Local Coverage Article

External Infusion Pumps - Policy Article

A52507

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Article ID
A52507
Article Title
External Infusion Pumps - Policy Article
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
07/18/2021
Revision Ending Date
N/A
Retirement Date
N/A
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Article Guidance

Article Text

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”).

External infusion pumps are covered under the Durable Medical Equipment benefit (Social Security Act §1861(s)(6)). In order for a beneficiary’s equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.

Drugs are only covered as a supply to a covered DME infusion pump. Drugs billed alone (without a covered pump being used) will be denied as statutorily noncovered (no benefit).

Infusion drugs started in a practitioner’s office, whether with or without a pump, must be billed to the local carrier and not the DME MAC. In these cases, the drug or biological may potentially be covered under section 1861(s)(2)(A) and (B) of the Act and is billable to the A/B MAC even though the entire administration of the drug or biological did not occur in the practitioner’s office or the hospital outpatient department. Equipment, such as an external infusion pump used to begin administration of the drug or biological that the patient takes home to complete the infusion, is not separately billable as durable medical equipment for a drug or biological paid under the section 1861(s)(2)(A) and (B) incident to benefit. These claims will be rejected as wrong jurisdiction. 

Disposable drug delivery systems, including elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the Medicare definition of durable medical equipment. Drugs and supplies used with disposable drug delivery systems are also non-covered items.

Catheter insertion devices for use with external insulin infusion pump infusion cannulas are included in the allowance for code A4224 and are not separately payable.

The DME MACs do not process claims for implantable infusion pumps (E0782, E0783, E0785, and E0786) or drugs and supplies used in conjunction with an implantable infusion pump. Claims for these items must be submitted to the A/B MAC.

Replacement batteries (K0601, K0602, K0603, K0604, K0605) are not separately payable when billed with a rented infusion pump.

Medicare only pays for one pump (K0455) for administering epoprostenol and treprostinil; the supplier is responsible for ensuring that there is an appropriate and acceptable contingency plan to address any emergency situations or mechanical failures of the equipment. A second pump provided as a backup will be denied as not separately payable.

REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provides a list of the specified codes, which is periodically updated. The link will be located here once it is available.

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD- related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.

Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.

DME INFORMATION FORM (DIF)

A DME Information Form (DIF) which has been completed, signed, and dated by the supplier, must be kept on file by the supplier and made available upon request.

The DIF for External Infusion Pumps is CMS Form 10125. The initial claim must include an electronic copy of the DIF.

A revised DIF must be submitted if:

  • A beneficiary begins using an infusion for one drug and subsequently the drug is changed, another drug is added, or if the code for a current drug changes. The additional new or changed drug or the new HCPCS code for the existing drug must be listed along with all other drugs for which the pump is used.
  • There is a change in the route of administration or a change in the method of administration of a drug.
  • The length of need previously entered on the DIF has expired and the ordering practitioner is extending the length of need for the item(s).

If information on an inotropic drug is requested, the supplier must submit a copy of the order and clinical documentation which includes information relating to each of the criteria (D1-D4) defined in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD. This information must come from the medical record.

For parenteral inotropic drugs, the cardiologist with training in the management of advanced heart failure who performs the initial evaluation does not need to be the prescriber for the parenteral inotropic drug. However, the prescribing practitioner must:

  • Verify that an initial evaluation was performed by a cardiologist with training in the management of advanced heart failure; and
  • Have documentation of the evaluation; and,
  • Provide a copy of the initial evaluation and the prescription for the item(s) to the DMEPOS supplier.

Parenteral inotropic claims that are grandfathered must also be in compliance with Medicare Claims Processing Manual (CMS Internet Only Manual 100-04) Chapter 20 break-in-service rules.

If additional information on epoprostenol or treprostinil is requested, the supplier should submit signed and dated information from the treating practitioner stating the beneficiary's diagnosis, the beneficiary's current symptoms caused by pulmonary hypertension, and date and results of the pulmonary artery pressure. There must be a statement that the pulmonary hypertension is not secondary to pulmonary venous hypertension or a disorder of the respiratory system. There must be a statement of whether oral calcium channel blocking agents were tried and if so, the results, and if not, why a trial was not conducted.

MODIFIERS

JB MODIFIER

For immune globulins (J1555, J1558, J1559, J1561, J1562, J1569, and J7799 (Cutaquig)) and associated infusion pump (E0779) claims where the route of administration is subcutaneous, a JB modifier must be added to each HCPCS code.

For immune globulin (J1558, J1575 and J7799 (Cutaquig)) and associated infusion pump (E0781) claims where the route of administration is subcutaneous, a JB modifier must be added to each HCPCS code.

For other methods of administration, no modifier should be added.

