Required Medical Evidence for Specific ICD-9 Codes

 

 

► Cases determined to have the following ICD-9 codes 240.0-246.9 (Disorder of the Thyroid gland) must have the following reported within the past year before impairment rating can take place:

*       Note from Physician with the following information:

·    Current symptoms

·         Physical exam findings of the area(s) affected

·    Any Biopsy information

·    Surgical history of site

 

► Cases determined to have the following ICD-9 code 280.0-285.9 (Anemia) must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

·         Current symptoms

·         Need for transfusion and the intervals involved

·         Current treatment(s) including prescriptions

o        Complete Blood Count with differential (CBC with Diff)

 

► Cases determined to have the following ICD-9 code 333.0-333.99 (Tremor) must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

·         Current symptoms

·         Physical exam findings of the area(s) affected:

o        Motor strength

o        Coordination

o        Dexterity

·         Functional Activity pertaining to Activity of Daily Living (ADL):

o        Buttoning shirt

o        Lacing shoes

o        Performing peg tasks

·         Current treatment(s)

 

► Cases determined to have the following ICD-9 codes 356.0- 357.9 (Peripheral Neuropathy, Polyneuropathy) must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

·         Current symptoms

·         Physical exam findings of the Upper Extremities

o        Motor strength

o        Coordination

o        Dexterity

·         Functional Activity pertaining to Activity of Daily Living (ADL):

o        Buttoning shirt

o        Lacing shoes

o        Performing peg tasks

·         Physical exam findings of the Lower Extremity

o        Motor strength

o        Coordination

·         Functional Activity pertaining to Activity of Daily Living (ADL): (Upper extremities)

o        Standing (with/without mechanical support and/or assistive device)

o        Walking

§         With/without assistance

§         Ability to start and stop walking

§         Limited to level surface

§         Difficulty with elevation/stairs

o        Loss of stature

o        Romberg Sign

·         Current treatment(s)

*       Electromyography (EMG)

 

► Cases determined to have the following ICD-9 code 362.0-362.9 and 366.0-366.9 (Cataracts) must have the following reported within the past year before impairment rating can take place:

Note from Physician with the following information:

*       Current symptoms

·         Physical exam findings

·         Current treatment(s)

·         Surgical procedure(s)

*       Visual Acuity testing, corrected

*       Visual Field testing

 

► Cases determined to have the following ICD-9 codes 389.0-389.9 (Hearing loss) must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

·    Current symptoms

·         Physical exam findings of the area(s) affected

*       Tympanometry

*       Speech Discrimination test

*       Pure Tone Audiogram of both ears

 

► Cases determined to have the following ICD-9 code 473.0-473.9 (Chronic Sinusitis) must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

·    Current symptoms including: headaches, balance problems

·         Physical exam findings of the area(s) affected

·    Current treatment(s) including prescriptions

*       Sinus CT

 

► Cases determined to have the following ICD-9 code 477.0-477.9 (Allergic Rhinitis) must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

·    Current symptoms including headaches, balance problems

·         Physical exam findings of the area(s) affected

·    Current treatment(s) including prescriptions

 

► Cases determined to have the following ICD-9 codes 491.0- 493.92, 496, 501, 506.0-506.9, 508.0-508.9, 511.0-511.9, 515, 518.0-518.89 (Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Bronchitis, Asbestosis, Chronic Respiratory condition) must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information

·         Current symptoms

·         Physical exam findings of the area(s) affected

·         Current treatment(s) including prescriptions

*       Pulmonary Function Test (PFT) with DLCO with pre/post bronchodilator

 

► Cases determined to have the following ICD-9 codes 571.0-573.9 (Liver Disease) must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

·         Current symptoms

·         Physical exam findings of the area(s) affected

·         Any Biopsy information

·         Surgical history of site

·         Nutritional Status and/or restrictions

·         Current treatment(s) including prescriptions

*       Liver Function Test (LFTs)

► Cases determined to have the following ICD-9 codes 580.0-593.9 (Upper Genitourinary Disease) must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

·         Current symptoms

·         Physical exam findings of the area(s) affected

·         Any Biopsy information

·         Surgical history

·         Current treatment(s) including prescriptions

·         Need for Dialysis and its schedule

·         Nutritional Status and/or restrictions

*       Kidney Function Test (Creatinine Clearance Test)

*       Serum Creatinine

*       Urine Analysis

 

► Cases determined to have the following ICD-9 codes 595.0-596.9 (Bladder Disease) must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

