CMS Pub. 100-04, ch. 32, § 90.2.1

Applicable

(Rev. 11035, Issued:10-13-21, Effective: 11-17-21; Implementation: 11-17-21)

ICD-10 is applicable to services on and after the implementation of ICD-.

For services provided use the appropriate code from the ICD-10 CM codes the table below..

See §90.2 for a list of covered conditions

ICD-10 Description

C91.00 Acute lymphoblastic leukemia not having achieved remission

C91.01 Acute lymphoblastic leukemia, in remission

C91.02 Acute lymphoblastic leukemia, in relapse

C91.10 Chronic lymphocytic leukemia of B-cell type not having achieved remission

C91.11 Chronic lymphocytic leukemia of B-cell type in remission

C91.12 Chronic lymphocytic leukemia of B-cell type in relapse

C91.30 Prolymphocytic leukemia of B-cell type not having achieved remission

C91.31 Prolymphocytic leukemia of B-cell type, in remission

C91.32 Prolymphocytic leukemia of B-cell type, in relapse

C91.50 Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved

remission

C91.51 Adult T-cell lymphoma/leukemia (HTLV-1-associated), in remission

C91.52 Adult T-cell lymphoma/leukemia (HTLV-1-associated), in relapse

C91.60 Prolymphocytic leukemia of T-cell type not having achieved remission

C91.61 Prolymphocytic leukemia of T-cell type, in remission

C91.62 Prolymphocytic leukemia of T-cell type, in relapse

C91.90 Lymphoid leukemia, unspecified not having achieved remission

C91.91 Lymphoid leukemia, unspecified, in remission

C91.92 Lymphoid leukemia, unspecified, in relapse

C91.A0 Mature B-cell leukemia Burkitt-type not having achieved remission

C91.A1 Mature B-cell leukemia Burkitt-type, in remission

C91.A2 Mature B-cell leukemia Burkitt-type, in relapse

C91.Z0 Other lymphoid leukemia not having achieved remission

C91.Z1 Other lymphoid leukemia, in remission

C91.Z2 Other lymphoid leukemia, in relapse

C92.00 Acute myeloblastic leukemia, not having achieved remission

C92.01 Acute myeloblastic leukemia, in remission

C92.02 Acute myeloblastic leukemia, in relapse

C92.10 Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission

C92.11 Chronic myeloid leukemia, BCR/ABL-positive, in remission

C92.12 Chronic myeloid leukemia, BCR/ABL-positive, in relapse

C92.20 Atypical chronic myeloid leukemia, BCR/ABL-negative, not having achieved

remission

C92.21 Atypical chronic myeloid leukemia, BCR/ABL-negative, in remission

C92.22 Atypical chronic myeloid leukemia, BCR/ABL-negative, in relapse

C92.30 Myeloid sarcoma, not having achieved remission

C92.31 Myeloid sarcoma, in remission

C92.32 Myeloid sarcoma, in relapse

C92.40 Acute promyelocytic leukemia, not having achieved remission

C92.41 Acute promyelocytic leukemia, in remission

C92.42 Acute promyelocytic leukemia, in relapse

C92.50 Acute myelomonocytic leukemia, not having achieved remission

C92.51 Acute myelomonocytic leukemia, in remission

C92.52 Acute myelomonocytic leukemia, in relapse

C92.60 Acute myeloid leukemia with 11q23-abnormality not having achieved

remission

C92.61 Acute myeloid leukemia with 11q23-abnormality in remission

C92.62 Acute myeloid leukemia with 11q23-abnormality in relapse

C92.90 Myeloid leukemia, unspecified, not having achieved remission

C92.91 Myeloid leukemia, unspecified in remission

C92.92 Myeloid leukemia, unspecified in relapse

C92 A0 Acute myeloid leukemia with multilineage dysplasia not having achieved

C92.Z0 Other myeloid leukemia not having achieved remission

C92.Z1 Other myeloid leukemia, in remission

C92.Z2 Other myeloid leukemia, in relapse

C93.00 Acute monoblastic/monocytic leukemia, not having achieved remission

C93.01 Acute monoblastic/monocytic leukemia, in remission