JW MODIFIER

Effective for claims with dates of service on or after January 1, 2017, the JW modifier must be used when billing for discarded drugs and biologicals.

Multi-use vials are not subject to payment for discarded amounts of drug or biologicals.

Because of the HCPCS code descriptors and the associated Units of Service (UOS) for DMEPOS items, the DME MACs expect rare use of the JW modifier on claims.

There are two scenarios that can occur:

Scenario 1
When the HCPCS code UOS is less than the drug quantity contained in the single use vial or single dose package, the following applies:

  • The quantity administered is billed on one claim line without the JW modifier; and,
  • The quantity discarded is billed on a separate claim line with the JW modifier.

In this scenario, the JW modifier must be billed on a separate line to provide payment for the amount of discarded drug or biological. For example:

  • A single use vial is labeled to contain 100 mg of a drug.
  • The drug's HCPCS code UOS is 1 UOS = 1 mg.
  • 95 mg of the 100 mg in the vial are administered to the beneficiary.
  • 5 mg remaining in the vial are discarded.
  • The 95 mg dose is billed on one claim line as 95 UOS.
  • The discarded 5 mg is billed as 5 UOS on a separate claim line with the JW modifier.
  • Both claim line items would be processed for payment.

Scenario 2
When the HCPCS code UOS is equal to or greater than the total of the actual dose and the amount discarded, use of the JW modifier is not permitted. If the quantity of drug administered is less that a full UOS, the billed UOS is rounded to the appropriate UOS. For example:

  • A single use vial is labeled to contain 100 mg of a drug.
  • The drug's HCPCS code UOS is 1 UOS = 100 mg.
  • 70 mg of the 100 mg in the vial are administered to the beneficiary.
  • 30 mg remaining in the vial are discarded.
  • The 70 mg dose is billed correctly by rounding up to one UOS (representing the entire 100 mg vial) on a single line item.
  • The single line item of 1 UOS would be processed for payment of the combined total 100 mg of administered and discarded drug.
  • The discarded 30 mg must not be billed as another 1 UOS on a separate line item with the JW modifier. Billing an additional 1 UOS for the discarded drug with the JW modifier is incorrect billing and will result in an overpayment.

Effective for claims with dates of service on or after January 1, 2017, suppliers must add a JW modifier to codes for infusion drugs, only if all of the criteria in the “Coverage Indications, Limitations and/or Medical Necessity” section of the related LCD have been met.

KX, GA, GY and GZ MODIFIERS:

For all claims for external insulin infusion pumps (E0784) and insulin (J1817), if the results of the beneficiary's C-peptide level or beta cell autoantibody test meet the requirements outlined in section IV of the Coverage Indications, Limitations, and/or Medical Necessity in the related LCD, a KX modifier should be added to the HCPCS code.

In the situation above describing use of the KX modifier, if all of the coverage criteria have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.

Claim lines billed for the above services without a KX, GA, or GZ modifier will be rejected as missing information.

An infusion drug not administered using a durable infusion pump must be billed using the appropriate HCPCS code plus the GY modifier.

CODING GUIDELINES

An ambulatory infusion pump (E0781) is an electrical or battery operated device, which is used to deliver solutions containing a parenteral drug under pressure at a regulated flow rate. It is small, portable, and designed to be carried by the beneficiary.

A stationary infusion pump (E0791) is an electrical device, which serves the same purpose as an ambulatory pump but is larger and typically mounted on a pole.

A disposable drug delivery system (A4305, A4306, A9274) is a device used to deliver solutions containing injectable drugs that is not reusable, i.e., it is used by a single beneficiary for a limited time and then discarded.

An infusion controller (E1399) is an electrical device, which regulates the flow of parenteral solutions under gravity pressure.

A reusable mechanical infusion pump (E0779) is a device used to deliver solutions containing parenteral drugs under pressure at a constant flow rate determined by the tubing with which it is used. It is small, portable, and designed to be carried by the beneficiary. It must be capable of a single infusion cycle of at least 8 hours.

Code E0780 describes a mechanical infusion pump which is similar to an E0779 pump, but which is only capable of a single infusion cycle of less than 8 hours.

Code K0455 describes an ambulatory electrical infusion pump, which is used for the administration of epoprostenol (J1325) and treprostinil (J3285).

Code A4221 describes all necessary supplies, such as dressings for the catheter site and flush solutions, not directly related to non-insulin drug infusions. The catheter site may be a peripheral intravenous line, a subcutaneous infusion catheter, a peripherally inserted central catheter (PICC), a centrally inserted intravenous line with either an external or a subcutaneous port, or an epidural catheter.

Code A4222 includes the cassette or bag, diluting solutions, tubing and other administration supplies, port cap changes, compounding charges, and preparation charges. This code is not used for a syringe-type reservoir.

