounter
T40.491A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter
T40.491D Poisoning by other synthetic narcotics, accidental (unintentional), subsequent encounter
T40.492A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter
T40.492D Poisoning by other synthetic narcotics, intentional self-harm, subsequent encounter
T40.493A Poisoning by other synthetic narcotics, assault, initial encounter
T40.493D Poisoning by other synthetic narcotics, assault, subsequent encounter
T40.494A Poisoning by other synthetic narcotics, undetermined, initial encounter
T40.494D Poisoning by other synthetic narcotics, undetermined, subsequent encounter
T40.495A Adverse effect of other synthetic narcotics, initial encounter
T40.495D Adverse effect of other synthetic narcotics, subsequent encounter
T40.496A Underdosing of other synthetic narcotics, initial encounter
T40.496D Underdosing of other synthetic narcotics, subsequent encounter
T40.601A Poisoning by unspecified narcotics, accidental (unintentional), initial encounter
T40.602A Poisoning by unspecified narcotics, intentional self-harm, initial encounter
T40.603A Poisoning by unspecified narcotics, assault, initial encounter
T40.604A Poisoning by unspecified narcotics, undetermined, initial encounter
T40.691A Poisoning by other narcotics, accidental (unintentional), initial encounter
T40.692A Poisoning by other narcotics, intentional self-harm, initial encounter
T40.693A Poisoning by other narcotics, assault, initial encounter
T40.694A Poisoning by other narcotics, undetermined, initial encounter
T40.711A Poisoning by cannabis, accidental (unintentional), initial encounter
T40.712A Poisoning by cannabis, intentional self-harm, initial encounter
T40.713A Poisoning by cannabis, assault, initial encounter
T40.714A Poisoning by cannabis, undetermined, initial encounter
T40.721A Poisoning by synthetic cannabinoids, accidental (unintentional), initial encounter
T40.722A Poisoning by synthetic cannabinoids, intentional self-harm, initial encounter
T40.723A Poisoning by synthetic cannabinoids, assault, initial encounter
T40.724A Poisoning by synthetic cannabinoids, undetermined, initial encounter
T40.8X1A Poisoning by lysergide [LSD], accidental (unintentional), initial encounter
T40.8X2A Poisoning by lysergide [LSD], intentional self-harm, initial encounter
T40.8X3A Poisoning by lysergide [LSD], assault, initial encounter
T40.8X4A Poisoning by lysergide [LSD], undetermined, initial encounter
T40.901A Poisoning by unspecified psychodysleptics [hallucinogens], accidental (unintentional), initial encounter
T40.902A Poisoning by unspecified psychodysleptics [hallucinogens], intentional self-harm, initial encounter
T40.903A Poisoning by unspecified psychodysleptics [hallucinogens], assault, initial encounter
T40.904A Poisoning by unspecified psychodysleptics [hallucinogens], undetermined, initial encounter
T40.991A Poisoning by other psychodysleptics [hallucinogens], accidental (unintentional), initial encounter
T40.992A Poisoning by other psychodysleptics [hallucinogens], intentional self-harm, initial encounter
T40.993A Poisoning by other psychodysleptics [hallucinogens], assault, initial encounter
T40.994A Poisoning by other psychodysleptics [hallucinogens], undetermined, initial encounter
T42.0X1A Poisoning by hydantoin derivatives, accidental (unintentional), initial encounter
T42.0X2A Poisoning by hydantoin derivatives, intentional self-harm, initial encounter
T42.0X3A Poisoning by hydantoin derivatives, assault, initial encounter
T42.0X4A Poisoning by hydantoin derivatives, undetermined, initial encounter
T42.3X1A Poisoning by barbiturates, accidental (unintentional), initial encounter
T42.3X2A Poisoning by barbiturates, intentional self-harm, initial encounter
T42.3X3A Poisoning by barbiturates, assault, initial encounter
T42.3X4A Poisoning by barbiturates, undetermined, initial encounter
T42.4X1A Poisoning by benzodiazepines, accidental (unintentional), initial encounter
T42.4X2A Poisoning by benzodiazepines, intentional self-harm, initial encounter
T42.4X3A Poisoning by benzodiazepines, assault, initial encounter
T42.4X4A Poisoning by benzodiazepines, undetermined, initial encounter
T42.6X1A Poisoning by other antiepileptic and sedative-hypnotic drugs, accidental (unintentional), initial encounter
T42.6X2A Poisoning by other antiepileptic and sedative-hypnotic drugs, intentional self-harm, initial encounter
T42.6X3A Poisoning by other antiepileptic and sedative-hypnotic drugs, assault, initial encounter
T42.6X4A Poisoning by other antiepileptic and sedative-hypnotic drugs, undetermined, initial encounter
T42.71XA Poisoning by unspecified antiepileptic and sedative-hypnotic drugs, accidental (unintentional), initial encounter
T42.72XA Poisoning by unspecified antiepileptic and sedative-hypnotic drugs, intentional self-harm, initial encounter
T42.73XA Poisoning by unspecified antiepileptic and sedative-hypnotic drugs, assault, initial encounter
T42.74XA Poisoning by unspecified antiepileptic and sedative-hypnotic drugs, undetermined, initial encounter
T43.011A Poisoning by tricyclic antidepressants, accidental (unintentional), initial encounter
T43.012A Poisoning by tricyclic antidepressants, intentional self-harm, initial encounter
T43.013A Poisoning by tricyclic antidepressants, assault, initial encounter
T43.014A Poisoning by tricyclic antidepressants, undetermined, initial encounter
T43.021A Poisoning by tetracyclic antidepressants, accidental (unintentional), initial encounter
T43.022A Poisoning by tetracyclic antidepressants, intentional self-harm, initial encounter
T43.023A Poisoning by tetracyclic antidepressants, assault, initial encounter
T43.024A Poisoning by tetracyclic antidepressants, undetermined, initial encounter
T43.1X1A Poisoning by monoamine-oxidase-inhibitor antidepressants, accidental (unintentional), initial encounter
T43.1X2A Poisoning by monoamine-oxidase-inhibitor antidepressants, intentional self-harm, initial encounter
T43.1X3A Poisoning by monoamine-oxidase-inhibitor antidepressants, assault, initial encounter
T43.1X4A Poisoning by monoamine-oxidase-inhibitor antidepressants, undetermined, initial encounter
T43.201A Poisoning by unspecified antidepressants, accidental (unintentional), initial encounter
T43.202A Poisoning by unspecified antidepressants, intentional self-harm, initial encounter
T43.203A Poisoning by unspecified antidepressants, assault, initial encounter
T43.204A Poisoning by unspecified antidepressants, undetermined, initial encounter
T43.211A Poisoning by selective serotonin and norepinephrine reuptake inhibitors, accidental (unintentional), initial encounter
T43.212A Poisoning by selective serotonin and norepinephrine reuptake inhibitors, intentional self-harm, initial encounter
T43.213A Poisoning by selective serotonin and norepinephrine reuptake inhibitors, assault, initial encounter
T43.214A Poisoning by selective serotonin and norepinephrine reuptake inhibitors, undetermined, initial encounter
T43.221A Poisoning by selective serotonin reuptake inhibitors, accidental (unintentional), initial encounter
T43.222A Poisoning by selective serotonin reuptake inhibitors, intentional self-harm, initial encounter
T43.223A Poisoning by selective serotonin reuptake inhibitors, assault, initial encounter
T43.224A Poisoning by selective serotonin reuptake inhibitors, undetermined, initial encounter
T43.291A Poisoning by other antidepressants, accidental (unintentional), initial encounter
T43.292A Poisoning by other antidepressants, intentional self-harm, initial encounter
T43.293A Poisoning by other antidepressants, assault, initial encounter
T43.294A Poisoning by other antidepressants, undetermined, initial encounter
T43.3X1A Poisoning by phenothiazine antipsychotics and neuroleptics, accidental (unintentional), initial encounter
T43.3X2A Poisoning by phenothiazine antipsychotics and neuroleptics, intentional self-harm, initial encounter
T43.3X3A Poisoning by phenothiazine antipsychotics and neuroleptics, assault, initial encounter
T43.3X4A Poisoning by phenothiazine antipsychotics and neuroleptics, undetermined, initial encounter
T43.4X1A Poisoning by butyrophenone and thiothixene neuroleptics, accidental (unintentional), initial encounter
T43.4X2A Poisoning by butyrophenone and thiothixene neuroleptics, intentional self-harm, initial encounter
T43.4X3A Poisoning by butyrophenone and thiothixene neuroleptics, assault, initial encounter
T43.4X4A Poisoning by butyrophenone and thiothixene neuroleptics, undetermined, initial encounter
T43.501A Poisoning by unspecified antipsychotics and neuroleptics, accidental (unintentional), initial encounter
T43.502A Poisoning by unspecified antipsychotics and neuroleptics, intentional self-harm, initial encounter
T43.503A Poisoning by unspecified antipsychotics and neuroleptics, assault, initial encounter
T43.504A Poisoning by unspecified antipsychotics and neuroleptics, undetermined, initial encounter
T43.591A Poisoning by other antipsychotics and neuroleptics, accidental (unintentional), initial encounter
T43.592A Poisoning by other antipsychotics and neuroleptics, intentional self-harm, initial encounter
T43.593A Poisoning by other antipsychotics and neuroleptics, assault, initial encounter
T43.594A Poisoning by other antipsychotics and neuroleptics, undetermined, initial encounter
T43.601A Poisoning by unspecified psychostimulants, accidental (unintentional), initial encounter
T43.602A Poisoning by unspecified psychostimulants, intentional self-harm, initial encounter
T43.603A Poisoning by unspecified psychostimulants, assault, initial encounter
T43.604A Poisoning by unspecified psychostimulants, undetermined, initial encounter
