Immunizations are generally excluded from coverage under Medicare unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as antirabies treatment or tetanus antitoxin or booster vaccine. In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such disease as smallpox, typhoid and polio, is not covered. In cases where a vaccination or inoculation is excluded from coverage, the entire charge will be denied (such as office visits, which were primarily for the purpose of administering a non-covered injection).
The vaccines listed below are eligible for payment. These vaccines may be reimbursed regardless of the setting in which they are furnished. In addition, the administration fee for these vaccines is also eligible for payment. Medicare provides specific coverage for influenza and pneumococcal vaccines for certain populations (see CMS National Coverage Determinations (NCDs) and other documentation); these vaccines are not addressed in this LCD; specific coverage information is available on the CMS and TrailBlazer Web sites.
Use the following codes to process the administration:
90471© – Immunization admin (For OPPS hospitals billing for the hepatitis B vaccine administration.) (For Comprehensive Outpatient Rehabilitation Facilities (CORFs) billing the influenza, pneumococcal and Hepatitis B vaccines.)
The vaccines listed below are eligible for payment. These vaccines may be reimbursed regardless of the setting in which they are furnished. In addition, the administration fee for these vaccines is also eligible for payment. Medicare provides specific coverage for influenza and pneumococcal vaccines for certain populations (see CMS National Coverage Determinations (NCDs) and other documentation); these vaccines are not addressed in this LCD; specific coverage information is available on the CMS and TrailBlazer Web sites.
Use the following codes to process the administration:
90471© – Immunization admin (For OPPS hospitals billing for the hepatitis B vaccine administration.) (For Comprehensive Outpatient Rehabilitation Facilities (CORFs) billing the influenza, pneumococcal and Hepatitis B vaccines.)
90472© – Immunization admin, each add (For OPPS hospitals billing for the hepatitis B vaccine administration.)
G0010 – Administration of hepatitis b vaccine (non-OPPS only.)
G0128 – Administration of the vaccines when provided by a registered nurse on 75X TOB (CORF.) (Part A only code)
Hepatitis B (90740, 90743, 90744, 90746, 90747) vaccine – For those who are at high or intermediate risk of contracting hepatitis B.
High-risk groups currently identified include:
- End-Stage Renal Disease (ESRD) patients.
- Hemophiliacs who receive Factor VIII or IX concentrates.
- Clients of institutions for the mentally retarded.
- People who live in the same household as a hepatitis B virus (HBV) carrier.
- Homosexual men.
- Illicit injectable drug abusers.
Intermediate risk groups currently identified include:
- Staff in institutions for the mentally retarded.
- Workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work (V05.3).
Exception:
People in the above listed groups would not be considered at high or intermediate risk of contracting hepatitis B if there is laboratory evidence positive for antibodies to hepatitis B. (ESRD patients are routinely tested for hepatitis B antibodies as part of their continuing monitoring and therapy.)
The vaccine may be administered upon the order of a doctor of medicine or osteopathy by home health agencies, SNFs, ESRD facilities, hospital outpatient departments, people recognized under the “incident to” physicians’ services provision of law and doctors of medicine and osteopathy. A charge separate from the ESRD composite rate will be recognized and paid for administration of the vaccine to ESRD patients.
Tetanus (90703, 90714, 90718) – These injections are covered when given for an acute injury to a person who is incompletely immunized.
When a tetanus booster is given to a patient in the absence of an injury, the injection does not meet the coverage criteria for Medicare (even though it may be appropriate preventive treatment).
Rabies (90675) – Rabies is a disease that is carried by animals and transmitted by a bite or scratch.
When administering a rabies vaccine to a human who has had an encounter with an animal that is at high risk for rabies, bill procedure code 90675 and give the appropriate ICD-9-CM code for the exposure.
