Allowable Covered Diagnosis Codes

60.4.1 – Allowable Covered Diagnosis Codes (Rev.10881; Issued: 08-06-2021; Effective: 09-07-2021; Implementation: 09-07- 2021) For services furnished on or after the implementation of ICD-10 the applicable ICD-10-CM diagnosis codes for this benefit are: ICD-10-CM Code Code Description 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 I26.01 Septic pulmonary embolism with acute cor pulmonale 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 I48.21 Permanent atrial fibrillation I67.6 Nonpyogenic thrombosis of intracranial venous system 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 I80.211 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 I80.221 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 I80.231 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 I80.241 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 I80.251 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 I80.291 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 I82.0 Budd-Chiari syndrome 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 I82.411 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 I82.421 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 I82.431 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 I82.441 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 I82.451 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 I82.461 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 I82.491 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 I82.511 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 I82.521 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 I82.531 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 I82.541 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 I82.551 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 I82.561 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 I82.591 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 I82.621 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 I82.721 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 I82.890 Acute embolism and thrombosis of other specified veins I82.891 Chronic embolism and thrombosis of other specified veins 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.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.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.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.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.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 O87.3 Cerebral venous thrombosis in the puerperium 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 Coverage policy can be found in Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, section 190.11 PT/INR. (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp