LCD Reference Article Billing and Coding Article

Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

A59160

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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General Information

Source Article ID
N/A
Article ID
A59160
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
Article Type
Billing and Coding
Original Effective Date
02/19/2023
Revision Effective Date
03/15/2024
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, §40 Discarded Drugs and Biologicals.

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Luteinizing Hormone-Releasing Hormone (LHRH) Analogs L39387.

*Note: The prescribing information for the dose and frequency of administration should be consistent with the United States Food and Drug Administration (FDA) approved labeling.

JW Modifier Requirement:

Effective January 1, 2017, The Centers for Medicare and Medicaid Services (CMS) issued CR 9603, regarding the use of the JW modifier for discarded Part B drugs and biologicals. Providers are required to use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded (except those provided under the CAP for Part B drugs and biologicals). Document the discarded drug or biological in the patient’s medical record when submitting claims with unused Part B drugs or biologicals from single use vials or single use packages that are appropriately discarded.

Administration code 96402 should be billed with HCPCS codes J1950, J9217, J9202, J3315, J1952 and J1954.

Administration codes 11981, 11982, and 11983 may be billed with HCPCS codes J9219 and J9225.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT® codes in their CPT® book.

Administration code 96402 should be billed with HCPCS code J1950.

Group 1 Codes
Code Description
96402 CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR; HORMONAL ANTI-NEOPLASTIC
J1950 INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG

Group 2

(3 Codes)
Group 2 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT® codes in their CPT® book.

Administration code 96402 should be billed with HCPCS codes J9217 and J1954.

Group 2 Codes
Code Description
96402 CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR; HORMONAL ANTI-NEOPLASTIC
J1954 INJECTION, LEUPROLIDE ACETATE FOR DEPOT SUSPENSION (CIPLA), 7.5 MG
J9217 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG

Group 3

(4 Codes)
Group 3 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT® codes in their CPT® book.

Administration codes 11981, 11982, and 11983 may be billed with HCPCS code J9219.

Group 3 Codes
Code Description
11981 INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)
11982 REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT
11983 REMOVAL WITH REINSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT
J9219 LEUPROLIDE ACETATE IMPLANT, 65 MG

Group 4

(2 Codes)
Group 4 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT® codes in their CPT® book.

Administration code 96402 should be billed with HCPCS code J9202.

Group 4 Codes
Code Description
96402 CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR; HORMONAL ANTI-NEOPLASTIC
J9202 GOSERELIN ACETATE IMPLANT, PER 3.6 MG

Group 5

(2 Codes)
Group 5 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT® codes in their CPT® book.

Administration code 96402 should be billed with HCPCS code J3315.

Group 5 Codes
Code Description
96402 CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR; HORMONAL ANTI-NEOPLASTIC
J3315 INJECTION, TRIPTORELIN PAMOATE, 3.75 MG

Group 6

(4 Codes)
Group 6 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT® codes in their CPT® book.

Administration codes 11981, 11982, and 11983 may be billed with HCPCS code J9225.

Group 6 Codes
Code Description
11981 INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)
11982 REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT
11983 REMOVAL WITH REINSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT
J9225 HISTRELIN IMPLANT (VANTAS), 50 MG

Group 7

(2 Codes)
Group 7 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT® codes in their CPT® book.

Administration code 96402 should be billed with HCPCS code J1952.

Group 7 Codes
Code Description
96402 CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR; HORMONAL ANTI-NEOPLASTIC
J1952 LEUPROLIDE INJECTABLE, CAMCEVI, 1 MG
N/A

CPT/HCPCS Modifiers

Group 1

(2 Codes)
Group 1 Paragraph

These modifiers are applicable to all codes listed in CPT/HCPCS Codes Groups 1-7.

Group 1 Codes
Code Description
JW DRUG AMOUNT DISCARDED/NOT ADMINISTERED TO ANY PATIENT
JZ ZERO DRUG AMOUNT DISCARDED/NOT ADMINISTERED TO ANY PATIENT
N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(162 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

These ICD-10-CM codes are applicable for J1950.

