Notification

Pegloticase (Krystexxa®)


Notification Issue Date: 10/01/2018



Policy Attachment


Attachment to Policy # 08.01.02d


Attachment:A

Policy #:08.01.02d

Description:ICD-10 Codes and Narratives

Title:Pegloticase (Krystexxa®)


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.



ICD-10 CODES AND NARRATIVES

MEDICALLY NECESSARY

M1A.00x0 Idiopathic chronic gout, unspecified site, without tophus (tophi)
M1A.00x1 Idiopathic chronic gout, unspecified site, with tophus (tophi)
M1A.0110 Idiopathic chronic gout, right shoulder, without tophus (tophi)
M1A.0111 Idiopathic chronic gout, right shoulder, with tophus (tophi)
M1A.0120 Idiopathic chronic gout, left shoulder, without tophus (tophi)
M1A.0121 Idiopathic chronic gout, left shoulder, with tophus (tophi)
M1A.0190 Idiopathic chronic gout, unspecified shoulder, without tophus (tophi)
M1A.0191 Idiopathic chronic gout, unspecified shoulder, with tophus (tophi)
M1A.0210 Idiopathic chronic gout, right elbow, without tophus (tophi)
M1A.0211 Idiopathic chronic gout, right elbow, with tophus (tophi)
M1A.0220 Idiopathic chronic gout, left elbow, without tophus (tophi)
M1A.0221 Idiopathic chronic gout, left elbow, with tophus (tophi)
M1A.0290 Idiopathic chronic gout, unspecified elbow, without tophus (tophi)
M1A.0291 Idiopathic chronic gout, unspecified elbow, with tophus (tophi)
M1A.0310 Idiopathic chronic gout, right wrist, without tophus (tophi)
M1A.0311 Idiopathic chronic gout, right wrist, with tophus (tophi)
M1A.0320 Idiopathic chronic gout, left wrist, without tophus (tophi)
M1A.0321 Idiopathic chronic gout, left wrist, with tophus (tophi)
M1A.0390 Idiopathic chronic gout, unspecified wrist, without tophus (tophi)
M1A.0391 Idiopathic chronic gout, unspecified wrist, with tophus (tophi)
M1A.0410 Idiopathic chronic gout, right hand, without tophus (tophi)
M1A.0411 Idiopathic chronic gout, right hand, with tophus (tophi)
M1A.0420 Idiopathic chronic gout, left hand, without tophus (tophi)
M1A.0421 Idiopathic chronic gout, left hand, with tophus (tophi)
M1A.0490 Idiopathic chronic gout, unspecified hand, without tophus (tophi)
M1A.0491 Idiopathic chronic gout, unspecified hand, with tophus (tophi)
M1A.0510 Idiopathic chronic gout, right hip, without tophus (tophi)
M1A.0511 Idiopathic chronic gout, right hip, with tophus (tophi)
M1A.0520 Idiopathic chronic gout, left hip, without tophus (tophi)
M1A.0521 Idiopathic chronic gout, left hip, with tophus (tophi)
M1A.0590 Idiopathic chronic gout, unspecified hip, without tophus (tophi)
M1A.0591 Idiopathic chronic gout, unspecified hip, with tophus (tophi)
M1A.0610 Idiopathic chronic gout, right knee, without tophus (tophi)
M1A.0611 Idiopathic chronic gout, right knee, with tophus (tophi)
M1A.0620 Idiopathic chronic gout, left knee, without tophus (tophi)
M1A.0621 Idiopathic chronic gout, left knee, with tophus (tophi)
M1A.0690 Idiopathic chronic gout, unspecified knee, without tophus (tophi)
M1A.0691 Idiopathic chronic gout, unspecified knee, with tophus (tophi)
M1A.0710 Idiopathic chronic gout, right ankle and foot, without tophus (tophi)
M1A.0711 Idiopathic chronic gout, right ankle and foot, with tophus (tophi)
M1A.0720 Idiopathic chronic gout, left ankle and foot, without tophus (tophi)
M1A.0721 Idiopathic chronic gout, left ankle and foot, with tophus (tophi)
M1A.0790 Idiopathic chronic gout, unspecified ankle and foot, without tophus (tophi)
M1A.0791 Idiopathic chronic gout, unspecified ankle and foot, with tophus (tophi)
M1A.08x0 Idiopathic chronic gout, vertebrae, without tophus (tophi)
M1A.08x1 Idiopathic chronic gout, vertebrae, with tophus (tophi)
M1A.09x0 Idiopathic chronic gout, multiple sites, without tophus (tophi)
M1A.09x1 Idiopathic chronic gout, multiple sites, with tophus (tophi)