Limitations
In the absence of injury or direct exposure, preventative immunizations (vaccination or inoculation) against such diseases as small pox, polio, diphtheria, etc., are not covered. These include:
90476©
|
Adenovirus vaccine, type 4
|
90698©
|
Dtap-hib-ip vaccine, im
|
90477©
|
Adenovirus vaccine, type 7
|
90700©
|
Dtap vaccine, < 7yrs, 1m
|
90581©
|
Anthrax vaccine, sc
|
90701©
|
Dtp vaccine, < 7yrs, 1m
|
90585©
|
Bcg vaccine, precut
|
90702©
|
Dt vaccine, im
|
90586©
|
Bcg vaccine, intravesical
|
90704©
|
Mumps vaccine, sc
|
90632©
|
Hep a vaccine, adult im
|
90705©
|
Measles vaccine, sc
|
90633©
|
Hep a vacc, ped/adol, 2 dose
|
90706©
|
Rubella vaccine, sc
|
90634©
|
Hep a vacc, ped/adol, 3 dose
|
90707©
|
Mmr vaccine, sc
|
90636©
|
Hep a/hep b vacc, adult im
|
90708©
|
Measles-rubella vaccine, sc
|
90644©
|
Hib/men/tt vaccine, im
|
90710©
|
Mmrv vaccine, sc
|
90645©
|
Hib vaccine, hboc, im
|
90712©
|
Oral poliovirus vaccine
|
90646©
|
Hib vaccine, prp-d, im
|
90713©
|
Poliovirus, ipv, sc/im
|
90647©
|
Hib vaccine, prp-omp, im
|
90715©
|
Tdap vaccine >7 im
|
90648©
|
Hib vaccine, prp-t, im
|
90716©
|
Chicken pox vaccine, sc
|
90649©
|
hpv vaccine 4 valent, im
|
90717©
|
Yellow fever vaccine, sc
|
90650©
|
hpv vaccine 2 valent, im
|
90719©
|
Diphtheria vaccine, im
|
Influenza virus vaccine
|
90720©
|
Dtp/hib vaccine, im
|
|
90660©*
|
Flu vaccine, nasal
|
90721©
|
Dtap/hib vaccine, im
|
90663©
|
Flu vacc pandemic h1n1
|
90723©
|
Dtap-hep b-ipv vaccine, im
|
90664©
|
Flu vacc pandemic intranasal
|
90725©
|
Cholera vaccine, injectable
|
90665©
|
Lyme disease vaccine, im
|
90727©
|
Plague vaccine, im
|
90666©
|
Flu vac pandem prsrv free im
|
90733©
|
Meningococcal vaccine, sc
|
90667©
|
Flu vac pandemic adjuvant im
|
90734©
|
Meningococcal vaccine, im
|
90668©
|
Flu vac pandemic splt im
|
90735©
|
Encephalitis vaccine, sc
|
90669©*
|
Pneumococcal vacc, 7 val im
|
90736©
|
Zoster vacc, sc
|
90670©
|
Pneumococcal vacc, 13 val im
|
|
|
Rabies vaccine, id
|
|
|
|
90680©
|
Rotovirus vaccine, 3 dose, oral
|
|
|
90681©
|
Rotavirus vacc 2 dose oral
|
|
|
90690©
|
Typhoid vaccine, oral
|
|
|
90691©
|
Typhoid vaccine, im
|
|
|
90692©
|
Typhoid vaccine, h-p, sc/id
|
|
|
90693©
|
Typhoid vaccine, akd, sc
|
|
|
90696©
|
Dtap-ipv vacc 4-6 yr im
|
|
|
In cases where a vaccination or inoculation is excluded from coverage, the entire charge will be denied (such as office visits, which were primarily for the purpose of administering a non-covered injection).
*Note: Coverage of 90660© (flu vaccine, nasal) is expanded for individuals ages 5 through 49 (previously non-covered). See CMS NCDs related to Flu vaccines for additional details.
*Note: Coverage of 90669© (pneumococcal vacc, 7 val im) is expanded for individuals younger than 5 years (previously non-covered). See CMS Change Request (CR) 5910 for additional details.