Code K0552 describes a syringe-type reservoir that is used with the K0455 pump when it is used to administer epoprostenol/treprostinil, or with an E0779 pump used to administer subcutaneous immune globulin. The reservoir may be either glass or plastic and includes the needle for drawing up the drug. This code does not include the drug for use in the reservoir. Code A4232 is invalid for submission to Medicare and should not be used for this purpose.

Claims for codes A4221, A4222 and K0552 must only be used with a non-insulin external infusion pump (E0779, E0780, E0781, E0791 or K0455). Claims with dates of service on or after January 01, 2017 for codes A4221, A4222 and K0552 used with an external infusion pump HCPCS code E0784 are incorrectly coded.

Code A4224 is all-inclusive and describes all necessary supplies (excluding the insulin reservoir – see code A4225) used with an external infusion pump (E0784) for the administration of continuous subcutaneous insulin and includes, but is not limited to, all cannulas, needles, dressings and infusion supplies. Separate billing for any item including an item using a specific HCPCS code, if one exists, will be denied as unbundling.

Code A4225 describes a syringe-type reservoir that is used with the external insulin infusion pump (E0784).

Claims for codes A4224 and A4225 must only be used with insulin infusion pumps (E0784). Claims with dates of service on or after January 01, 2017 for codes A4224 and A4225 used with an external infusion pump other than code E0784 are incorrectly coded.

HCPCS Supply Codes Associated with External Infusion Pumps HCPCS Codes

The following table describes HCPCS supply codes that are used with different types of external infusion pumps. The HCPCS codes listed in the “Associated Codes” column should be used with the corresponding “Pump HCPCS code.” Claims for supply codes listed in the “Non-Associated Codes” column will be denied as incorrect coding, if they are being used with an external infusion pump listed in the “Pump HCPCS Code” column of the same line.

Pump HCPCS Code Associated Codes Non-Associated Codes
E0779 A4221, A4222, K0552* A4224, A4225
E0780 A4221, A4222 A4224, A4225, K0552
E0781 A4221, A4222 A4224, A4224, K0552
E0784 A4224, A4225 A4221, A4222, K0552
E0791 A4221, A4222 A4224, A4225, K0552
K0455 A4221, A4222, K0552* A4224, A4225


*
For E0779 and K0455 pumps, either A4222 or K0552 may be billed, but not both.

Insulin infusion pumps with integrated continuous glucose sensing capabilities must be coded using HCPCS codes E0784 (EXTERNAL AMBULATORY INFUSION PUMP, INSULIN) and K0554 (RECEIVER (MONITOR), DEDICATED, FOR USE WITH THERAPEUTIC GLUCOSE CONTINUOUS MONITOR SYSTEM). The related accessories/supplies for these integrated units must be coded using HCPCS codes A4224 (SUPPLIES FOR MAINTENANCE OF INSULIN INFUSION CATHETER, PER WEEK), A4225 (SUPPLIES FOR EXTERNAL INSULIN INFUSION PUMP, SYRINGE TYPE CARTRIDGE, STERILE, EACH), and K0553 (SUPPLY ALLOWANCE FOR THERAPEUTIC CONTINUOUS GLUCOSE MONITOR (CGM), INCLUDES ALL SUPPLIES AND ACCESSORIES, 1 MONTH SUPPLY = 1 UNIT OF SERVICE). Please refer to the Glucose Monitors LCD related Policy Article (A52464) for more information regarding coding guidelines for continuous glucose monitors.

Codes A4230 (infusion set for external insulin pump, non-needle cannulas type) and A4231 (infusion set for external insulin pump, needle type) are not valid for claim submission to the DME MAC because they are included in code A4224.

Use A4223 for infusion supplies not used with a covered external infusion pump.

Drugs used in a durable external infusion pump must be coded using the appropriate HCPCS codes. If the drug does not have a distinct code, then use the unclassified drug code J7799. Do not use code J9999 - this code is not valid for claims billed to the DME MAC.

An infusion drug not administered using a durable infusion pump must be billed using the appropriate HCPCS code plus the GY modifier. If the drug does not have a unique code, use the unclassified drug code, J3490.

Use code J2274 only for morphine sulfate that is labeled "preservative free.” Morphine sulfate that is not labeled "preservative free" must be coded J2270.

Use code J1817 for insulin administered through an external insulin pump (E0784).

Codes A4602, K0604 and K0605 describe lithium batteries commonly used in external infusion pumps. Note that each code has an associated voltage. Claims for lithium batteries for external insulin infusion pumps (E0784) that do not use a voltage described by either code A4602, K0604 and K0605 must be billed using code A9999.

Levodopa-Carbidopa enteral suspension is supplied as a single-use cassette. One unit of service contains 2000 mg levodopa and 500 mg carbidopa in 100 mL of enteral suspension. 