M1A.10x0 Lead-induced chronic gout, unspecified site, without tophus (tophi)
M1A.10x1 Lead-induced chronic gout, unspecified site, with tophus (tophi)
M1A.1110 Lead-induced chronic gout, right shoulder, without tophus (tophi)
M1A.1111 Lead-induced chronic gout, right shoulder, with tophus (tophi)
M1A.1120 Lead-induced chronic gout, left shoulder, without tophus (tophi)
M1A.1121 Lead-induced chronic gout, left shoulder, with tophus (tophi)
M1A.1190 Lead-induced chronic gout, unspecified shoulder, without tophus (tophi)
M1A.1191 Lead-induced chronic gout, unspecified shoulder, with tophus (tophi)
M1A.1210 Lead-induced chronic gout, right elbow, without tophus (tophi)
M1A.1211 Lead-induced chronic gout, right elbow, with tophus (tophi)
M1A.1220 Lead-induced chronic gout, left elbow, without tophus (tophi)
M1A.1221 Lead-induced chronic gout, left elbow, with tophus (tophi)
M1A.1290 Lead-induced chronic gout, unspecified elbow, without tophus (tophi)
M1A.1291 Lead-induced chronic gout, unspecified elbow, with tophus (tophi)
M1A.1310 Lead-induced chronic gout, right wrist, without tophus (tophi)
M1A.1311 Lead-induced chronic gout, right wrist, with tophus (tophi)
M1A.1320 Lead-induced chronic gout, left wrist, without tophus (tophi)
M1A.1321 Lead-induced chronic gout, left wrist, with tophus (tophi)
M1A.1390 Lead-induced chronic gout, unspecified wrist, without tophus (tophi)
M1A.1391 Lead-induced chronic gout, unspecified wrist, with tophus (tophi)
M1A.1410 Lead-induced chronic gout, right hand, without tophus (tophi)
M1A.1411 Lead-induced chronic gout, right hand, with tophus (tophi)
M1A.1420 Lead-induced chronic gout, left hand, without tophus (tophi)
M1A.1421 Lead-induced chronic gout, left hand, with tophus (tophi)
M1A.1490 Lead-induced chronic gout, unspecified hand, without tophus (tophi)
M1A.1491 Lead-induced chronic gout, unspecified hand, with tophus (tophi)
M1A.1510 Lead-induced chronic gout, right hip, without tophus (tophi)
M1A.1511 Lead-induced chronic gout, right hip, with tophus (tophi)
M1A.1520 Lead-induced chronic gout, left hip, without tophus (tophi)
M1A.1521 Lead-induced chronic gout, left hip, with tophus (tophi)
M1A.1590 Lead-induced chronic gout, unspecified hip, without tophus (tophi)
M1A.1591 Lead-induced chronic gout, unspecified hip, with tophus (tophi)
M1A.1610 Lead-induced chronic gout, right knee, without tophus (tophi)
M1A.1611 Lead-induced chronic gout, right knee, with tophus (tophi)
M1A.1620 Lead-induced chronic gout, left knee, without tophus (tophi)
M1A.1621 Lead-induced chronic gout, left knee, with tophus (tophi)
M1A.1690 Lead-induced chronic gout, unspecified knee, without tophus (tophi)
M1A.1691 Lead-induced chronic gout, unspecified knee, with tophus (tophi)
M1A.1710 Lead-induced chronic gout, right ankle and foot, without tophus (tophi)
M1A.1711 Lead-induced chronic gout, right ankle and foot, with tophus (tophi)
M1A.1720 Lead-induced chronic gout, left ankle and foot, without tophus (tophi)
M1A.1721 Lead-induced chronic gout, left ankle and foot, with tophus (tophi)
M1A.1790 Lead-induced chronic gout, unspecified ankle and foot, without tophus (tophi)
M1A.1791 Lead-induced chronic gout, unspecified ankle and foot, with tophus (tophi)
M1A.18x0 Lead-induced chronic gout, vertebrae, without tophus (tophi)
M1A.18x1 Lead-induced chronic gout, vertebrae, with tophus (tophi)
M1A.19x0 Lead-induced chronic gout, multiple sites, without tophus (tophi)
M1A.19x1 Lead-induced chronic gout, multiple sites, with tophus (tophi)
M1A.20x0 Drug-induced chronic gout, unspecified site, without tophus (tophi)
M1A.20x1 Drug-induced chronic gout, unspecified site, with tophus (tophi)
M1A.2110 Drug-induced chronic gout, right shoulder, without tophus (tophi)
M1A.2111 Drug-induced chronic gout, right shoulder, with tophus (tophi)
