Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA08.009h


Attachment:A

Policy #:MA08.009h

Description:ICD-10 DIAGNOSIS CODES

Title:Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.



MEDICALLY NECESSARY

SUBCUTANEOUS IMMUNE GLOBULIN (SCIG)
C9399, J1555, J1559, J1561, J1569, J1575, AND J3590 are medically necessary when reported with the following diagnosis codes:

D80.0 Hereditary hypogammaglobulinemia
D80.2 Selective deficiency of immunoglobulin A [IgA]
D80.3 Selective deficiency of immunoglobulin G [IgG] subclasses

D80.4 Selective deficiency of immunoglobulin M [IgM]
D80.5 Immunodeficiency with increased immunoglobulin M [IgM]
D80.6 Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia
D81.0 Severe combined immunodeficiency [SCID] with reticular dysgenesis
D81.1 Severe combined immunodeficiency [SCID] with low T- and B-cell numbers
D81.2 Severe combined immunodeficiency [SCID] with low or normal B-cell numbers
D81.5 Purine nucleoside phosphorylase [PNP] deficiency
D81.6 Major histocompatibility complex class I deficiency
D81.7 Major histocompatibility complex class II deficiency
D81.89 Other combined immunodeficiencies
D81.9 Combined immunodeficiency, unspecified
D82.0 Wiskott-Aldrich syndrome
D82.1 Di George's syndrome
D82.4
Hyperimmunoglobulin E [IgE] syndrome
D83.0 Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function
D83.1 Common variable immunodeficiency with predominant immunoregulatory T-cell disorders
D83.2 Common variable immunodeficiency with autoantibodies to B- or T-cells
D83.8 Other common variable immunodeficiencies
D83.9 Common variable immunodeficiency, unspecified
G11.3 Cerebellar ataxia with defective DNA repair
G61.81 Chronic inflammatory demyelinating polyneuritis

INTRAVENOUS IMMUNE GLOBULIN (IVIG)
J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, AND J1599 are medically necessary when reported with the following diagnosis codes:

B20 Human immunodeficiency virus [HIV] disease

B25.0 Cytomegaloviral pneumonitis

B25.1 Cytomegaloviral hepatitis

B25.2 Cytomegaloviral pancreatitis

B25.8 Other cytomegaloviral diseases

B25.9 Cytomegaloviral disease, unspecified

C90.00 Multiple myeloma not having achieved remission

C90.01 Multiple myeloma in remission

C90.02 Multiple myeloma 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

D47.2 Monoclonal gammopathy

D59.0 Drug-induced autoimmune hemolytic anemia

D59.1 Other autoimmune hemolytic anemias

D59.9 Acquired hemolytic anemia, unspecified

D61.01 Constitutional (pure) red blood cell aplasia

D68.0 Von Willebrand's disease

D68.311 Acquired hemophilia

D68.312 Antiphospholipid antibody with hemorrhagic disorder

D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors

D69.3 Immune thrombocytopenic purpura

D69.41 Evans syndrome

D69.42 Congenital and hereditary thrombocytopenia purpura

D69.49 Other primary thrombocytopenia

D80.0 Hereditary hypogammaglobulinemia
D80.2 Selective deficiency of immunoglobulin A [IgA]
D80.3 Selective deficiency of immunoglobulin G [IgG] subclasses
D80.4 Selective deficiency of immunoglobulin M [IgM]
D80.5 Immunodeficiency with increased immunoglobulin M [IgM]
D80.6 Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia
D81.0 Severe combined immunodeficiency [SCID] with reticular dysgenesis
D81.1 Severe combined immunodeficiency [SCID] with low T- and B-cell numbers