Billing For a Single Administration
Providers should bill the appropriate Procedure immunization administration code(s) 90465, 90467, 90471, or 90473 (Immunization administration…first injection/first administration/one vaccine) when administering one immunization. The next line on the claim form must contain the specific Procedure code for the vaccine, with $0.00 in the “billed charges” column (see pg. 102 for an
example).
• Do not report Procedure codes 90465 and 90467 on the same date of service
• Do not report Procedure codes 90471 and 90473 on the same date of service
2007 Louisiana Medicaid Professional Services Provider Training 98
Billing for Multiple Administrations
When administering more than one immunization, providers should bill as described above for a single administration. The appropriate procedure code(s) 90466, 90468, 90472, and 90474 (Immunization administration…each additional injection/administration/vaccine) should then be listed with the appropriate number of units for the additional vaccines placed in the “units” column. The specific vaccines should then be listed on subsequent lines. The number of specific vaccines listed after Procedure administration codes should match the number of units listed in the units column. Examples of this scenario are on pages 103 through 107.
• Use Procedure codes 90466 and/or 90468 with 90465 OR 90467 to report more than one vaccine administered. Do NOT use 90466 and/or 90468 with 90471 or 90473.
• Use Procedure codes 90472 and/or 90474 with 90471 OR 90473 to report more than one vaccine administered. Do NOT use 90472 and/or 90474 with 90465 or 90467.
Hard Copy Claim Filing for Greater Than Four Administrations
When billing hard copy claims for more than four immunizations and the six-line claim form limit is exceeded, providers should bill on two CMS-1500 claim forms. The first claim should follow the instructions above for billing the single administration. A second CMS-1500 claim form should be used to bill the remaining immunizations as described above for billing multiple administrations. An example is shown on pages 104 and 105.
Billing For a Single Administration
Providers should bill the appropriate Procedure immunization administration code(s) 90465, 90467, 90471, or 90473 (Immunization administration…first injection/first administration/one vaccine) when administering one immunization. The next line on the claim form must contain the specific Procedure code for the vaccine, with $0.00 in the “billed charges” column (see pg. 102 for an
example).
• Do not report Procedure codes 90465 and 90467 on the same date of service
• Do not report Procedure codes 90471 and 90473 on the same date of service
2007 Louisiana Medicaid Professional Services Provider Training 98
Billing for Multiple Administrations
When administering more than one immunization, providers should bill as described above for a single administration. The appropriate procedure code(s) 90466, 90468, 90472, and 90474 (Immunization administration…each additional injection/administration/vaccine) should then be listed with the appropriate number of units for the additional vaccines placed in the “units” column. The specific vaccines should then be listed on subsequent lines. The number of specific vaccines listed after Procedure administration codes should match the number of units listed in the units column. Examples of this scenario are on pages 103 through 107.
• Use Procedure codes 90466 and/or 90468 with 90465 OR 90467 to report more than one vaccine administered. Do NOT use 90466 and/or 90468 with 90471 or 90473.
• Use Procedure codes 90472 and/or 90474 with 90471 OR 90473 to report more than one vaccine administered. Do NOT use 90472 and/or 90474 with 90465 or 90467.
Hard Copy Claim Filing for Greater Than Four Administrations
When billing hard copy claims for more than four immunizations and the six-line claim form limit is exceeded, providers should bill on two CMS-1500 claim forms. The first claim should follow the instructions above for billing the single administration. A second CMS-1500 claim form should be used to bill the remaining immunizations as described above for billing multiple administrations. An example is shown on pages 104 and 105.
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, used the drug, and made good faith efforts to minimize the unused portion of the drug in how it is supplied, then 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 the 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.
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, 22X, 23X, 71X, 72X, 73X, 75X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X is 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 Bill Type and Revenue Codes applicable for use with 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.
