CPT j codes - Drugs and Biologicals, Non-Chemotherapeutic

This LCD explains the coverage criteria for selected drugs and biologicals. The agents discussed in this LCD in no way constitute a complete list of drugs and biologicals covered by Medicare. Contractors implement LCDs to apply the standard of reasonable and necessary in situations not covered by specific national policy. In particular, coverage criteria for drugs used to treat cancer, immune deficiency syndromes, as well as acute and chronic treatments of eye disease are explained in separate LCDs and are not included in this LCD. This LCD has been promulgated to establish the clinical conditions for which the included drugs are considered to be safe and effective and otherwise medically reasonable and necessary and, thus, covered by Medicare.
Note: This LCD and the related Article do NOT describe drug and biological coverage under the Medicare Part D benefit.
Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 50, describes national policy regarding Medicare guidelines for coverage of drugs and biologicals. The pertinent national policy can be referenced in the attached Article.
Effective for dates of service on or after January 1, 2008, all claims for administration of Part B anti-anemia drugsother than Erythropoiesis Stimulating Agents (ESAs) used in the treatment of cancer that are not self-administered shall require the most recent Hematocrit (HCT) and/or Hemoglobin (Hgb). This requirement will be implemented for claims received on or after April 7, 2008. Refer to Claims Processing Manual Pub. 100-04, Chapter 17, Section 80.8, for further coverage/coding guidance. See the limited coverage below for codes J1750 (use for services provided on or after January 1, 2009; use J1751 and J1752 for services provided January 1 through March 31, 2008; use Q4098 for services provided April 1 through December 31, 2008), J1756 and J2916.
Zoledronic acid for Osteoporosis:
Medicare covers zoledronic acid for certain people with osteoporosis who are unable to take an oral bisphosphonate because of a medical or surgical condition, such as those people:
  • Who have severe esophageal disease (e.g., ulcerations, strictures).
    • Use ICD-9-CM codes 530.0, 530.20-530.21, 530.3 and 710.1.
  • Who are unable to take anything by mouth.
    • Use ICD-9-CM codes 530.87, V44.1, V45.72 and V45.75.
  • Who are unable to sit or stand for prolonged periods.
    • Use ICD-9-CM code V49.84.
  • Who are unable to take an oral bisphosphonate for other special medical circumstances that justify the method of administration.
    • Use codes 995.29 and V12.79.
The person must have osteoporosis as evidenced by a spine, hip or pelvis Bone Mineral Density (BMD) T-score -2.5 or a low-trauma hip fracture or a 10-year all major osteoporosis-related fracture probability of ≥ 20 percent based on the U.S.-adapted World Health Organization (WHO) absolute fracture risk model (FRAX®). When intravenous zoledronic acid is used, the medical record must clearly reflect that the parenteral agent, rather than the oral agent, is the medically prudent choice.
Parenteral Iron Supplementation:
Medicare expects that most patients with iron deficiency will not require parenteral iron supplementation. Medicare coverage for parenteral iron products is limited to parenteral iron administered to iron-deficient patients in whom oral and/or enteral (if applicable) iron or enteral iron therapy has been demonstrated to have been ineffective, or in other clinical circumstances (such as the need for large iron doses not possible via oral/enteral administration or the need for more rapid repletion of iron stores than possible via oral/enteral administration in patients with severe symptomatic iron deficiency).
Self-Administration of Drug or Biological
Drugs provided during acute inpatient stays and qualified skilled nursing facility stays are generally covered if Medicare requirements are met. Coverage of drugs and biologicals under Part B is generally limited to the type of drugs that cannot be self-administered and meet “incident to” requirements. One requirement for coverage of drugs and biologicals is that the drug must be of a type that is usually not self-administered. Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 50.2, gives guidance for determining whether a drug or biological is considered self-administered, or access our Web site at http://www.trailblazerhealth.com/Medicare.aspx, select “Specialty Services,” “Drugs-Biologicals” and then “Self-Administered Drugs.”
Immunizations
Immunizations are not covered unless the medication is directly related to the treatment of an injury or there is direct exposure to a disease or condition. Preventive immunizations are specifically not covered with the exception of influenza, pneumococcal and hepatitis B vaccines. See national reference in attached article and in the “Immunizations – 4I-83” LCD.
Drug Wastage
Medicare provides payment for the discarded drug/biological remaining in a single-use drug product after administering what is reasonable and necessary for the patient’s condition. If the physician has made good faith efforts to minimize the unused portion of the drug/biological in how patients are scheduled and how he ordered, accepted, stored and used the drug, and made good faith efforts to minimize the unused portion of the drug in how it is supplied, the program will cover the amount of drug discarded along with the amount administered. Documentation requirements are given below. Coding and billing instructions can be referenced in attached article. Refer to national policy: Medicare Claims Processing Manual – Pub. 100-04, Chapter 17, Section 40.
Note: The JW modifier is not used on claims for drugs or biologicals provided under the Competitive Acquisition Program (CAP). Reference to national policy: Medicare Claims Processing Manual, Pub. 100-04, Chapter 17, Section 100.2.9.
LCD Individual Consideration
Certain unusual uses of certain drugs may be covered on an “LCD Individual Consideration” basis. Such situations are described in the notes under the limited coverage for each drug. Instructions on submitting a redetermination for “LCD Individual Consideration” are given in the attached article.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 18X, 21X, 22X, 23X, 28X, 71X, 72X, 73X, 75X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
025X, 0636
CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
J0129
Injection, abatacept, per 10 mg
J0150
Injection, adenosine for therapeutic use, 6 mg (not to be used to report any adenosine phosphate compounds; instead use A9270)
J1212
Injection, dimethyl sulfoxide (DMSO), 50%, 50 ml
J1260
Injection, dolasetron mesylate, 10 mg
J1300
Injection, eculizumab, 10 mg
J1450
Injection, fluconazole, 200 mg
J1645
Injection, dalteparin sodium, per 2,500 IU
J1650
Injection, enoxaparin sodium, 10 mg
J1652
Injection, fondaparinux sodium, 0.5 mg
J1655
Injection, tinzaparin sodium, 1,000 IU
J1745
Injection, infliximab, 10 mg
J1750
Injection, iron dextran, 50 mg
J1756
Injection, iron sucrose, 1 mg
J1930
Injection, lanreotide, 1 mg
J2248
Injection, micafungin sodium 1 mg
J2323
Injection, natalizumab, 1 mg
J2353
Injection, octreotide, depot form for intramuscular injection, 1 mg
J2355
Injection, oprelvekin, 5 mg
J2430
Injection, pamidronate, per 30 mg
J2503
Injection, pegaptanib sodium, 0.3 mg
J2778
Injection, ranibizumab, 0.5 mg
J2796
Injection, romiplostim, 10 mcg
J2916
Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg
J3487
Injection, zoledronic acid (Zometa®), 1 mg
J3488
Injection, zoledronic acid (Reclast®), 1 mg
Q0138*
Ferumoxytol, non-esrd, 1.0 mg
Note: Use code Q0138* for claims with dates of service on or after January 1, 2010, and code J3490 (when used to identify ferumoxytol) for claims with dates of service on or after June 30, 2009, to December 31, 2009.
Q0139*
Ferumoxytol, esrd use, 1.0 mg
Note: Use code Q0139* for claims with dates of service on or after January 1, 2010, and code J3490 (when used to identify ferumoxytol) for claims with dates of service on or after June 30, 2009, to December 31, 2009.
Q3025
Injection, interferon beta-1a, 11 mcg for intramuscular use (Avonex)
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Note: The limited coverage for HCPCS code J0894 (injection, decitabine, 1 mg) may be found in the TrailBlazer LCD, “Drugs and Biologicals – Chemotherapeutic – 4I-92AB.
Note: The limited coverage for HCPCS codes for injection, bevacizumab – J9035 (injection, bevacizumab, 10 mg when used for cancer treatment and when treating eye disease) and C9257 (injection, bevacizumab, 0.25 mg) (OPPS and ASC) may be found in the TrailBlazer LCD, “Drugs and Biologicals – Chemotherapeutic – 4I-92AB.”
Medicare is establishing the following limited coverage for HCPCS code J0129:
Covered for:
714.0
Rheumatoid arthritis
714.30
Polyarticular juvenile rheumatoid arthritis, chronic or unspecified
714.31
Polyarticular juvenile rheumatoid arthritis, acute
Medicare is establishing the following limited coverage for HCPCS code J0150:
Covered for:
427.0
Paroxysmal supraventricular tachycardia
Medicare is establishing the following limited coverage for HCPCS code J1212:
Covered for:
595.1
Chronic interstitial cystitis
595.82
Irradiation cystitis
Medicare is establishing the following limited coverage for HCPCS code J1260:
Covered for:
V58.11
Encounter for antineoplastic chemotherapy
V58.49
Other specified aftercare following surgery
Medicare is establishing the following limited coverage for HCPCS code J1300:
Covered for:
283.2
Hemoglobinuria due to hemolysis from external causes
Medicare is establishing the following limited coverage for HCPCS code J1450:
Note: Medicare expects that most patients with candidal infections limited to mucosal surfaces (including the esophagus) will not require parenteral anti-fungal medications. Clinical necessity for parenteral antifungal medications for such patients must be clearly documented in the patient’s medical record.
Covered for:
112.4–112.5
Candidiasis
112.81
Candidal endocarditis
112.83–112.84
Candidiasis of other specified sites
Medicare is establishing the following limited coverage for HCPCS code J1645:
Covered for:
410.71
Subendocardial myocardial infarction, initial episode of care
411.1
Unstable angina
V12.51*
Personal history of venous thrombosis and embolism
Note: Use code V12.51* to report prophylactic use of dalteparin to prevent cancer related recurrent VTE.
V54.81*
Aftercare following joint replacement
Note: Use code V54.81* to indicate prophylaxis for pulmonary and deep-vein thrombophlebitis in the immediate postoperative period following hip replacements.
V54.89*
Other orthopedic aftercare
Note: Use code V54.89* to indicate prophylaxis for pulmonary and deep-vein thrombophlebitis in the immediate postoperative period following other hip surgery.
V58.49*
Other specified aftercare following surgery
Note: Use code V58.49* to indicate prophylaxis for pulmonary and deep-vein thrombophlebitis in the immediate postoperative period following abdominal surgery.
Medicare is establishing the following limited coverage for HCPCS code J1650:
Covered for:
410.71
Subendocardial myocardial infarction, initial episode of care
411.1
Unstable angina
415.11–415.12
Pulmonary embolism and infarction
415.19
Other pulmonary embolism and infarction
451.11
Thrombophlebitis of femoral vein
451.19
Thrombophlebitis, other
451.81
Thrombophlebitis, iliac vein
451.83
Thrombophlebitis, deep veins of upper extremities
451.89
Thrombophlebitis, other
453.0
Hepatic vein thrombosis
453.2–453.3
Other venous embolism and thrombosis
453.40–453.42
Venous embolism and thrombosis of deep vessels of lower extremity
453.50–453.52
Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity
453.6
Venous embolism and thrombosis of superficial vessels of lower extremity
453.71–453.77
Acute venous embolism and thrombosis of superficial veins of upper extremity
453.79
Chronic venous embolism and thrombosis of other specified veins
453.81–453.87
Acute venous embolism and thrombosis of superficial veins of upper extremity
453.89
Acute venous embolism and thrombosis of other specified veins
V54.81*
Aftercare following joint replacement
Note: Use code V54.81* to indicate prophylaxis for pulmonary and deep-vein thrombophlebitis in the immediate postoperative period following knee and hip replacements.
V58.49*
Other specified aftercare following surgery
Note: Use code V58.49* to indicate prophylaxis for pulmonary and deep-vein thrombophlebitis in the immediate postoperative period following gynecologic, urologic and colorectal surgery.
Medicare is establishing the following limited coverage for HCPCS code J1652:
Covered for:
415.11–415.12
Pulmonary embolism and infarction
415.19
Other pulmonary embolism and infarction
451.11
Thrombophlebitis of femoral vein
451.19
Thrombophlebitis, other
451.81
Thrombophlebitis, iliac vein
451.83
Thrombophlebitis, deep veins of upper extremities
451.89
Thrombophlebitis, other
453.0
Hepatic vein thrombosis
453.2–453.3
Other venous embolism and thrombosis
453.40–453.42
Venous embolism and thrombosis of deep vessels of lower extremity
453.50–453.52
Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity
453.6
Venous embolism and thrombosis of superficial vessels of lower extremity
453.71–453.77
Acute venous embolism and thrombosis of superficial veins of upper extremity
453.79
Chronic venous embolism and thrombosis of other specified veins
453.81–453.87
Acute venous embolism and thrombosis of superficial veins of upper extremity
453.89
Acute venous embolism and thrombosis of other specified veins
V54.81*
Aftercare following joint replacement
Note: Use V54.81* to indicate prophylaxis for pulmonary and deep vein thrombophlebitis in the immediate postoperative period following knee and hip replacements.