D81.2 Severe combined immunodeficiency [SCID] with low or normal B-cell numbers
D81.5 Purine nucleoside phosphorylase [PNP] deficiency
D81.6 Major histocompatibility complex class I deficiency
D81.7 Major histocompatibility complex class II deficiency
D81.89 Other combined immunodeficiencies
D81.9 Combined immunodeficiency, unspecified
D82.0 Wiskott-Aldrich syndrome
D82.1 Di George's syndrome
D82.4
Hyperimmunoglobulin E [IgE] syndrome
D83.0 Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function
D83.1 Common variable immunodeficiency with predominant immunoregulatory T-cell disorders
D83.2 Common variable immunodeficiency with autoantibodies to B- or T-cells
D83.8 Other common variable immunodeficiencies
D83.9 Common variable immunodeficiency, unspecified
D89.810 Acute graft-versus-host disease
D89.811 Chronic graft-versus-host disease
D89.812 Acute on chronic graft-versus-host disease
D89.813 Graft-versus-host disease, unspecified
G11.3 Cerebellar ataxia with defective DNA repair
G25.82 Stiff-man syndrome
G35 Multiple sclerosis
G60.3 Idiopathic progressive neuropathy
G61.0 Guillain-Barre syndrome
G61.81 Chronic inflammatory demyelinating polyneuritis
G61.82 Multifocal motor neuropathy
G61.89 Other inflammatory polyneuropathies

G61.9 Inflammatory polyneuropathy, unspecified
G62.81 Critical illness polyneuropathy
G62.89 Other specified polyneuropathies
G62.9 Polyneuropathy, unspecified
G64 Other disorders of peripheral nervous system

G70.00 Myasthenia gravis without (acute) exacerbation
G70.01 Myasthenia gravis with (acute) exacerbation
G70.80 Lambert-Eaton syndrome, unspecified
G70.81 Lambert-Eaton syndrome in disease classified elsewhere
G73.1 Lambert-Eaton syndrome in neoplastic disease

G73.3 Myasthenic syndromes in other diseases classified elsewhere

I78.8 Other diseases of capillaries

L10.0 Pemphigus vulgaris

L10.1 Pemphigus vegetans

L10.2 Pemphigus foliaceous

L10.3 Brazilian pemphigus [fogo selvagem]

L10.4 Pemphigus erythematosus

L10.5 Drug-induced pemphigus

L10.81 Paraneoplastic pemphigus

L10.89 Other pemphigus

L10.9 Pemphigus, unspecified

L12.0 Bullous pemphigoid

L12.1 Cicatricial pemphigoid

L12.30 Acquired epidermolysis bullosa, unspecified

L12.8 Other pemphigoid

L12.9 Pemphigoid, unspecified

L13.8 Other specified bullous disorders

L14 Bullous disorders in diseases classified elsewhere

L51.1 Stevens-Johnson syndrome

L51.2 Toxic epidermal necrolysis [Lyell]

L51.3 Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome

L90.8 Other atrophic disorders of skin

L91.8 Other hypertrophic disorders of the skin

L98.5 Mucinosis of the skin

M30.3 Mucocutaneous lymph node syndrome [Kawasaki]

M32.10 Systemic lupus erythematosus, organ or system involvement unspecified

M33.00 Juvenile dermatomyositis, organ involvement unspecified

M33.01 Juvenile dermatomyositis with respiratory involvement

M33.02 Juvenile dermatomyositis with myopathy

M33.09 Juvenile dermatomyositis with other organ involvement

M33.10 Other dermatomyositis, organ involvement unspecified

M33.11 Other dermatomyositis with respiratory involvement

M33.12 Other dermatomyositis with myopathy

M33.19 Other dermatomyositis with other organ involvement

M33.20 Polymyositis, organ involvement unspecified

M33.21 Polymyositis with respiratory involvement

M33.22 Polymyositis with myopathy

M33.29 Polymyositis with other organ involvement

M33.90 Dermatopolymyositis, unspecified, organ involvement unspecified

M33.91 Dermatopolymyositis, unspecified with respiratory involvement

M33.92 Dermatopolymyositis, unspecified with myopathy

M33.99 Dermatopolymyositis, unspecified with other organ involvement

M36.0 Dermato(poly)myositis in neoplastic disease

O36.0910 Maternal care for other rhesus isoimmunization, first trimester, not applicable or unspecified

O36.0911 Maternal care for other rhesus isoimmunization, first trimester, fetus 1

O36.0912 Maternal care for other rhesus isoimmunization, first trimester, fetus 2

O36.0913 Maternal care for other rhesus isoimmunization, first trimester, fetus 3

O36.0914 Maternal care for other rhesus isoimmunization, first trimester, fetus 4

O36.0915 Maternal care for other rhesus isoimmunization, first trimester, fetus 5