·         Current signs/symptoms (frequency, nocturia, loss of control, urgency, dribbling)

·         Physical exam findings of the area(s) affected

·         Any Biopsy information

·         Surgical history

·         Current treatment(s) including prescriptions

 

► Cases determined to have the following ICD-9 codes 692.0-697.9, 703.0-703.9, and 782.0-782.9 (Dermatitis, Skin Rash) must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

·         Current symptoms

·         Physical exam findings of the area in question

·         Activities of Daily Living (ADLs)

·         Current treatment(s)

·         Patch testing information when available

 `

Cancers

(in alphabetical order)

 

All information has to be submitted in the past 12 months including the diagnostic tests.

 

 Bladder Cancer

* Note from Physician with the following information:

·         Current symptoms to include urinary frequency/nocturia, reflex activity of the bladder

·         Physical exam findings of the area(s) affected

·         Remission status and number of years in remission

·         Surgical History to the area

·         Activities of Daily Living (ADLs)

·         Current treatment(s)

 

Breast Cancer in Women of Childbearing years (Individual ages 15-44 years of age)

 * Note from Physician with the following information:

·         Current symptoms

·         Physical exam findings of the area(s) affected

·         Remission status and number of years in remission

·         Surgical History to the area

·         Activities of Daily Living (ADLs)

·         Current treatment(s)

 

Breast Cancer in Men and Women beyond childbearing years (older than 44 years old)

Not ratable under 5th Edition of the Guides

 

Colon Cancer

 * Note from Physician with the following information:

·         Current symptoms including weight loss and percentage

·         Presence of any stomas

·         Physical exam findings of the area(s) affected

·         Remission status and number of years in remission

·         Surgical History to the area

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

 

 

Esophogeal Cancer

 * Note from Physician with the following information:

·         Current symptoms including weight loss and percentage

·         Presence of any stomas

·         Physical exam findings of the area(s) affected

·         Remission status and number of years in remission

·         Surgical History to the area

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

 

Gallbladder Cancer

 * Note from Physician with the following information:

·         Current symptoms including weight loss and percentage, and jaundice

·         Presence of any stomas

·         Physical exam findings of the area(s) affected

·         Remission status and number of years in remission

·         Surgical History to the area

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

*       Liver Function Tests (LFTs)

 

Hodgkin’s Lymphoma

*       Note from Physician with the following information:

·         Current symptoms including weight loss and percentage

·         Physical exam findings of the area(s) affected

·         Remission status and number of years in remission

·         Surgical History to the area

·         Activities of Daily Living (ADLs)

·         Current treatment(s)

* Complete Blood Count (CBC) with differential

* Pathology report if available

 

Hypo-pharyngeal Cancer

*       Note from Physician with the following information:

·         Current symptoms including weight loss and percentage

·         Physical exam findings of the area(s) affected

·         Remission status and number of years in remission

·         Presence of any stomas

·         Surgical History to the area

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

·         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü       Audibility

ü       Intelligibility

ü       Functional Efficiency

 

 

Laryngeal Cancer

*       Note from Physician with the following information:

·         Current symptoms including nutritional status, weight loss and percentage

·         Physical exam findings

·         Surgical history to the area

·         Presence of any stomas

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

·         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü       Audibility

ü       Intelligibility

ü       Functional Efficiency

Leukemias (includes Acute/Chronic Lymphocytic Leukemia (ALL/CLL) and Acute/Chronic Myelocytic Leukemia (AML/CML))

*       Note from Physician with the following information:

·         Current symptoms including nutritional status, weight loss and percentage

·         Physical exam findings including any liver or spleen abnormalities

·         Activities of Daily Living (ADLs)

·         Current treatment(s)

*       Complete Blood Count (CBC) with differential

*       Liver Function Tests (LFTs)

 

Liver Cancer

*       Note from Physician with the following information:

·         Current symptoms including nutritional status, weight loss and percentage, presence of jaundice

·         Physical exam findings of the area(s) affected including presence of ascites

·         Surgical history to the area

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

*       Liver Function Tests (LFTs)

Lung Cancer

*       Note from Physician with the following information:

·         Current symptoms including nutritional status, weight loss and percentage

·         Physical exam findings

·         Surgical history to the area

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

*       Pulmonary Function Test (PFT)

 

Multiple Myeloma

*       Note from Physician with the following information:

·         Current symptoms including nutritional status, weight loss and percentage

·         Physical exam findings including any spleen abnormalities

·         Activities of Daily Living (ADLs)

·         Current treatment(s)

*       Complete Blood Count (CBC) with differential

 

Mylodysplastic Syndrome

*       Note from Physician with the following information:

·         Current symptoms including nutritional status, weight loss and percentage

·         Physical exam findings including any spleen abnormalities

·         Activities of Daily Living (ADLs)

·         Current treatment(s)

*       Complete Blood Count (CBC) with differential

 

Nasal Cancer

*       Note from Physician with the following information:

·         Current symptoms including nutritional status, weight loss and percentage

·         Physical exam findings

·         Surgical history to the area

·         Presence of any stomas

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

·         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü       Audibility

ü       Intelligibility

ü       Functional Efficiency

 

Nasopharyngeal

*       Note from Physician with the following information:

·         Current symptoms including weight loss and percentage

·         Physical exam findings of the area(s) affected

·         Remission status and number of years in remission

·         Presence of any stomas

·         Surgical History to the area

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

·         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü       Audibility

ü       Intelligibility

ü       Functional Efficiency

 

Kidney Cancer

                See Renal Cancer

 

Pancreatic Cancer

 * Note from Physician with the following information:

·         Current symptoms including weight loss and percentage, and jaundice

·         Physical exam findings of the area(s) affected

·         Remission status and number of years in remission

·         Surgical History to the area

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

*       Liver and Pancreatic Function Tests

 

Pharyngeal Cancer

*       Note from Physician with the following information:

·         Current symptoms including weight loss and percentage

·         Physical exam findings of the area(s) affected

·         Remission status and number of years in remission

·         Presence of any stomas

·         Surgical History to the area

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

·         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü       Audibility

ü       Intelligibility

ü       Functional Efficiency

 

Polycythemia Vera

*       Note from Physician with the following information:

·         Current symptoms including nutritional status, weight loss and percentage

·         Physical exam findings including any spleen abnormalities

·         Activities of Daily Living (ADLs)

·         Current treatment(s)

*       Complete Blood Count (CBC) with differential

Prostate Cancer

*       Note from Physician with the following information:

·         Current symptoms including nutritional status, weight loss and percentage along with urinary control and sexual function after surgery if prostatectomy was performed

·         Physical exam findings including pain induced by metastatic lesions

·         Activities of Daily Living (ADLs)

·         Surgical history to the affected area

·         Current treatment(s)

 

Renal Cancer

*       Note from Physician with the following information:

·         Current symptoms including nutritional status, weight loss and percentage

·         Physical exam findings

·         Need for dialysis and schedule

·         Kidney transplant

·         Surgical history to the affected area

·         Presence of any stomas

·         Activities of Daily Living (ADLs)

·         Current treatment(s)

*       Kidney Function Test (Creatinine Clearance Test)

*       Serum Blood Urea Nitrogen (BUN) and Creatinine

*       Urine Analysis

 

Skin Cancer

*       Note from Physician with the following information:

·         Current symptoms

·         Physical exam findings of the area(s) affected

·         Physical exam findings of the area in question

·         Activities of Daily Living (ADLs)

·         Current treatment(s)

 

Small Intestinal Cancer (duodenum, jejunum, ileum)

*       Note from Physician with the following information:

·         Current symptoms including weight loss and percentage

·         Presence of any stomas

·         Physical exam findings of the area(s) affected

·         Remission status and number of years in remission

·         Surgical History to the area

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

 

Thyroid Cancer

*       Note from Physician with the following information:

·         Current symptoms including weight loss and percentage

·         Physical exam findings of the area(s) affected

·         Remission status and number of years in remission

·         Surgical History to the area

·         Activities of Daily Living (ADLs)

·         Current treatment(s) and presence of other illnesses allowing for only partial hormone replacement

 

 

Tongue Cancer

*       Note from Physician with the following information:

·         Current symptoms including weight loss and percentage

·         Physical exam findings of the area(s) affected

·         Remission status and number of years in remission

·         Surgical History to the area

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

·         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü       Audibility

ü       Intelligibility

ü       Functional Efficiency

 

 

 

 

 

Tracheal Cancer

*       Note from Physician with the following information:

·         Current symptoms including nutritional status, weight loss and percentage

·         Physical exam findings

·         Surgical history to the area

·         Presence of any stomas

·         Activities of Daily Living (ADLs) to include any limitation on diet

·         Current treatment(s)

·         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü       Audibility

ü       Intelligibility

ü       Functional Efficiency