M1A.2120 Drug-induced chronic gout, left shoulder, without tophus (tophi)
M1A.2121 Drug-induced chronic gout, left shoulder, with tophus (tophi)
M1A.2190 Drug-induced chronic gout, unspecified shoulder, without tophus (tophi)
M1A.2191 Drug-induced chronic gout, unspecified shoulder, with tophus (tophi)
M1A.2210 Drug-induced chronic gout, right elbow, without tophus (tophi)
M1A.2211 Drug-induced chronic gout, right elbow, with tophus (tophi)
M1A.2220 Drug-induced chronic gout, left elbow, without tophus (tophi)
M1A.2221 Drug-induced chronic gout, left elbow, with tophus (tophi)
M1A.2290 Drug-induced chronic gout, unspecified elbow, without tophus (tophi)
M1A.2291 Drug-induced chronic gout, unspecified elbow, with tophus (tophi)
M1A.2310 Drug-induced chronic gout, right wrist, without tophus (tophi)
M1A.2311 Drug-induced chronic gout, right wrist, with tophus (tophi)
M1A.2320 Drug-induced chronic gout, left wrist, without tophus (tophi)
M1A.2321 Drug-induced chronic gout, left wrist, with tophus (tophi)
M1A.2390 Drug-induced chronic gout, unspecified wrist, without tophus (tophi)
M1A.2391 Drug-induced chronic gout, unspecified wrist, with tophus (tophi)
M1A.2410 Drug-induced chronic gout, right hand, without tophus (tophi)
M1A.2411 Drug-induced chronic gout, right hand, with tophus (tophi)
M1A.2420 Drug-induced chronic gout, left hand, without tophus (tophi)
M1A.2421 Drug-induced chronic gout, left hand, with tophus (tophi)
M1A.2490 Drug-induced chronic gout, unspecified hand, without tophus (tophi)
M1A.2491 Drug-induced chronic gout, unspecified hand, with tophus (tophi)
M1A.2510 Drug-induced chronic gout, right hip, without tophus (tophi)
M1A.2511 Drug-induced chronic gout, right hip, with tophus (tophi)
M1A.2520 Drug-induced chronic gout, left hip, without tophus (tophi)
M1A.2521 Drug-induced chronic gout, left hip, with tophus (tophi)
M1A.2590 Drug-induced chronic gout, unspecified hip, without tophus (tophi)
M1A.2591 Drug-induced chronic gout, unspecified hip, with tophus (tophi)
M1A.2610 Drug-induced chronic gout, right knee, without tophus (tophi)
M1A.2611 Drug-induced chronic gout, right knee, with tophus (tophi)
M1A.2620 Drug-induced chronic gout, left knee, without tophus (tophi)
M1A.2621 Drug-induced chronic gout, left knee, with tophus (tophi)
M1A.2690 Drug-induced chronic gout, unspecified knee, without tophus (tophi)
M1A.2691 Drug-induced chronic gout, unspecified knee, with tophus (tophi)
M1A.2710 Drug-induced chronic gout, right ankle and foot, without tophus (tophi)
M1A.2711 Drug-induced chronic gout, right ankle and foot, with tophus (tophi)
M1A.2720 Drug-induced chronic gout, left ankle and foot, without tophus (tophi)
M1A.2721 Drug-induced chronic gout, left ankle and foot, with tophus (tophi)
M1A.2790 Drug-induced chronic gout, unspecified ankle and foot, without tophus (tophi)
M1A.2791 Drug-induced chronic gout, unspecified ankle and foot, with tophus (tophi)
M1A.28x0 Drug-induced chronic gout, vertebrae, without tophus (tophi)
M1A.28x1 Drug-induced chronic gout, vertebrae, with tophus (tophi)
M1A.29x0 Drug-induced chronic gout, multiple sites, without tophus (tophi)
M1A.29x1 Drug-induced chronic gout, multiple sites, with tophus (tophi)
M1A.30x0 Chronic gout due to renal impairment, unspecified site, without tophus (tophi)
M1A.30x1 Chronic gout due to renal impairment, unspecified site, with tophus (tophi)
M1A.3110 Chronic gout due to renal impairment, right shoulder, without tophus (tophi)
M1A.3111 Chronic gout due to renal impairment, right shoulder, with tophus (tophi)
M1A.3120 Chronic gout due to renal impairment, left shoulder, without tophus (tophi)
M1A.3121 Chronic gout due to renal impairment, left shoulder, with tophus (tophi)
M1A.3190 Chronic gout due to renal impairment, unspecified shoulder, without tophus (tophi)