T43.611A Poisoning by caffeine, accidental (unintentional), initial encounter
T43.612A Poisoning by caffeine, intentional self-harm, initial encounter
T43.613A Poisoning by caffeine, assault, initial encounter
T43.614A Poisoning by caffeine, undetermined, initial encounter
T43.621A Poisoning by amphetamines, accidental (unintentional), initial encounter
T43.622A Poisoning by amphetamines, intentional self-harm, initial encounter
T43.623A Poisoning by amphetamines, assault, initial encounter
T43.624A Poisoning by amphetamines, undetermined, initial encounter
T43.631A Poisoning by methylphenidate, accidental (unintentional), initial encounter
T43.632A Poisoning by methylphenidate, intentional self-harm, initial encounter
T43.633A Poisoning by methylphenidate, assault, initial encounter
T43.634A Poisoning by methylphenidate, undetermined, initial encounter
T43.651A Poisoning by methamphetamines accidental (unintentional), initial encounter
T43.652A Poisoning by methamphetamines intentional self-harm, initial encounter
T43.653A Poisoning by methamphetamines, assault, initial encounter
T43.654A Poisoning by methamphetamines, undetermined, initial encounter
T43.691A Poisoning by other psychostimulants, accidental (unintentional), initial encounter
T43.692A Poisoning by other psychostimulants, intentional self-harm, initial encounter
T43.693A Poisoning by other psychostimulants, assault, initial encounter
T43.694A Poisoning by other psychostimulants, undetermined, initial encounter
T43.8X1A Poisoning by other psychotropic drugs, accidental (unintentional), initial encounter
T43.8X2A Poisoning by other psychotropic drugs, intentional self-harm, initial encounter
T43.8X3A Poisoning by other psychotropic drugs, assault, initial encounter
T43.8X4A Poisoning by other psychotropic drugs, undetermined, initial encounter
T43.91XA Poisoning by unspecified psychotropic drug, accidental (unintentional), initial encounter
T43.92XA Poisoning by unspecified psychotropic drug, intentional self-harm, initial encounter
T43.93XA Poisoning by unspecified psychotropic drug, assault, initial encounter
T43.94XA Poisoning by unspecified psychotropic drug, undetermined, initial encounter
T45.0X1A Poisoning by antiallergic and antiemetic drugs, accidental (unintentional), initial encounter
T45.0X2A Poisoning by antiallergic and antiemetic drugs, intentional self-harm, initial encounter
T45.0X3A Poisoning by antiallergic and antiemetic drugs, assault, initial encounter
T45.0X4A Poisoning by antiallergic and antiemetic drugs, undetermined, initial encounter
T46.0X1A Poisoning by cardiac-stimulant glycosides and drugs of similar action, accidental (unintentional), initial encounter
T46.0X2A Poisoning by cardiac-stimulant glycosides and drugs of similar action, intentional self-harm, initial encounter
T46.0X3A Poisoning by cardiac-stimulant glycosides and drugs of similar action, assault, initial encounter
T46.0X4A Poisoning by cardiac-stimulant glycosides and drugs of similar action, undetermined, initial encounter
T50.901A Poisoning by unspecified drugs, medicaments and biological substances, accidental (unintentional), initial encounter
T50.902A Poisoning by unspecified drugs, medicaments and biological substances, intentional self-harm, initial encounter
T50.903A Poisoning by unspecified drugs, medicaments and biological substances, assault, initial encounter
T50.904A Poisoning by unspecified drugs, medicaments and biological substances, undetermined, initial encounter
T50.911A Poisoning by multiple unspecified drugs, medicaments and biological substances, accidental (unintentional), initial encounter
T50.912A Poisoning by multiple unspecified drugs, medicaments and biological substances, intentional self-harm, initial encounter
T50.913A Poisoning by multiple unspecified drugs, medicaments and biological substances, assault, initial encounter
T50.914A Poisoning by multiple unspecified drugs, medicaments and biological substances, undetermined, initial encounter
T50.915A Adverse effect of multiple unspecified drugs, medicaments and biological substances, initial encounter
Z03.89 Encounter for observation for other suspected diseases and conditions ruled out
Z51.81 Encounter for therapeutic drug level monitoring
Z79.3 Long term (current) use of hormonal contraceptives
Z79.891 Long term (current) use of opiate analgesic
Z79.899 Other long term (current) drug therapy
Z91.141 Patient's other noncompliance with medication regimen due to financial hardship
Z91.148 Patient's other noncompliance with medication regimen for other reason
Z91.190 Patient's noncompliance with other medical treatment and regimen due to financial hardship
Z91.198 Patient's noncompliance with other medical treatment and regimen for other reason
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10-CM Codes that Support Medical Necessity” section of this article.