V54.89*
Other orthopedic aftercare
Note: Use V54.89* to indicate prophylaxis for pulmonary and deep vein thrombophlebitis in the immediate postoperative period following hip fracture surgery.
Medicare is establishing the following limited coverage for HCPCS code J1655:
Covered for:
415.11–415.12
Pulmonary embolism and infarction
415.19
Other pulmonary embolism and infarction
451.11
Thrombophlebitis of femoral vein
451.19
Thrombophlebitis, other
451.81
Thrombophlebitis, iliac vein
451.83
Thrombophlebitis, deep veins of upper extremities
451.89
Thrombophlebitis, other
453.0
Hepatic vein thrombosis
453.2–453.3
Other venous embolism and thrombosis
453.40–453.42
Venous embolism and thrombosis of deep vessels of lower extremity
453.50-453.52
Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity
453.6
Venous embolism and thrombosis of superficial vessels of lower extremity
453.71–453.77
Acute venous embolism and thrombosis of superficial veins of upper extremity
453.79
Chronic venous embolism and thrombosis of other specified veins
453.81–453.87
Acute venous embolism and thrombosis of superficial veins of upper extremity
453.89
Acute venous embolism and thrombosis of other specified veins
Medicare is establishing the following limited coverage for CPT/HCPCS code J1745:
Covered for:
555.0–555.2
Regional enteritis
555.9
Regional enteritis, unspecified site
556.0–556.1
Ulcerative (chronic) colitis
556.5–556.6
Ulcerative (chronic) colitis
556.9
Ulcerative colitis, unspecified
696.0–696.1
Psoriasis and similar disorders
711.10–711.19
Arthropathy associated with Reiter’s disease and nonspecific urethritis
713.1
Arthropathy associated with gastrointestinal conditions other than infections
713.3
Arthropathy associated with dermatological disorders
714.0
Rheumatoid arthritis
720.0
Ankylosing spondylitis
Note: Individual consideration for J1745 will be given if the infliximab is used to treat refractory pyoderma gangrenosum (ICD-9-CM diagnosis code 686.01) and documentation received by Medicare demonstrates that all available, medically appropriate, conventional treatments have been utilized and failed to control the disease. An adequate trial for each treatment must be documented.
Coverage of parenteral iron preparations, HCPCS codes J1750, J1756, J2916 and J3490 (when used to report ferumoxytol)/Q0138, Q0139 (effective January 1, 2010): Medicare expects that most patients with iron deficiency will not require parenteral iron supplementation. Medicare will cover parenteral iron preparations, but coverage is limited to those iron-deficient patients in whom oral iron or enteral iron therapy has been demonstrated to have been ineffective, or in other clinical circumstances (such as the need for larger iron doses not possible to provide through oral administration or the need for rapid repletion of iron stores in patients with severe symptomatic iron deficiency) in which oral or enteral iron therapy is otherwise unacceptable.
See “Coding Guidelines” in associated LCD article for further parenteral iron preparation coding requirements.
Medicare is establishing the following limited coverage for HCPCS code J1750:
Covered for diagnoses:
280.0–280.1
Iron deficiency anemias
280.8–280.9
Iron deficiency anemias, other, unspecified
Medicare is establishing the following limited coverage for HCPCS code J1756 (requires dual diagnosis):
Covered for primary diagnoses:
280.0–280.1
Iron deficiency anemias
280.8–280.9
Iron deficiency anemias, other, unspecified
Covered for secondary diagnoses:
579.8–579.9
Intestinal malabsorption
585.3–585.6*
Chronic kidney disease (CKD)
995.20*
Unspecified adverse effect of unspecified drug, medicinal and biological substance
995.27*
Other drug allergy
Note: Use code 995.20* or 995.27* to indicate non-CKD patients for whom oral or enteral iron therapy is unacceptable and/or who have experienced an adverse reaction to iron dextran.
Medicare is establishing the following limited coverage for HCPCS code J2916 (requires dual diagnosis):
Covered for primary diagnoses:
280.0*–280.1*
Iron deficiency anemias
280.9*
Iron deficiency anemia, unspecified
Note: Codes 280.0*–280.1* and 280.9* as the primary diagnosis require a secondary (dual) diagnosis from the table below.
Covered for secondary diagnoses:
579.8–579.9
Intestinal malabsorption
585.6*
End stage renal disease (ESRD)
Note: Use code 585.6* to indicate ESRD patients on dialysis receiving supplemental epoetin.
995.20*
Unspecified adverse effect of unspecified drug, medicinal and biological substance
995.27*
Other drug allergy
Note: Use code 995.20* or 995.27* to indicate non-ESRD patients for whom oral or enteral iron therapy is unacceptable and/or who have experienced an adverse reaction to iron dextran.
Medicare is establishing the following limited coverage for HCPCS code J3490 (when used to identify ferumoxytol)for claims with dates of service on or after June 30, 2009, to December 31, 2009, and HCPCS codes Q0138 and Q0139 for claims with dates of service on or after January 1, 2010 (requires dual diagnosis):
Covered for primary diagnoses:
280.0*–280.1*
Iron deficiency anemias
280.9*
Iron deficiency anemia, unspecified
Note: Codes 280.0*–280.1* and 280.9* as the primary diagnosis require a secondary (dual) diagnosis from the table below.
Covered for secondary diagnoses:
579.8–579.9
Intestinal malabsorption
585.3–585.6*
Chronic kidney disease
995.20*
Unspecified adverse effect of unspecified drug, medicinal and biological substance
995.27*
Other drug allergy
Note: Use code 995.20* or 995.27* to indicate non-CKD patients for whom oral or enteral iron therapy is unacceptable and/or who have experienced an adverse reaction to iron dextran.
Medicare is establishing the following limited coverage for HCPCS code J1930:
Covered for:
153.4
Malignant neoplasm of cecum
157.4
Malignant neoplasm of islets of Langerhans
211.7
Benign neoplasms, islets of Langerhans
253.0
Acromegaly
259.2
Carcinoid syndrome
558.2*
Toxic gastroenteritis and colitis
Note: Use code 558.2* to indicate chemotherapy-induced diarrhea.
Medicare is establishing the following limited coverage for HCPCS code J2248:
Covered for:
112.5
Disseminated systemic candidiasis
112.84
Candidal esophagitis
V42.81–V42.82
Organ or tissue replaced by transplant
Medicare is establishing the following limited coverage for HCPCS code J2323:
340
Multiple sclerosis
555.0–555.2
Regional enteritis (Crohn’s disease)
555.9
Unspecified regional enteritis (Crohn’s disease)
Medicare is establishing the following limited coverage for HCPCS code J2353:
Covered for:
153.4
Malignant neoplasm of cecum
157.4
Malignant neoplasm of islets of Langerhans
209.00–209.03
Malignant carcinoid tumors of the small intestine
209.10–209.17
Malignant carcinoid tumors of the appendix, large intestine and rectum
209.20209.27
Malignant carcinoid tumors of the other and unspecified sites
209.29
Malignant carcinoid tumors of the other sites
209.30–209.36
Malignant poorly differentiated neuroendocrine tumors
211.7
Benign neoplasms, islets of Langerhans
253.0
Acromegaly
259.2
Carcinoid syndrome
558.2*
Toxic gastroenteritis and colitis
Note: Use code 558.2* to indicate chemotherapy-induced diarrhea.
Medicare is establishing the following limited coverage for HCPCS code J2355:
Covered for:
287.41
Posttransfusion purpura
287.49
Other secondary thrombocytopenia
Medicare is establishing the following limited coverage for HCPCS code J2430:
Covered for:
174.0–174.6
Malignant neoplasm of female breast
174.8
Malignant neoplasm of other specified sites of female breast
175.0
Malignant neoplasm of male nipple and areola
175.9
Malignant neoplasm of other and unspecified sites of male breast
198.5
Secondary malignant neoplasm of bone and bone marrow
203.00–203.02
Multiple myeloma and immunoproliferative neoplasms
275.42
Hypercalcemia
731.0
Paget’s disease of bone
756.51
Osteogenesis imperfecta
Note: LCD Individual Consideration for J2430 will be given if the IV pamidronate is being used to treat osteoporosis or osteopenia and documentation is available to document that all available (as medically appropriate) oral agents have been tried and have caused such side effects that the drugs were discontinued. An adequate trial (not less than one month) for each drug must be demonstrated. In this case, side effects (e.g., esophagitis, nausea, etc.) and associated attempts at their amelioration must be properly documented.
