Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA08.007q


Attachment:F

Policy #:MA08.007q

Description:Diagnosis codes that represent primary immunodeficiencies that are covered under the Medicare medical benefit (Part B) for intravenous immune globulin when given in the home setting

Title:Medicare Part B vs. Part D Crossover Drugs

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


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.


PRIMARY IMMUNODEFICIENCY DIAGNOSIS CODES

Intravenous Immune Globulin (IVIG) is covered under the Medicare medical benefit (Part B) when given in the home setting for the following primary immunodeficiencies:

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

D80.7 Transient hypogammaglobulinemia of infancy

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

Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A

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