Group 1 Codes
Code Description
XX000 Not Applicable
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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2024 R7

Article revised and published on 10/24/2024 effective for dates of service on and after 10/01/2024 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM codes have been deleted and therefore have been removed from the article in Code Group 1: M51.36 and M51.37. The following ICD-10-CM codes have been added to the article in Code Group 1: M51.360, M51.361, M51.362, M51.369, M51.370, M51.371, M51.372, and M51.379.

10/01/2023 R6

Article revised and published on 10/26/2023 effective for dates of service on and after 10/01/2023 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code has been deleted and therefore has been removed from the article: I47.1 in Code Group 1. The following ICD-10-CM codes have been added to the article: I47.11, I47.19, R40.2A in Code Group 1.

04/01/2023 R5

Article revised and published on 04/06/2023 effective for dates of service on and after 04/01/2023 to reflect an ICD-10-CM Code Update. The following ICD-10-CM codes have been added to the Article: Z91.141 and Z91.148 in ICD-10-CM Group 1.

10/01/2022 R4

Article revised and published on 10/20/2022 effective for dates of service on and after 10/01/2022 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM codes have been added to the article: E87.21, E87.22, E87.29, I47.21, I47.29, T43.651A, T43.652A, T43.653A, T43.654A, Z91.190 and Z91.198 in Group 1. The following ICD-10-CM codes have been deleted and therefore have been removed from the article: E87.2, I47.2 and Z91.19 in Group 1.

10/01/2021 R3

Article revised and published on 10/14/2021 effective for dates of service on and after 10/01/2021 to reflect the Annual ICD-10-CM Code Updates.

The following ICD-10 code(s) have been deleted and therefore have been removed from the Group 1 ICD-10-CM Codes that Support Medical Necessity: M54.5, T40.7X1A, T40.7X2A, T40.7X3A, and T40.7X4A

The following ICD-10-CM code(s) have been added to the Group 1 ICD-10-CM Codes that Support Medical Necessity: M54.50, M54.51, M54.59, T40.711A, T40.712A, T40.713A, T40.714A, T40.721A, T40.722A, T40.723A and T40.724A

10/01/2020 R2

Revision Number: 2
Publication: September 2020 Connection
LCR A/B2020-065

Explanation of revision: Based on CR 11895 and CR 11845 (Annual 2021 ICD-10-CM Update), ICD-10 Codes T40.4X1A, T40.4X2A, T40.4X3A, and T40.4X4A were removed and ICD-10 Codes F10.130, F10.131, F10.132, F11.13, F12.13, F13.130, F13.131, F13.132, F14.13, F14.93, F15.13, F19.130, F19.131, F19.132, M25.59, T40.491A, T40.491D, T40.492A, T40.492D, T40.493A, T40.493D, T40.494A, T40.494D, T40.495A, T40.495D, T40.496A, and T40.496D were added to the “ICD-10 Codes that Support Medical Necessity/Group 1 Codes:” section of this billing and coding article. Additional formatting changes have been made throughout the document. The effective date of this revision is based on date of service.

03/06/2020 R1

Revision Number: 1
Publication: March 2020 Connection
LCR A/B2020-017

Explanation of revision: Based on review of the billing and coding article, the “CPT/HCPCS Codes/Group 1 Codes:” and “ICD-10 Codes that Support Medical Necessity/Group 1 Paragraph:” sections of the billing and coding article were revised to remove CPT code 83789 as it is not a test for drugs. The effective date of this revision is for claims processed on or after 03/06/2020, for dates of service on or after 01/01/16.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
10/18/2024 10/01/2024 - N/A Currently in Effect You are here
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