Claims for levodopa-carbidopa for dates of service on or after January 09, 2015 through December 31, 2015, must be submitted using the DME miscellaneous code J7799 (NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME).

Claims for levodopa-carbidopa for dates of service on or after January 01, 2016 must be submitted using the HCPCS code J7340 (CARBIDOPA 5 MG/LEVODOPA 20 MG ENTERAL SUSPENSION, 100 ML).

One unit of service (UOS) of blinatumomab (J9039) equals one (1) microgram (mcg), and thus, 1 vial equals 35 UOS. Reconstituted blinatumomab must be prepared using the combination of vials that result in the least amount of wastage for the dosage amount being administered. There are two alternative infusion protocols that can be used. For each protocol, the following apply:

  • For beneficiaries using a 2-day infusion protocol, five (5) vials (175 UOS) should be used to reconstitute three bags, each containing 56 mcg (56 UOS) of blinatumomab, which can be refrigerated (2°C to 8°C), and used within six-days.
  • For beneficiaries utilizing a 7-day infusion protocol, six (6) vials (210 UOS) should be used to reconstitute one bag (containing 210 mcg of blinatumomab), which is infused over 7 days.

Claims for blinatumomab for dates of service on or after December 03, 2014 through December 31, 2015, must be submitted using the DME miscellaneous code J7799 (NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME).

Claims for blinatumomab for dates of service on or after January 01, 2016, must be submitted using the HCPCS code J9039 (INJECTION, BLINATUMOMAB, 1 MICROGRAM).

HYQVIA is administered subcutaneously through an E0781 pump that is pre-programmed, and the E0781 pump must be delivered to the Medicare beneficiary in a “locked mode” (i.e., the patient is unable to self-adjust the infusion rate).

Claims for HYQVIA for dates of service on or after September 12, 2015 through December 31, 2015, must be submitted using the DME miscellaneous code J7799 (NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME).

Claims for HYQVIA for dates of service on or after January 01, 2016 must be submitted using the HCPCS code J1575 (INJECTION, IMMUNE GLOBULIN/HYALURONIDASE, (HYQVIA), 100 MG IMMUNEGLOBULIN).

Code J7999 (COMPOUNDED DRUG, NOT OTHERWISE CLASSIFIED) must be used for any compounded drugs administered using an external infusion pump for dates of service on or after January 01, 2016.

When Q9977 or J7999 is billed for a compounded drug, the claim must be accompanied by the standard written order information, and a clear statement of the amount dispensed.

Claims for CUVITRU for dates of service on or before December 31, 2017 must be submitted using the HCPCS code J7799 (NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME). One UOS equals one hundred (100) milligrams (mg).

Claims for CUVITRU for dates of service on or after January 01, 2018 must be submitted using HCPCS code J1555 (INJECTION, IMMUNE GLOBULIN (CUVITRU), 100 MG). One UOS equals one hundred (100) mg.

Claims for Xembify for dates of service on or after July 3, 2019 through June 30, 2020 must be submitted using the HCPCS code J7799 (NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME). One UOS equals one hundred (100) mg. Claims for Xembify for dates of service on or after July 1, 2020 must be submitted using the HCPCS code J1558 (INJECTION, IMMUNE GLOBULIN (XEMBIFY), 100 MG)

Claims for Cutaquig for dates of service on or after December 12, 2018 must be submitted using the HCPCS code J7799 (NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME). One UOS equals one hundred (100) mg.

Claims for Hizentra for beneficiaries with CIDP for dates of service on or after July 18, 2021 must be submitted using the HCPCS code J1559 (INJECTION, IMMUNE GLOBULIN (HIZENTRA), 100 MG). One UOS equals one hundred (100) mg.

Specific infusion pump HCPCS codes are used with specific SCIg preparations according to the table below.

Infusion Pump SCIg Preparation
E0779 J1555, J1559, J1561, J1562, J1569
E0781 J1575
E0779 or E0781 J1558, J7799 (Cutaquig)


Professional Services

Professional services include nursing services, training and education (not otherwise paid for as durable medical equipment), remote monitoring, and monitoring services for the provision of home infusion therapy furnished by a qualified home infusion supplier with administration of certain transitional home infusion drugs administered through an item of DME.

For claims with dates of service on or after January 01, 2019 through December 31, 2020, codes G0068, G0069, and G0070 are used to bill for the professional services rendered on the applicable infusion drug administration calendar day for each payment category. Providers should report visit length in 15-minute increments (15 minutes = 1unit). Suppliers must ensure that the appropriate drug associated with the visit is billed with the visit or no more than 30 days prior to the visit.

In the event that multiple visits occur on the same date of service, suppliers must only bill for one visit and should report the highest paying visit with the applicable drug. Claims reporting multiple visits on the same line item date of service will be returned as unprocessable.

Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.

Coding Information

CPT/HCPCS Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on "Coverage Indications, Limitations and/or Medical Necessity" for other coverage criteria and payment information.

For HCPCS codes E0784 and J1817:

Group 1 Codes
CodeDescription
E08.00 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma
E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma
E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma
E08.21 Diabetes mellitus due to underlying condition with diabetic nephropathy
E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease
E08.29 Diabetes mellitus due to underlying condition with other diabetic kidney complication
E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema
E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye
E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye
E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3219 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye
E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye
E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3299 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3319 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E08.3392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3399 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye
E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye
E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3419 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye
E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye
E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3499 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye
E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye
E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral
E08.3519 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, unspecified eye
E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E08.3529 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E08.3539 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E08.3541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E08.3542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E08.3549 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye
E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye
E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral
E08.3559 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, unspecified eye
E08.3591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye
E08.3592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye
E08.3593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral
E08.3599 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, unspecified eye
E08.36 Diabetes mellitus due to underlying condition with diabetic cataract
E08.37X1 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right eye
E08.37X2 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left eye
E08.37X3 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral
E08.37X9 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, unspecified eye
E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication
E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified
E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy
E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy
E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy
E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy
E08.49 Diabetes mellitus due to underlying condition with other diabetic neurological complication
E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene
E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E08.59 Diabetes mellitus due to underlying condition with other circulatory complications
E08.610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy
E08.618 Diabetes mellitus due to underlying condition with other diabetic arthropathy
E08.620 Diabetes mellitus due to underlying condition with diabetic dermatitis
E08.621 Diabetes mellitus due to underlying condition with foot ulcer
E08.622 Diabetes mellitus due to underlying condition with other skin ulcer
E08.628 Diabetes mellitus due to underlying condition with other skin complications
E08.630 Diabetes mellitus due to underlying condition with periodontal disease
E08.638 Diabetes mellitus due to underlying condition with other oral complications
E08.641 Diabetes mellitus due to underlying condition with hypoglycemia with coma
E08.649 Diabetes mellitus due to underlying condition with hypoglycemia without coma
E08.65 Diabetes mellitus due to underlying condition with hyperglycemia
E08.69 Diabetes mellitus due to underlying condition with other specified complication
E08.8 Diabetes mellitus due to underlying condition with unspecified complications
E08.9 Diabetes mellitus due to underlying condition without complications
E09.00 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma
E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma
E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma
E09.21 Drug or chemical induced diabetes mellitus with diabetic nephropathy
E09.22 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease
E09.29 Drug or chemical induced diabetes mellitus with other diabetic kidney complication
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema
E09.3211 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E09.3212 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3219 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E09.3291 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E09.3292 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E09.3293 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3299 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E09.3311 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E09.3312 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3319 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E09.3391 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E09.3392 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E09.3393 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3399 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E09.3411 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E09.3412 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3419 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E09.3491 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E09.3492 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E09.3493 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3499 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E09.3511 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E09.3512 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E09.3519 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
E09.3521 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E09.3522 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E09.3523 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E09.3529 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E09.3531 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E09.3532 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E09.3533 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E09.3539 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E09.3541 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E09.3542 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E09.3543 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E09.3549 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E09.3551 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E09.3552 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E09.3553 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E09.3559 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye
E09.3591 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E09.3592 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E09.3593 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E09.3599 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract
E09.37X1 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E09.37X2 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E09.37X3 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E09.37X9 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye
E09.39 Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication
E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified
E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy
E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy
E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy
E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy
E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication
E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene
E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
E09.59 Drug or chemical induced diabetes mellitus with other circulatory complications
E09.610 Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy
E09.618 Drug or chemical induced diabetes mellitus with other diabetic arthropathy
E09.620 Drug or chemical induced diabetes mellitus with diabetic dermatitis
E09.621 Drug or chemical induced diabetes mellitus with foot ulcer
E09.622 Drug or chemical induced diabetes mellitus with other skin ulcer
E09.628 Drug or chemical induced diabetes mellitus with other skin complications
E09.630 Drug or chemical induced diabetes mellitus with periodontal disease
E09.638 Drug or chemical induced diabetes mellitus with other oral complications
E09.641 Drug or chemical induced diabetes mellitus with hypoglycemia with coma
E09.649 Drug or chemical induced diabetes mellitus with hypoglycemia without coma
E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia
E09.69 Drug or chemical induced diabetes mellitus with other specified complication
E09.8 Drug or chemical induced diabetes mellitus with unspecified complications
E09.9 Drug or chemical induced diabetes mellitus without complications
E10.10 Type 1 diabetes mellitus with ketoacidosis without coma
E10.11 Type 1 diabetes mellitus with ketoacidosis with coma
E10.21 Type 1 diabetes mellitus with diabetic nephropathy
E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease
E10.29 Type 1 diabetes mellitus with other diabetic kidney complication
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E10.3211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E10.3212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3219 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E10.3291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E10.3292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3299 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E10.3311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E10.3312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3319 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E10.3391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E10.3392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E10.3393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3399 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E10.3411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E10.3412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3419 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E10.3491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E10.3492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E10.3493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3499 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E10.3519 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
