Wtc 5

WTC-5 Medical Code Request Form
(ex: ICD, CPT, HCPCS, DME)

Submission Instructions: Please complete this form and send it to the World Trade Center
Health Program at [email protected]. Please do not include any member personally
identifiable information (PII). Incomplete forms will be sent back for more information.

Requester Information

Request Date

Choose a CCE/NPN

Requester Name

Requester E-mail

Requester Phone

Clinical Director Name

Clinical Director Signature

Request Urgency

Urgency Rationale

Urgent
Routine

Code Request Information

Code Type

Code Number

Code Description

Rationale: Please describe the medical condition or procedure/service represented by this code. Please also
include medical/scientific evidence-based information on the medical necessity of this code and its relationship
to a WTC-related/medically associated condition. If request is for an ICD code addition as a WTC–Associated
condition, please note to which WTC-related condition it is being associated and how it is associated
(progression of the WTC-related condition, due to treatment of the WTC-related condition, etc.). Please identify
any additional benefit that this code would provide to the WTCHP in relation to similar codes that are already
available through the program.

Requested Codebook Placement

Condition Type
Placement for ICD Code Request

Adjustment Disorder
Anxiety
Cancer Diagnostics
Cancer Treatment
Depression
Diagnostics
Gastroesophageal Reflux Disease
Interstitial Lung Disease (including Sarcoid)
Monitoring
Musculoskeletal Disorders
Obstructive Airway Disease
Post Traumatic Stress Disorder
Substance Abuse
Survivor Screening
Upper Respiratory Disease
Other

Placement for Procedure Code Request

Cancer Diagnostics
Cancer Treatment
Diagnostics
Monitoring
Survivor Screening
Treatment

CCE/NPN Clinical Director Comments and Approval of Request

CCE/NPN Clinical Director Comments:

CCE/NPN Clinical Director Signature and Credentials

Date Signed: