Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 08.00.13v


Attachment:B

Policy #:08.00.13v

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.



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

THIS IS NOT AN ALL INCLUSIVE LIST

D71 Functional disorders of polymorphonuclear neutrophils

D80.0 Hereditary hypogammaglobulinemia

D80.1 Nonfamilial 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

D80.8 Other immunodeficiencies with predominantly antibody defects

D80.9 Immunodeficiency with predominantly antibody defects, unspecified

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

D81.4 Nezelof's syndrome
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

D82.3 Immunodeficiency following hereditary defective response to Epstein-Barr virus

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:

THIS IS NOT AN ALL INCLUSIVE LIST

A48.3 Toxic shock syndrome

B20 Human immunodeficiency virus [HIV] disease

B97.6 Parvovirus as the cause of diseases classified elsewhere

D47.2 Monoclonal gammopathy

D59.0 Drug-induced autoimmune hemolytic anemia

D59.1 Other autoimmune hemolytic anemias

D63.8 Anemia in other chronic diseases classified elsewhere

D66 Hereditary factor VIII deficiency

D68.0 Von Willebrand's disease

D68.311 Acquired hemophilia
D68.61 Antiphospholipid syndrome
D69.3 Immune thrombocytopenic purpura

D70.8 Other neutropenia

D71 Functional disorders of polymorphonuclear neutrophils

D80.0 Hereditary hypogammaglobulinemia

D80.1 Nonfamilial 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

D80.8 Other immunodeficiencies with predominantly antibody defects

D80.9 Immunodeficiency with predominantly antibody defects, unspecified

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

D81.4 Nezelof's syndrome

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

D82.3 Immunodeficiency following hereditary defective response to Epstein-Barr virus

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

E83.118 Other hemochromatosis

G04.00 Acute disseminated encephalitis and encephalomyelitis, unspecified

G04.01 Postinfectious acute disseminated encephalitis and encephalomyelitis (postinfectious ADEM)

G04.02 Postimmunization acute disseminated encephalitis, myelitis and encephalomyelitis

G04.81 Other encephalitis and encephalomyelitis

G11.3 Cerebellar ataxia with defective DNA repair

G25.82 Stiff-man syndrome

G35 Multiple sclerosis

G36.0 Neuromyelitis optica [Devic]
G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus
G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus
G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus

G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus

G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus

G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus

G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus

G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus

G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus

G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus

G40.803 Other epilepsy, intractable, with status epilepticus

G40.804 Other epilepsy, intractable, without status epilepticus

G40.813 Lennox-Gastaut syndrome, intractable, with status epilepticus

G40.814 Lennox-Gastaut syndrome, intractable, without status epilepticus
G40.823 Epileptic spasms, intractable, with status epilepticus

G40.824 Epileptic spasms, intractable, without status epilepticus

G40.911 Epilepsy, unspecified, intractable, with status epilepticus

G40.919 Epilepsy, unspecified, intractable, without status epilepticus
G40.A11 Absence epileptic syndrome, intractable, with status epilepticus
G40.A19 Absence epileptic syndrome, intractable, without status epilepticus

G40.B11 Juvenile myoclonic epilepsy, intractable, with status epilepticus

G40.B19 Juvenile myoclonic epilepsy, intractable, without status epilepticus

G61.0 Guillain-Barre syndrome

G61.81 Chronic inflammatory demyelinating polyneuritis

G61.82 Multifocal motor neuropathy

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

I78.8 Other diseases of capillaries

L10.0 Pemphigus vulgaris

L10.2 Pemphigus foliaceous

L12.0 Bullous pemphigoid

L12.1 Cicatricial pemphigoid

L12.30 Acquired epidermolysis bullosa, unspecified

L12.31 Epidermolysis bullosa due to drug

L12.35 Other acquired epidermolysis bullosa

L51.1 Stevens-Johnson syndrome

L51.2 Toxic epidermal necrolysis [Lyell]

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

L51.9 Erythema multiforme, unspecified

L98.5 Mucinosis of the skin

M30.1 Polyarteritis with lung involvement [Churg-Strauss]

M30.3 Mucocutaneous lymph node syndrome [Kawasaki]