E10.3521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E10.3522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E10.3529 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E10.3531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E10.3532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E10.3539 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E10.3541 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E10.3542 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E10.3543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E10.3549 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E10.3551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E10.3552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E10.3553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E10.3559 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye
E10.3591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E10.3592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E10.3599 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E10.36 Type 1 diabetes mellitus with diabetic cataract
E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E10.37X9 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye
E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication
E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy
E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E10.44 Type 1 diabetes mellitus with diabetic amyotrophy
E10.49 Type 1 diabetes mellitus with other diabetic neurological complication
E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.59 Type 1 diabetes mellitus with other circulatory complications
E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E10.618 Type 1 diabetes mellitus with other diabetic arthropathy
E10.620 Type 1 diabetes mellitus with diabetic dermatitis
E10.621 Type 1 diabetes mellitus with foot ulcer
E10.622 Type 1 diabetes mellitus with other skin ulcer
E10.628 Type 1 diabetes mellitus with other skin complications
E10.630 Type 1 diabetes mellitus with periodontal disease
E10.638 Type 1 diabetes mellitus with other oral complications
E10.641 Type 1 diabetes mellitus with hypoglycemia with coma
E10.649 Type 1 diabetes mellitus with hypoglycemia without coma
E10.65 Type 1 diabetes mellitus with hyperglycemia
E10.69 Type 1 diabetes mellitus with other specified complication
E10.8 Type 1 diabetes mellitus with unspecified complications
E10.9 Type 1 diabetes mellitus without complications
E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma
E11.21 Type 2 diabetes mellitus with diabetic nephropathy
E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease
E11.29 Type 2 diabetes mellitus with other diabetic kidney complication
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E11.3211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E11.3212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E11.3312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3319 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E11.3392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E11.3412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3419 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E11.3492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E11.3519 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E11.3532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E11.3539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E11.3541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E11.3542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E11.3543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E11.3549 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E11.3551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E11.3552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E11.3559 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye
E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E11.3599 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E11.36 Type 2 diabetes mellitus with diabetic cataract
E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E11.37X9 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye
E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication
E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.44 Type 2 diabetes mellitus with diabetic amyotrophy
E11.49 Type 2 diabetes mellitus with other diabetic neurological complication
E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.59 Type 2 diabetes mellitus with other circulatory complications
E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E11.618 Type 2 diabetes mellitus with other diabetic arthropathy
E11.620 Type 2 diabetes mellitus with diabetic dermatitis
E11.621 Type 2 diabetes mellitus with foot ulcer
E11.622 Type 2 diabetes mellitus with other skin ulcer
E11.628 Type 2 diabetes mellitus with other skin complications
E11.630 Type 2 diabetes mellitus with periodontal disease
E11.638 Type 2 diabetes mellitus with other oral complications
E11.641 Type 2 diabetes mellitus with hypoglycemia with coma
E11.649 Type 2 diabetes mellitus with hypoglycemia without coma
E11.65 Type 2 diabetes mellitus with hyperglycemia
E11.69 Type 2 diabetes mellitus with other specified complication
E11.8 Type 2 diabetes mellitus with unspecified complications
E11.9 Type 2 diabetes mellitus without complications
E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E13.01 Other specified diabetes mellitus with hyperosmolarity with coma
E13.10 Other specified diabetes mellitus with ketoacidosis without coma
E13.11 Other specified diabetes mellitus with ketoacidosis with coma
E13.21 Other specified diabetes mellitus with diabetic nephropathy
E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease
E13.29 Other specified diabetes mellitus with other diabetic kidney complication
E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema
E13.3211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E13.3212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3219 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E13.3291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E13.3292 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E13.3293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3299 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E13.3311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E13.3312 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3319 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E13.3391 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E13.3392 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E13.3393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3399 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E13.3411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E13.3412 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3419 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E13.3491 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E13.3492 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E13.3493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3499 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E13.3512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E13.3519 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
E13.3521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E13.3522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E13.3523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E13.3529 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E13.3531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E13.3532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E13.3533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E13.3539 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E13.3541 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E13.3542 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E13.3543 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E13.3549 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E13.3551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E13.3552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E13.3553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E13.3559 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye
E13.3591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E13.3592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E13.3593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E13.3599 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E13.36 Other specified diabetes mellitus with diabetic cataract
E13.37X1 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E13.37X2 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E13.37X3 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E13.37X9 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye
E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication
E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified
E13.41 Other specified diabetes mellitus with diabetic mononeuropathy
E13.42 Other specified diabetes mellitus with diabetic polyneuropathy
E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy
E13.44 Other specified diabetes mellitus with diabetic amyotrophy
E13.49 Other specified diabetes mellitus with other diabetic neurological complication
E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene
E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
E13.59 Other specified diabetes mellitus with other circulatory complications
E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy
E13.618 Other specified diabetes mellitus with other diabetic arthropathy
E13.620 Other specified diabetes mellitus with diabetic dermatitis
E13.621 Other specified diabetes mellitus with foot ulcer
E13.622 Other specified diabetes mellitus with other skin ulcer
E13.628 Other specified diabetes mellitus with other skin complications
E13.630 Other specified diabetes mellitus with periodontal disease
E13.638 Other specified diabetes mellitus with other oral complications
E13.641 Other specified diabetes mellitus with hypoglycemia with coma
E13.649 Other specified diabetes mellitus with hypoglycemia without coma
E13.65 Other specified diabetes mellitus with hyperglycemia
E13.69 Other specified diabetes mellitus with other specified complication
E13.8 Other specified diabetes mellitus with unspecified complications
E13.9 Other specified diabetes mellitus without complications
O24.415 Gestational diabetes mellitus in pregnancy, controlled by oral hypoglycemic drugs
O24.425 Gestational diabetes mellitus in childbirth, controlled by oral hypoglycemic drugs
O24.435 Gestational diabetes mellitus in puerperium, controlled by oral hypoglycemic drugs