0550, 0559, 0636, 0771
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.
|
90675©
|
Rabies vaccine, im
|
90703©
|
Tetanus vaccine, im
|
90714©
|
Td vaccine no prsrv >/= 7 im
|
90718©
|
Td vaccine > 7, im
|
90740©
|
Hep b vacc, ill pat 3 dose im
|
90743©
|
Hep b vacc, adol, 2 dose, im
|
90744©
|
Hep b vaccine, ped/adol, im
|
90746©
|
Hep b vaccine, adult, im
|
90747©
|
Hep b vaccine, ill pat, im
|
G0010
|
Administration of hepatitis b vaccine
|
G0128
|
Administration of the vaccines when provided by a registered nurse on 75X TOB (CORF)(Part A only)
|
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 preventive services.
Medicare is establishing the following limited coverage for hepatitis B (CPT/HCPCS codes 90740, 90743, 90744, 90746, 90747 and G0010):
Covered for:
286.0–286.1
|
Coagulation defects
|
302.0
|
Ego-dystonic sexual orientation
|
304.00–304.03
|
Opioid type dependence
|
304.10–304.13
|
Sedative, hypnotic or anxiolytic dependence
|
304.20–304.23
|
Cocaine dependence
|
304.30–304.33
|
Cannabis dependence
|
304.40–304.43
|
Amphetamine and other psychostimulant dependence
|
304.50–304.53
|
Hallucinogen dependence
|
304.60–304.63
|
Other specified drug dependence
|
304.70–304.73
|
Combinations of opioid type drug with any other
|
304.80–304.83
|
Combinations of drug dependence excluding opioid type drug
|
304.90–304.93
|
Unspecified drug dependence
|
305.90–305.93
|
Nondependent abuse of drugs
|
318.1–318.2
|
Other specified mental retardation
|
319
|
Unspecified mental retardation
|
585.1–585.6
|
Chronic kidney disease (CKD)
|
585.9
|
Chronic kidney disease, unspecified
|
758.0
|
Down’s syndrome
|
V05.3
|
Need for viral hepatitis prophylactic vaccination and inoculation against single disease
|
Medicare is establishing the following limited coverage for tetanus (CPT/HCPCS codes 90703, 90714 and 90718):
Covered for:
870.0–870.4
|
Open wound of ocular adnexa
|
870.8–870.9
|
Open wound of ocular adnexa
|
871.0–871.7
|
Open wound of eyeball
|
871.9
|
Unspecified open wound of eyeball
|
872.00–872.02
|
Open wound, external ear without mention of complication
|
872.10–872.12
|
Open wound, external ear, complicated
|
872.61–872.64
|
Open wound, other specified parts of ear, without mention of complication
|
872.69
|
Open wound, other and multiple sites of ear, without mention of complication
|
872.71–872.74
|
Open wound, other specified parts of ear, complicated
|
872.79
|
Open wound, other and multiple sites of ear, complicated
|
872.8–872.9
|
Open wound of ear
|
873.0–873.1
|
Other open wound of head
|
873.20–873.22
|
Open wound of nose, without mention of complication
|
873.29
|
Open wound of multiple sites of nose, without mention of complication
|
873.30–873.33
|
Open wound of nose, complicated
|
873.39
|
Open wound of multiple sites of nose, complicated
|
873.40–873.44
|
Open wound of face, without mention of complication
|
873.49
|
Open wound of other and multiple sites of face, without mention of complication
|
873.50–873.54
|
Open wound of face, complicated
|
873.59
|
Open wound of other and multiple sites of face, complicated
|
873.60–873.65
|
Open wound of internal structures of mouth, without mention of complication
|
873.69
|
Open wound of other and multiple sites of internal structures of mouth, without mention of complication
|
873.70–873.75
|
Open wound of internal structures of mouth, complicated
|
873.79
|
Open wound of other and multiple sites of internal structures of mouth, complicated
|
873.8–873.9
|
Other open wound of head
|
874.00–874.02
|
Open wound of larynx and trachea, without mention of complication
|
874.10–874.12
|
Open wound of larynx and trachea, complicated
|
874.2–874.5
|
Open wound of neck
|
874.8–874.9
|
Open wound of neck
|
875.0–875.1
|
Open wound of chest (wall)
|
876.0–876.1
|
Open wound of back
|
877.0–877.1
|
Open wound of buttock
|
878.0–878.9
|
Open wound of genital organs (external), including traumatic amputation
|
879.0–879.9
|
Open wound of other and unspecified sites, except limbs
|
880.00–880.03
|
Open wound of shoulder and upper arm, without mention of complication
|
880.09
|
Open wound of multiple sites of shoulder and upper arm, without mention of complication
|
880.10–880.13
|
Open wound of shoulder and upper arm, complicated
|
880.19
|
Open wound of multiple sites of shoulder and upper arm, complicated
|
880.20–880.23
|
Open wound of shoulder and upper arm, with tendon involvement
|
880.29
|
Open wound of multiple sites of shoulder and upper arm, with tendon involvement
|
881.00–881.02
|
Open wound of elbow, forearm and wrist, without mention of complication
|
881.10–881.12
|
Open wound of elbow, forearm and wrist, complicated
|
881.20–881.22
|
Open wound of elbow, forearm and wrist, with tendon involvement
|
882.0–882.2
|
Open wound of hand except finger(s) alone
|
883.0–883.2
|
Open wound of finger(s)
|
884.0–884.2
|
Multiple and unspecified open wound of upper limb
|
885.0–885.1
|
Traumatic amputation of thumb (complete) (partial)
|
886.0–886.1
|
Traumatic amputation of other finger(s) (complete) (partial)
|
887.0–887.7
|
Traumatic amputation of arm and hand (complete) (partial)
|
890.0–890.2
|
Open wound of hip and thigh
|
891.0–891.2
|
Open wound of knee, leg (except thigh) and ankle
|
892.0–892.2
|
Open wound of foot except toe(s) alone
|
893.0–893.2
|
Open wound of toe(s)
|
894.0–894.2
|
Multiple and unspecified open wound of lower limb
|
895.0–895.1
|
Traumatic amputation of toe(s) (complete) (partial)
|
896.0–896.3
|
Traumatic amputation of foot (complete) (partial)
|
897.0–897.7
|
Traumatic amputation of leg(s) (complete) (partial)
|
910.6–910.9
|
Superficial injury of face, neck, and scalp except eye
|
911.6–911.9
|
Superficial injury of trunk
|
912.6–912.9
|
Superficial injury of shoulder and upper arm
|
913.6–913.9
|
Superficial injury of elbow, forearm, and wrist
|
914.6–914.9
|
Superficial injury of hand(s) except finger(s) alone
|
915.6–915.9
|
Superficial injury of finger(s)
|
916.6–916.9
|
Superficial injury of hip, thigh, leg, and ankle
|
917.6–917.9
|
Superficial injury of foot and toes
|
918.9
|
Other and unspecified superficial injuries of eye
|
919.6–919.9
|
Superficial injury of other, multiple, and unspecified site
|
959.01
|
Head injury, unspecified
|
959.09
|
Injury of face and neck
|
959.11–959.14
|
Injury, trunk
|
959.19
|
Injury, other sites of trunk
|
959.2–959.9
|
Injury, other and unspecified
|
Medicare is establishing the following limited coverage for rabies (CPT/HCPCS code 90675):
Covered for:
872.00–872.02
|
Open wound, external ear without mention of complication
|
872.10–872.12
|
Open wound, external ear, complicated
|
872.79
|
Open wound of ear, other and multiple sites, complicated
|
872.8–872.9
|
Open wound of ear, part unspecified
|
873.0–873.1
|
Open wound of scalp
|
873.20
|
Open wound of nose, unspecified site, without mention of complication
|
873.29
|
Open wound of nose, multiple sites, without mention of complication
|
873.30
|
Open wound of nose, unspecified site, complicated
|
873.39
|
Open wound of nose, multiple sites, complicated
|
873.40–873.44
|
Open wound of face, without mention of complication
|
873.49
|
Open wound of other and multiple sites of face, without mention of complication
|
873.50–873.54
|
Open wound of face, complicated
|
873.59
|
Open wound of other and multiple sites of face, complicated
|
873.60
|
Open wound of mouth, unspecified site, without mention of complication
|
873.69
|
Open wound of other and multiple sites of mouth, without mention of complication