C93.02 Acute monoblastic/monocytic leukemia, in relapse

C93.10 Chronic myelomonocytic leukemia not having achieved remission

C93.11 Chronic myelomonocytic leukemia, in remission

C93.12 Chronic myelomonocytic leukemia, in relapse

C93.30 Juvenile myelomonocytic leukemia, not having achieved remission

C93.31 Juvenile myelomonocytic leukemia, in remission

C93.32 Juvenile myelomonocytic leukemia, in relapse

C93.90 Monocytic leukemia, unspecified, not having achieved remission

C93.91 Monocytic leukemia, unspecified in remission

C93.92 Monocytic leukemia, unspecified in relapse

C93.Z0 Other monocytic leukemia, not having achieved remission

C93.Z1 Other monocytic leukemia, in remission

C93.Z2 Other monocytic leukemia, in relapse

C94.00 Acute erythroid leukemia, not having achieved remission

C94.01 Acute erythroid leukemia, in remission

C94.02 Acute erythroid leukemia, in relapse

C94.20 Acute megakaryoblastic leukemia not having achieved remission

C94.21 Acute megakaryoblastic leukemia, in remission

C94.22 Acute megakaryoblastic leukemia, in relapse

C94.30 Mast cell leukemia not having achieved remission

C94.31 Mast cell leukemia, in remission

C94.32 Mast cell leukemia, in relapse

C94.80 Other specified leukemias not having achieved remission

C94.81 Other specified leukemias, in remission

C94.82 Other specified leukemias, in relapse

C95.00 Acute leukemia of unspecified cell type not having achieved remission

C95.01 Acute leukemia of unspecified cell type, in remission

C95.02 Acute leukemia of unspecified cell type, in relapse

C95.10 Chronic leukemia of unspecified cell type not having achieved remission

C95.11 Chronic leukemia of unspecified cell type, in remission

C95.12 Chronic leukemia of unspecified cell type, in relapse

C95.90 Leukemia, unspecified not having achieved remission

C95.91 Leukemia, unspecified, in remission

C95.92 Leukemia, unspecified, in relapse

D45 Polycythemia vera

III. For the treatment of aplastic anemia; see table below for

ICD-10- CM codes)

If ICD-10-CM is applicable, the following ranges of ICD-10-CM

codes are also covered for AuSCT:

• Resistant non-Hodgkin’s lymphomas, ICD-10-CM

diagnosis codes C82.01-C85.29, C85.81- C86.6, C96.4, and

C96.Z-C96.9.

• Tandem transplantation (multiple rounds of autologous

stem cell transplantation) for patients with multiple

myeloma, ICD-10-CM codes C90.00, C90.01, C90.02

and D47.Z9

NOTE: The following conditions are not covered:

• Acute leukemia not in remission

• Chronic granulocytic leukemia

• Solid tumors (other than neuroblastoma)

• Multiple myeloma

• For Medicare beneficiaries age 64 or older, all forms of

amyloidosis, primary and non-primary

• Non-primary amyloidosis

Also coverage for conditions other than those specifically designated as

covered in §90.2 or specifically designated as non-covered in this

section or in §90.3will be at the discretion of the individual contractor.

ICD-10 Description

D60.0 Chronic acquired pure red cell aplasia

D60.1 Transient acquired pure red cell aplasia

D60.8 Other acquired pure red cell aplasias

D60.9 Acquired pure red cell aplasia, unspecified

D61.01 Constitutional (pure) red blood cell aplasia

D61.09 Other constitutional aplastic anemia

D61.1 Drug-induced aplastic anemia

D61.2 Aplastic anemia due to other external agents

D61.3 Idiopathic aplastic anemia

D61.810 Antineoplastic chemotherapy induced pancytopenia

D61.811 Other drug-induced pancytopenia

D61.818 Other pancytopenia

D61.82 Myelophthisis

D61.89 Other specified aplastic anemias and other bone marrow failure syndromes

D61.9 Aplastic anemia, unspecified