This article contains billing and coding guidelines that complement the Local Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and Off-Label Uses.
The intravenous form of ibandronate was approved by the Food and Drug Administration (FDA) for use every three (3) months.
Specific coding guidelines for this drug:
Ibandronate sodium is available in oral and intravenous forms. National Government Services will consider the intravenous form to be “reasonable and necessary” only for patients for whom biphosphonate therapy including oral ibandronate sodium is medically necessary and who cannot tolerate oral therapy. Documentation must show that the patient cannot tolerate oral biphosphonates or that they are otherwise medically contraindicated.
Coding Information:
- When submitting claims for senile osteoporosis or other osteoporosis, ICD-10-CM code K20.80, K20.81, K20.90, K20.91 or Z87.19 should only be added to claims to indicate that the patient has severe esophagitis and cannot take the oral drugs.
- When submitting claims for senile osteoporosis or other osteoporosis, ICD-10-CM code T50.995A-T50.995S, Y63.8, Z91.89 or Z92.89 should only be added to claims to indicate that the patient cannot tolerate oral ibandronate sodium.
- For management of hypercalcemia of malignancy (E83.52), the rationale for the use of the drug and the related malignancy must be documented in the patient’s medical record.
- When submitting claims for patients with osteoporosis as a complication of transplant, the related complication of transplant code as well as T50.995A-T50.995S or Z87.19 is required.
- When ibandronate is used to prevent osteoporosis in a postmenopausal woman who is not being treated for osteopenia, the claim should include the -GY modifier which will result in denial of Medicare payment.
Utilization:
Dose and frequency should be in accordance with the FDA label or recognized compendia (for off-label uses). When services are performed in excess of established parameters, they may be subject to review for medical necessity.
FDA and Compendia Review:
American Society of Health-System Pharmacists, Inc. AHFS Drug Information®. Bethesda, MD: 2007.
Clinical Pharmacology Web site. http://www.clinicalpharmacology.com/. Accessed 08/21/2023.
Lexi-Drugs Web site. http://online.lexi.com. Accessed 08/21/2023.
Micromedex DrugDex®. http://www.micromedexsolutions.com/home/dispatch. Accessed 08/21/2023.
National Comprehensive Cancer Network Web site. http://www.nccn.org/index.asp. Accessed 08/21/2023.
U.S. Food and Drug Administration label approved 01/06/2006 accessed on line at http://www.accessdata.fda.gov/scripts/cder/drugsatfda/ on 11/19/2007.
United States Pharmacopoeia (USP), Volume I; Drug Information for the Health Care Professional, 2007.