O36.0919 Maternal care for other rhesus isoimmunization, first trimester, other fetus

O36.0920 Maternal care for other rhesus isoimmunization, second trimester, not applicable or unspecified

O36.0921 Maternal care for other rhesus isoimmunization, second trimester, fetus 1

O36.0922 Maternal care for other rhesus isoimmunization, second trimester, fetus 2

O36.0923 Maternal care for other rhesus isoimmunization, second trimester, fetus 3

O36.0924 Maternal care for other rhesus isoimmunization, second trimester, fetus 4

O36.0925 Maternal care for other rhesus isoimmunization, second trimester, fetus 5

O36.0929 Maternal care for other rhesus isoimmunization, second trimester, other fetus

O36.0930 Maternal care for other rhesus isoimmunization, third trimester, not applicable or unspecified

O36.0931 Maternal care for other rhesus isoimmunization, third trimester, fetus 1

O36.0932 Maternal care for other rhesus isoimmunization, third trimester, fetus 2

O36.0933 Maternal care for other rhesus isoimmunization, third trimester, fetus 3

O36.0934 Maternal care for other rhesus isoimmunization, third trimester, fetus 4

O36.0935 Maternal care for other rhesus isoimmunization, third trimester, fetus 5

O36.0939 Maternal care for other rhesus isoimmunization, third trimester, other fetus

O36.0990 Maternal care for other rhesus isoimmunization, unspecified trimester, not applicable or unspecified

O36.0991 Maternal care for other rhesus isoimmunization, unspecified trimester, fetus 1

O36.0992 Maternal care for other rhesus isoimmunization, unspecified trimester, fetus 2

O36.0993 Maternal care for other rhesus isoimmunization, unspecified trimester, fetus 3

O36.0994 Maternal care for other rhesus isoimmunization, unspecified trimester, fetus 4

O36.0995 Maternal care for other rhesus isoimmunization, unspecified trimester, fetus 5

O36.0999 Maternal care for other rhesus isoimmunization, unspecified trimester, other fetus

P07.00 Extremely low birth weight newborn, unspecified weight

P07.01 Extremely low birth weight newborn, less than 500 grams

P07.02 Extremely low birth weight newborn, 500-749 grams

P07.03 Extremely low birth weight newborn, 750-999 grams

P07.10 Other low birth weight newborn, unspecified weight

P07.14 Other low birth weight newborn, 1000-1249 grams

P07.15 Other low birth weight newborn, 1250-1499 grams

T86.00 Unspecified complication of bone marrow transplant

T86.01 Bone marrow transplant rejection

T86.02 Bone marrow transplant failure

T86.03 Bone marrow transplant infection

T86.09 Other complications of bone marrow transplant

T86.11 Kidney transplant rejection

T86.21 Heart transplant rejection

T86.31 Heart-lung transplant rejection

T86.5 Complications of stem cell transplant

T86.810 Lung transplant rejection

Z48.21 Encounter for aftercare following heart transplant

Z48.22 Encounter for aftercare following kidney transplant

Z48.23 Encounter for aftercare following liver transplant

Z48.24 Encounter for aftercare following lung transplant

Z48.280 Encounter for aftercare following heart-lung transplant

Z48.290 Encounter for aftercare following bone marrow transplant

Z48.298 Encounter for aftercare following other organ transplant

Z94.0 Kidney transplant status

Z94.1 Heart transplant status

Z94.2 Lung transplant status

Z94.3 Heart and lungs transplant status

Z94.4 Liver transplant status

Z94.81 Bone marrow transplant status

Z94.84 Stem cells transplant status


THE FOLLOWING PIDD DIAGNOSIS CODES REQUIRE FURTHER REVIEW TO ENSURE THAT THE IMMUNODEFICIENCY IS OF PRIMARY ORIGIN:

D80.1 Nonfamilial hypogammaglobulinemia

D80.7 Transient hypogammaglobulinemia of infancy



NOT COVERED

INTRAVENOUS IMMUNE GLOBULIN (IVIG)

IVIG is not covered for the following diagnosis:

G72.41 Inclusion body myositis [IBM]

Version Effective Date: 10/21/2019
Version Issued Date: 10/21/2019
Version Reissued Date: N/A

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