|
873.70
|
Open wound of mouth, unspecified site, complicated
|
873.79
|
Open wound of other and multiple sites of mouth, complicated
|
873.8–873.9
|
Other and unspecified open wound of head
|
874.8–874.9
|
Open wound of neck, other and unspecified parts
|
875.0–875.1
|
Open wound of chest (wall)
|
876.0–876.1
|
Open wound of back
|
877.0–877.1
|
Open wound of buttocks
|
878.0–878.9
|
Open wound of genital organs (external), including traumatic amputation
|
879.0–879.9
|
Open wound of other and unspecified sites, except limbs
|
880.00–880.03
|
Open wound of shoulder and upper arm, without mention of complication
|
880.09
|
Open wound of multiple sites of shoulder and upper arm, without mention of complication
|
880.10–880.13
|
Open wound of shoulder and upper arm, complicated
|
880.19
|
Open wound of multiple sites of shoulder and upper arm, complicated
|
880.20–880.23
|
Open wound of shoulder and upper arm, with tendon involvement
|
880.29
|
Open wound of multiple sites of shoulder and upper arm, with tendon involvement
|
881.00–881.02
|
Open wound of elbow, forearm and wrist, without mention of complication
|
881.10–881.12
|
Open wound of elbow, forearm and wrist, complicated
|
881.20–881.22
|
Open wound of elbow, forearm and wrist, with tendon involvement
|
882.0–882.2
|
Open wound of hand except finger(s) alone
|
883.0–883.2
|
Open wound of finger(s)
|
884.0–884.2
|
Multiple and unspecified open wound of upper limb
|
885.0–885.1
|
Traumatic amputation of thumb (complete) (partial)
|
886.0–886.1
|
Traumatic amputation of other finger(s) (complete) (partial)
|
887.0–887.7
|
Traumatic amputation of arm and hand (complete) (partial)
|
890.0–890.2
|
Open wound of hip and thigh
|
891.0–891.2
|
Open wound of knee, leg (except thigh) and ankle
|
892.0–892.2
|
Open wound of foot except toe(s) alone
|
893.0–893.2
|
Open wound of toe(s)
|
894.0–894.2
|
Multiple and unspecified open wound of lower limb
|
895.0–895.1
|
Traumatic amputation of toe(s) (complete) (partial)
|
896.0–896.3
|
Traumatic amputation of foot (complete) (partial)
|
897.0–897.7
|
Traumatic amputation of leg(s) (complete) (partial)
|
910.8–910.9
|
Other and unspecified superficial injury of face, neck and scalp
|
911.8–911.9
|
Other and unspecified superficial injury of trunk
|
912.8–912.9
|
Other and unspecified superficial injury of shoulder and upper arm
|
913.8–913.9
|
Other and unspecified superficial injury of elbow, forearm, and wrist
|
914.8–914.9
|
Other and unspecified superficial injury of hand(s) except finger(s) alone
|
915.8–915.9
|
Other and unspecified superficial injury of finger(s)
|
916.8–916.9
|
Other and unspecified superficial injury of hip, thigh, leg, and ankle
|
917.8–917.9
|
Other and unspecified superficial injury of foot and toes
|
919.8–919.9
|
Other and unspecified superficial injury of other, multiple, and unspecified site
|
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.
Claims for hepatitis B vaccinations must include the identification number of the referring physician.
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
Utilization Guidelines
In accordance with CMS ruling 95-1(V), utilization of the service(s) should be consistent with locally acceptable standards of practice.
Compliance with the provisions in this LCD may be monitored and addressed through postpayment data analysis and subsequent medical review audits.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.
Sources of Information and Basis for Decision
J4 (CO, NM, OK, TX) MAC Consolidation
TrailBlazer adopted, unchanged, the TrailBlazer LCD, “Immunizations”, for the Jurisdiction 4 (J4) MAC transition.
Full disclosure of the sources of information is found with original contractor LCD.