M1A.3191 Chronic gout due to renal impairment, unspecified shoulder, with tophus (tophi)
M1A.3210 Chronic gout due to renal impairment, right elbow, without tophus (tophi)
M1A.3211 Chronic gout due to renal impairment, right elbow, with tophus (tophi)
M1A.3220 Chronic gout due to renal impairment, left elbow, without tophus (tophi)
M1A.3221 Chronic gout due to renal impairment, left elbow, with tophus (tophi)
M1A.3290 Chronic gout due to renal impairment, unspecified elbow, without tophus (tophi)
M1A.3291 Chronic gout due to renal impairment, unspecified elbow, with tophus (tophi)
M1A.3310 Chronic gout due to renal impairment, right wrist, without tophus (tophi)
M1A.3311 Chronic gout due to renal impairment, right wrist, with tophus (tophi)
M1A.3320 Chronic gout due to renal impairment, left wrist, without tophus (tophi)
M1A.3321 Chronic gout due to renal impairment, left wrist, with tophus (tophi)
M1A.3390 Chronic gout due to renal impairment, unspecified wrist, without tophus (tophi)
M1A.3391 Chronic gout due to renal impairment, unspecified wrist, with tophus (tophi)
M1A.3410 Chronic gout due to renal impairment, right hand, without tophus (tophi)
M1A.3411 Chronic gout due to renal impairment, right hand, with tophus (tophi)
M1A.3420 Chronic gout due to renal impairment, left hand, without tophus (tophi)
M1A.3421 Chronic gout due to renal impairment, left hand, with tophus (tophi)
M1A.3490 Chronic gout due to renal impairment, unspecified hand, without tophus (tophi)
M1A.3491 Chronic gout due to renal impairment, unspecified hand, with tophus (tophi)
M1A.3510 Chronic gout due to renal impairment, right hip, without tophus (tophi)
M1A.3511 Chronic gout due to renal impairment, right hip, with tophus (tophi)
M1A.3520 Chronic gout due to renal impairment, left hip, without tophus (tophi)
M1A.3521 Chronic gout due to renal impairment, left hip, with tophus (tophi)
M1A.3590 Chronic gout due to renal impairment, unspecified hip, without tophus (tophi)
M1A.3591 Chronic gout due to renal impairment, unspecified hip, with tophus (tophi)
M1A.3610 Chronic gout due to renal impairment, right knee, without tophus (tophi)
M1A.3611 Chronic gout due to renal impairment, right knee, with tophus (tophi)
M1A.3620 Chronic gout due to renal impairment, left knee, without tophus (tophi)
M1A.3621 Chronic gout due to renal impairment, left knee, with tophus (tophi)
M1A.3690 Chronic gout due to renal impairment, unspecified knee, without tophus (tophi)
M1A.3691 Chronic gout due to renal impairment, unspecified knee, with tophus (tophi)
M1A.3710 Chronic gout due to renal impairment, right ankle and foot, without tophus (tophi)
M1A.3711 Chronic gout due to renal impairment, right ankle and foot, with tophus (tophi)
M1A.3720 Chronic gout due to renal impairment, left ankle and foot, without tophus (tophi)
M1A.3721 Chronic gout due to renal impairment, left ankle and foot, with tophus (tophi)
M1A.3790 Chronic gout due to renal impairment, unspecified ankle and foot, without tophus (tophi)
M1A.3791 Chronic gout due to renal impairment, unspecified ankle and foot, with tophus (tophi)
M1A.38x0 Chronic gout due to renal impairment, vertebrae, without tophus (tophi)
M1A.38x1 Chronic gout due to renal impairment, vertebrae, with tophus (tophi)
M1A.39x0 Chronic gout due to renal impairment, multiple sites, without tophus (tophi)
M1A.39x1 Chronic gout due to renal impairment, multiple sites, with tophus (tophi)
M1A.40x0 Other secondary chronic gout, unspecified site, without tophus (tophi)
M1A.40x1 Other secondary chronic gout, unspecified site, with tophus (tophi)
M1A.4110 Other secondary chronic gout, right shoulder, without tophus (tophi)
M1A.4111 Other secondary chronic gout, right shoulder, with tophus (tophi)