M31.30 Wegener's granulomatosis without renal involvement

M31.31 Wegener's granulomatosis with renal involvement

M31.7 Microscopic polyangiitis

M32.0 Drug-induced systemic lupus erythematosus

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

M32.11 Endocarditis in systemic lupus erythematosus

M32.12 Pericarditis in systemic lupus erythematosus

M32.13 Lung involvement in systemic lupus erythematosus

M32.14 Glomerular disease in systemic lupus erythematosus

M32.15 Tubulo-interstitial nephropathy in systemic lupus erythematosus

M32.19 Other organ or system involvement in systemic lupus erythematosus

M32.8 Other forms of systemic lupus erythematosus

M32.9 Systemic lupus erythematosus, unspecified

M33.00 Juvenile dermatomyositis, organ involvement unspecified

M33.01 Juvenile dermatomyositis with respiratory involvement

M33.02 Juvenile dermatomyositis with myopathy

M33.03 Juvenile dermatomyositis without 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

M33.13 Other dermatomyositis without 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

M33.93 Dermatopolymyositis, unspecified without myopathy

M33.99 Dermatopolymyositis, unspecified with other organ involvement

M36.0 Dermato(poly)myositis in neoplastic disease

O36.8210 Fetal anemia and thrombocytopenia, first trimester, not applicable or unspecified

O36.8211 Fetal anemia and thrombocytopenia, first trimester, fetus 1

O36.8212 Fetal anemia and thrombocytopenia, first trimester, fetus 2

O36.8213 Fetal anemia and thrombocytopenia, first trimester, fetus 3

O36.8214 Fetal anemia and thrombocytopenia, first trimester, fetus 4

O36.8215 Fetal anemia and thrombocytopenia, first trimester, fetus 5

O36.8219 Fetal anemia and thrombocytopenia, first trimester, other fetus

O36.8220 Fetal anemia and thrombocytopenia, second trimester, not applicable or unspecified

O36.8221 Fetal anemia and thrombocytopenia, second trimester, fetus 1

O36.8222 Fetal anemia and thrombocytopenia, second trimester, fetus 2

O36.8223 Fetal anemia and thrombocytopenia, second trimester, fetus 3

O36.8224 Fetal anemia and thrombocytopenia, second trimester, fetus 4

O36.8225 Fetal anemia and thrombocytopenia, second trimester, fetus 5

O36.8229 Fetal anemia and thrombocytopenia, second trimester, other fetus

O36.8230 Fetal anemia and thrombocytopenia, third trimester, not applicable or unspecified

O36.8231 Fetal anemia and thrombocytopenia, third trimester, fetus 1

O36.8232 Fetal anemia and thrombocytopenia, third trimester, fetus 2

O36.8233 Fetal anemia and thrombocytopenia, third trimester, fetus 3

O36.8234 Fetal anemia and thrombocytopenia, third trimester, fetus 4

O36.8235 Fetal anemia and thrombocytopenia, third trimester, fetus 5

O36.8239 Fetal anemia and thrombocytopenia, third trimester, other fetus

O36.8290 Fetal anemia and thrombocytopenia, unspecified trimester, not applicable or unspecified

O36.8291 Fetal anemia and thrombocytopenia, unspecified trimester, fetus 1

O36.8292 Fetal anemia and thrombocytopenia, unspecified trimester, fetus 2

O36.8293 Fetal anemia and thrombocytopenia, unspecified trimester, fetus 3

O36.8294 Fetal anemia and thrombocytopenia, unspecified trimester, fetus 4

O36.8295 Fetal anemia and thrombocytopenia, unspecified trimester, fetus 5

O36.8299 Fetal anemia and thrombocytopenia, unspecified trimester, other fetus

O99.111 Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, first trimester

O99.112 Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, second trimester

O99.113 Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, third trimester

O99.119 Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, unspecified trimester

P55.0 Rh isoimmunization of newborn

P55.1 ABO isoimmunization of newborn

P61.0 Transient neonatal thrombocytopenia

P78.84 Gestational alloimmune liver disease
T86.01 Bone marrow transplant rejection

T86.11 Kidney transplant rejection

T86.21 Heart transplant rejection

T86.31 Heart-lung transplant rejection

T86.41 Liver transplant rejection

T86.5 Complications of stem cell transplant

T86.810 Lung transplant rejection

T86.850 Intestine transplant rejection

T86.890 Other transplanted tissue rejection

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

Z94.82 Intestine transplant status

Z94.84 Stem cells transplant status

Version Effective Date: 10/21/2019
Version Issued Date: 10/21/2019
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.