Group 2

Group 2 Paragraph

For HCPCS code J1457:

Group 2 Codes
CodeDescription
E83.52 Hypercalcemia

Group 3

Group 3 Paragraph

For primary immune deficiency disorders HCPCS codes J1555, J1558, J1559, J1561, J1562, J1569, J1575 and J7799 (Cutaquig):

Group 3 Codes
CodeDescription
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

Group 4

Group 4 Paragraph

For HCPCS code for J7340:

Group 4 Codes
CodeDescription
G20 Parkinson's disease

Group 5

Group 5 Paragraph

For HCPCS code for J9039:

Group 5 Codes
CodeDescription
C91.00 Acute lymphoblastic leukemia not having achieved remission
C91.01 Acute lymphoblastic leukemia, in remission
C91.02 Acute lymphoblastic leukemia, in relapse

Group 6

Group 6 Paragraph

For HCPCS code J1559, for CIDP:

Group 6 Codes
CodeDescription
G61.81 Chronic inflammatory demyelinating polyneuritis

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

For the specific HCPCS codes indicated above, all ICD-10 codes that are not specified in the previous section.

For all other HCPCS codes, ICD-10 codes are not specified.

Group 1 Codes

N/A

ICD-10-PCS Codes

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Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
07/18/2021 R18

Revision Effective Date: 07/18/2021
MODIFIERS:
Removed: Registered trademark symbol from first use of Cutaquig
CODING GUIDELINES:
Added: Supply codes associated with external infusion pumps HCPCS codes table
Added: Billing instruction for Hizentra for beneficiaries with CIDP using the HCPCS code J1559
Removed: Registered trademark symbol from first use of Xembify
Added: A table to identify which infusion pump is used for which specific SCIg preparations
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Group 3 paragraph to include “primary immune deficiency disorders”
Added: Group 6 listing for HCPCS code J1559, for CIDP

06/03/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

09/15/2020 R17

Revision Effective Date: 09/15/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: Information related to HCPCS code E0787, which is invalid for Medicare submission for DOS on or after 09/15/2020
MODIFIERS:
Removed: HCPCS code E0787
CODING GUIDELINES:
Removed: Guidelines for HCPCS codes E0787 and A4226
Added: Coding guidelines for insulin infusion pumps with integrated continuous glucose sensing capabilities
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Removed: HCPCS code E0787 from Group 1 Paragraph

09/17/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

09/06/2020 R16

Revision Effective Date: 09/06/2020
MODIFIERS:
Added: J1558 and J7799 (Cutaquig) to the JB modifier requirements
CODING GUIDELINES:
Added: Billing instructions for Xembify based on DOS
Added: UOS billing instruction for J7799 (Cutaquig)
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Added: J1558 and J7799 (Cutaquig) to the Group 3 paragraph

07/23/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.