Note: The limited coverage for HCPCS code J9035 (injection, bevacizumab, 10 mg) may be found in the TrailBlazer LCD, “Drugs and Biologicals – Chemotherapeutic – 4I-92AB.”
Medicare is establishing the following limited coverage for HCPCS code J2778:
Covered for:
362.35
Cent retinal vein occlus
362.36
Venous tributary occlus
362.52
Exudative senile macular degeneration (wet)
Medicare is establishing the following limited coverage for HCPCS code J2796:
Covered for:
287.31
Immune thrombocytopenic purpura
Medicare is establishing the following limited coverage for HCPCS code J2503:
Covered for:
362.07
Diabetic macular edema
362.52
Exudative senile macular degeneration (wet)
Medicare is establishing the following limited coverage for HCPCS code J3487:
Covered for:
185*
Malignant neoplasm of prostate
Note: Code 185* is covered for patients with drug-induced osteopenia secondary to androgen deprivation therapy for prostate cancer. Patients should have evidence for clinically significant bone loss.
198.5
Secondary malignant neoplasm of bone and bone marrow
203.00–203.02
Multiple myeloma and immunoproliferative neoplasms
275.42
Hypercalcemia
731.0
Paget’s disease of bone
Medicare is establishing the following limited coverage for HCPCS code J3488:
Covered for:
731.0
Paget’s disease of bone
Medicare is establishing the following dual diagnosis limited coverage for HCPCS code J3488 when used in the treatment of osteoporosis:
Covered for primary diagnosis:
733.01
Senile osteoporosis
733.09*
Other osteoporosis
Use 733.09* for drug-induced osteoporosis only.
The following are secondary (dual) diagnoses to be used with 733.01 or 733.09 (primary diagnosis) to meet limited coverage for HCPCS code J3488
530.0
Achalasia and cardiospasm
530.20–530.21
Ulcer of esophagus
530.3
Stricture and stenosis of the esophagus
530.87
Mechanical complication of esophagostomy
710.1
Systemic sclerosis
995.29
Unspecified adverse effect of other drug, medicinal or biological substance
V12.79
Personal history of other digestive system disease
V44.1
Gastrostomy
V45.72
Acquired absence of intestine (large) (small)
V45.75
Acquired absence of stomach
V49.84
Bed confinement status
Medicare is establishing the following limited coverage for HCPCS code Q3025:
Note: Code Q3025 is covered only when administered under the direct supervision of a physician.
Covered for:
340
Multiple sclerosis
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Parenteral Iron Preparations
When parenteral iron preparations are reported for Medicare payment, the medical record must clearly reflect that oral or enteral (if applicable) administration was insufficient or inadequate. Underlying clinical conditions necessitating parenteral administration of iron and reported diagnoses must be clearly demonstrated in the record.
Zoledronic Acid for Osteoporosis
When intravenous zoledronic acid is used, the medical record must clearly reflect that the parenteral agent, rather than the oral agent, is the medically prudent choice. Medicare covers zoledronic acid for certain people with osteoporosis who are unable to take an oral bisphosphonate because of a medical or surgical condition such as those people with:
  • An inability to take an oral bisphosphonate.
  • A medical or surgical condition responsible for her inability to take oral bisphosphonates.
  • A spine, hip or pelvis BMD T-score of ≤ -2.5 or a low-trauma hip fracture.
  • A 10-year all major osteoporosis-related fracture probability of ≥ 20 percent based on the U.S.-adapted WHO absolute fracture risk model (FRAX®).
Drug Wastage Documentation Requirements
Any amount wasted must be clearly documented in the medical record, regardless of whether the JW modifier will be used in billing for the drug/biological, with:
  • Date and time.
  • Amount of medication wasted.
  • Reason for the wastage.
Appendices
N/A

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