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I am a licensed medical professional. I acknowledge that the test
requested herein is medically necessary and the patient is eligible
for the test. I attest that the documentation of medical necessity for
tests ordered is documented in the patient’s medical record, which
will be made available upon request of performing laboratory and/or
third-party payer. Note: Tests not ordered by the physician who is
treating the beneficiary are not reimbursable. Order codes are updated
but CPT Codes are not impacted.
3452 Lake Lynda Dr Building 100
Orlando, FL 32817
ICD-10 Codes (ICD Diagnosis codes are mandatory):
The following commonly used diagnosis codes are listed as a
convenience only. Ordering physicians should use ICD-10 codes that
best describe the reason for performing tests, whether or not that
code is listed below.
B18.0 Chronic viral hepatitis B with delta-agentB18.1 Chronic viral hepatitis B without delta-agentB18.2 Chronic viral hepatitis CB18.8 Other chronic viral hepatitisK70.0 Alcoholic fatty LiverK70.2 Alcoholic fibrosis and sclerosis of liverK73.0 Chronic persistent hepatitis, not elsewhere classifiedK73.1 Chronic lobular hepatitis, not elsewhere classifiedK73.2 Chronic active hepatitis, not elsewhere classifiedR94.5 Abnormal results of liver function studiesK74.0 Hepatic fibrosisK74.1 Hepatic sclerosisK74.2 Hepatic fibrosis with hepatic sclerosisK74.3 Primary biliary cirrhosisK74.4 Secondary biliary cirrhosisK74.69 Other cirrhosis of liverK75.4 Autoimmune hepatitisK75.81 Nonalcoholic steatohepatitis (NASH)K76.0 Fatty(change of) liver not elsewhere classified
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