M1A.4120 Other secondary chronic gout, left shoulder, without tophus (tophi)
M1A.4121 Other secondary chronic gout, left shoulder, with tophus (tophi)
M1A.4190 Other secondary chronic gout, unspecified shoulder, without tophus (tophi)
M1A.4191 Other secondary chronic gout, unspecified shoulder, with tophus (tophi)
M1A.4210 Other secondary chronic gout, right elbow, without tophus (tophi)
M1A.4211 Other secondary chronic gout, right elbow, with tophus (tophi)
M1A.4220 Other secondary chronic gout, left elbow, without tophus (tophi)
M1A.4221 Other secondary chronic gout, left elbow, with tophus (tophi)
M1A.4290 Other secondary chronic gout, unspecified elbow, without tophus (tophi)
M1A.4291 Other secondary chronic gout, unspecified elbow, with tophus (tophi)
M1A.4310 Other secondary chronic gout, right wrist, without tophus (tophi)
M1A.4311 Other secondary chronic gout, right wrist, with tophus (tophi)
M1A.4320 Other secondary chronic gout, left wrist, without tophus (tophi)
M1A.4321 Other secondary chronic gout, left wrist, with tophus (tophi)
M1A.4390 Other secondary chronic gout, unspecified wrist, without tophus (tophi)
M1A.4391 Other secondary chronic gout, unspecified wrist, with tophus (tophi)
M1A.4410 Other secondary chronic gout, right hand, without tophus (tophi)
M1A.4411 Other secondary chronic gout, right hand, with tophus (tophi)
M1A.4420 Other secondary chronic gout, left hand, without tophus (tophi)
M1A.4421 Other secondary chronic gout, left hand, with tophus (tophi)
M1A.4490 Other secondary chronic gout, unspecified hand, without tophus (tophi)
M1A.4491 Other secondary chronic gout, unspecified hand, with tophus (tophi)
M1A.4510 Other secondary chronic gout, right hip, without tophus (tophi)
M1A.4511 Other secondary chronic gout, right hip, with tophus (tophi)
M1A.4520 Other secondary chronic gout, left hip, without tophus (tophi)
M1A.4521 Other secondary chronic gout, left hip, with tophus (tophi)
M1A.4590 Other secondary chronic gout, unspecified hip, without tophus (tophi)
M1A.4591 Other secondary chronic gout, unspecified hip, with tophus (tophi)
M1A.4610 Other secondary chronic gout, right knee, without tophus (tophi)
M1A.4611 Other secondary chronic gout, right knee, with tophus (tophi)
M1A.4620 Other secondary chronic gout, left knee, without tophus (tophi)
M1A.4621 Other secondary chronic gout, left knee, with tophus (tophi)
M1A.4690 Other secondary chronic gout, unspecified knee, without tophus (tophi)
M1A.4691 Other secondary chronic gout, unspecified knee, with tophus (tophi)
M1A.4710 Other secondary chronic gout, right ankle and foot, without tophus (tophi)
M1A.4711 Other secondary chronic gout, right ankle and foot, with tophus (tophi)
M1A.4720 Other secondary chronic gout, left ankle and foot, without tophus (tophi)
M1A.4721 Other secondary chronic gout, left ankle and foot, with tophus (tophi)
M1A.4790 Other secondary chronic gout, unspecified ankle and foot, without tophus (tophi)
M1A.4791 Other secondary chronic gout, unspecified ankle and foot, with tophus (tophi)
M1A.48x0 Other secondary chronic gout, vertebrae, without tophus (tophi)
M1A.48x1 Other secondary chronic gout, vertebrae, with tophus (tophi)
M1A.49x0 Other secondary chronic gout, multiple sites, without tophus (tophi)
M1A.49x1 Other secondary chronic gout, multiple sites, with tophus (tophi)
M1A.9xx0 Chronic gout, unspecified, without tophus (tophi)
M1A.9xx1 Chronic gout, unspecified, with tophus (tophi)

EXPERIMENTAL INVESTIGATIONAL

E79.0 Hyperuricemia without signs of inflammatory arthritis and tophaceous disease [asymptomatic]


Version Effective Date: 01/01/2019
Version Issued Date: 12/31/2018
Version Reissued Date: N/A

Connect with Us        


© 2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.