05/31/2020 R15

Revision Effective Date: 05/31/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “physician’s” to “practitioner’s”
Removed: REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO 42 CFR 410.38(g) section
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
DME INFORMATION FORM (DIF):
Revised: “physician” to “practitioner”
MODIFIERS:
Added: J7799 (
Xembify®) to the JB modifier requirements
CODING GUIDELINES:
Revised: 'detailed order' to 'standard written order'
Added: UOS billing instruction for J7799 (Xembify®)
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Added: J7799 (
Xembify®) to the Group 3 paragraph

04/16/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2020 R14

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES
Added: PDAC approval requirement for HCPCS code E0787
KX, GA, GY and GZ MODIFIERS:
Added: HCPCS code E0787
CODING GUIDELINES:
Added: Coding information for E0787 and A4226
Added: All-inclusive statement to A4224
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
Added: E0787 to Group 1
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”

12/19/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

08/13/2019 R13

Revision Effective Date: 08/13/2019
ICD-10 CODES THAT ARE COVERED:
Added: Codes D80.2, D80.3, D80.4, D80.6, D80.7, D81.5, D82.1, D82.4, and G11.3 to Group 3 per update to Medicare Benefit Policy Manual, Chapter 15, section 50.6

07/25/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2019 R12

Revision History Effective Date: 01/01/2019
CODING GUIDELINES:
Added: Professional services description
ICD-10 CODES THAT ARE COVERED:
Added: All diagnosis codes formerly listed in the LCD
ICD-10 CODES THAT ARE NOT COVERED:
Added: Notation excluding all unlisted diagnosis codes from coverage

02/14/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2018 R11

Revision Effective Date: 01/01/2018
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Clarified claims adjudication of pumps when an infusion is started in the physician’s office  

06/07/2018: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2018 R10

Revision Effective Date: 01/01/2018
CODING GUIDELINES: 
Added: Treprostinil to K0455
Added: HCPCS code J9039
Updated: Levodopa-Carbidopa UOS
Removed: Coding instructions for HCPCS Q9977 for DOS between July 01, 2015 through December 31, 2015

04/19/2018: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination. 

07/11/2017 R9

Revision Effective Date: 07/11/2017
CODING GUIDELINES:
Revised: Clarified blinatumomab UOS, and added instructions  for a 7-day infusion protocol

Revised: Added HCPCS code J1555 for CUVITRU effective for claims on or after 01/01/2018

11/30/2017: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2017 R8

Revision Effective Date: 01/01/2017
CODING GUIDELINES:
Revised: A4221 descriptor to include subcutaneous infusion catheter
Revised: Typographical error K0522 to correct code of K0552
Added: Coding guidelines for Cuvitru (J7799) - effective 9/13/2016


 

01/01/2017 R7 Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Replaced: A4221 with A4224 when using catheter insertion devices
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: 42 CFR 410.38(g), DIF and Modifiers requirements
CODING GUIDELINES:
Added: Billing instructions for A4224 and A4225
RELATED LOCAL COVERAGE DOCUMENTS:
Added: The LCD-related Standard Documentation Requirements Language Article

07/01/2016 R6 Revision Effective Date: 07/01/2016
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Language regarding payment rules for infusion drugs started in a physician’s office or hospital outpatient department. – Effective 4/25/2016
07/01/2016 R5 Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.
01/01/2016 R4 Revision Effective Date: 01/01/2016
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Standard Documentation Language to remove start date verbiage from Prescription Requirements (Effective 11/5/2015)
CODING GUIDELINES:
Updated: HCPCS Code Q9977 cross-walked to J7999
Added: J1575, J7340, J9039 (previously J7799)
Updated: Billing instructions, by HCPCS code, based on dates of service.
12/01/2015 R3 Revision Effective Date: 12/01/2015
Draft Policy Article promoted to final
CODING GUIDELINES:
Added: Q9977 (Compounded drug NOC)
10/01/2015 R2 Revision Effective Date: 01/01/2015 (March 2015 Publication)
CODING GUIDELINES:
Revised: Units of service for blinatumomab
Added: Instructions for least wastage of blinatumomab; inadvertently omitted from previous publication
10/01/2015 R1 Revision Effective Date: 10/01/2015
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: “When required by state law” from ACA new prescription requirements
Revised: Face-to-Face Requirements for treating practitioner
CODING GUIDELINES:
Added: Coding requirements for lithium batteries
Deleted: References to codes J2271 and J2275
Added: Levodopa-Carbidopa enteral suspension (effective for dates of service on or after 01/09/2015)
Added: Blinatumomab (effective for dates of service on or after 12/03/2014)

Associated Documents

Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
05/27/2021 07/18/2021 - N/A Currently in Effect You are here
09/08/2020 09/15/2020 - 07/17/2021 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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