Group 1 Codes
Code Description
C08.0 Malignant neoplasm of submandibular gland
C08.1 Malignant neoplasm of sublingual gland
C08.9 Malignant neoplasm of major salivary gland, unspecified
C48.0 Malignant neoplasm of retroperitoneum
C48.1 Malignant neoplasm of specified parts of peritoneum
C48.2 Malignant neoplasm of peritoneum, unspecified
C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum
C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.019 Malignant neoplasm of nipple and areola, unspecified female breast
C50.021 Malignant neoplasm of nipple and areola, right male breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.029 Malignant neoplasm of nipple and areola, unspecified male breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.119 Malignant neoplasm of central portion of unspecified female breast
C50.121 Malignant neoplasm of central portion of right male breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.129 Malignant neoplasm of central portion of unspecified male breast
C50.211 Malignant neoplasm of upper-inner quadrant of right female breast
C50.212 Malignant neoplasm of upper-inner quadrant of left female breast
C50.219 Malignant neoplasm of upper-inner quadrant of unspecified female breast
C50.221 Malignant neoplasm of upper-inner quadrant of right male breast
C50.222 Malignant neoplasm of upper-inner quadrant of left male breast
C50.229 Malignant neoplasm of upper-inner quadrant of unspecified male breast
C50.311 Malignant neoplasm of lower-inner quadrant of right female breast
C50.312 Malignant neoplasm of lower-inner quadrant of left female breast
C50.319 Malignant neoplasm of lower-inner quadrant of unspecified female breast
C50.321 Malignant neoplasm of lower-inner quadrant of right male breast
C50.322 Malignant neoplasm of lower-inner quadrant of left male breast
C50.329 Malignant neoplasm of lower-inner quadrant of unspecified male breast
C50.411 Malignant neoplasm of upper-outer quadrant of right female breast
C50.412 Malignant neoplasm of upper-outer quadrant of left female breast
C50.419 Malignant neoplasm of upper-outer quadrant of unspecified female breast
C50.421 Malignant neoplasm of upper-outer quadrant of right male breast
C50.422 Malignant neoplasm of upper-outer quadrant of left male breast
C50.429 Malignant neoplasm of upper-outer quadrant of unspecified male breast
C50.511 Malignant neoplasm of lower-outer quadrant of right female breast
C50.512 Malignant neoplasm of lower-outer quadrant of left female breast
C50.519 Malignant neoplasm of lower-outer quadrant of unspecified female breast
C50.521 Malignant neoplasm of lower-outer quadrant of right male breast
C50.522 Malignant neoplasm of lower-outer quadrant of left male breast
C50.529 Malignant neoplasm of lower-outer quadrant of unspecified male breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.619 Malignant neoplasm of axillary tail of unspecified female breast
C50.621 Malignant neoplasm of axillary tail of right male breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.629 Malignant neoplasm of axillary tail of unspecified male breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.819 Malignant neoplasm of overlapping sites of unspecified female breast
C50.821 Malignant neoplasm of overlapping sites of right male breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
C50.829 Malignant neoplasm of overlapping sites of unspecified male breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
C50.919 Malignant neoplasm of unspecified site of unspecified female breast
C50.921 Malignant neoplasm of unspecified site of right male breast
C50.922 Malignant neoplasm of unspecified site of left male breast
C50.929 Malignant neoplasm of unspecified site of unspecified male breast
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C56.3 Malignant neoplasm of bilateral ovaries
C56.9 Malignant neoplasm of unspecified ovary
C57.00 Malignant neoplasm of unspecified fallopian tube
C57.01 Malignant neoplasm of right fallopian tube
C57.02 Malignant neoplasm of left fallopian tube
D25.0 Submucous leiomyoma of uterus
D25.1 Intramural leiomyoma of uterus
D25.2 Subserosal leiomyoma of uterus
D25.9 Leiomyoma of uterus, unspecified
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D62 Acute posthemorrhagic anemia
E22.8 Other hyperfunction of pituitary gland
N80.01 Superficial endometriosis of the uterus
N80.02 Deep endometriosis of the uterus
N80.03 Adenomyosis of the uterus
N80.111 Superficial endometriosis of right ovary
N80.112 Superficial endometriosis of left ovary
N80.113 Superficial endometriosis of bilateral ovaries
N80.121 Deep endometriosis of right ovary
N80.122 Deep endometriosis of left ovary
N80.123 Deep endometriosis of bilateral ovaries
N80.211 Superficial endometriosis of right fallopian tube
N80.212 Superficial endometriosis of left fallopian tube
N80.213 Superficial endometriosis of bilateral fallopian tubes
N80.219 Superficial endometriosis of unspecified fallopian tube
N80.221 Deep endometriosis of right fallopian tube
N80.222 Deep endometriosis of left fallopian tube
N80.223 Deep endometriosis of bilateral fallopian tubes
N80.229 Deep endometriosis of unspecified fallopian tube
N80.311 Superficial endometriosis of the anterior cul-de-sac
N80.312 Deep endometriosis of the anterior cul-de-sac
N80.321 Superficial endometriosis of the posterior cul-de-sac
N80.322 Deep endometriosis of the posterior cul-de-sac
N80.331 Superficial endometriosis of the right pelvic sidewall
N80.332 Superficial endometriosis of the left pelvic sidewall
N80.333 Superficial endometriosis of bilateral pelvic sidewall
N80.341 Deep endometriosis of the right pelvic sidewall
N80.342 Deep endometriosis of the left pelvic sidewall
N80.343 Deep endometriosis of the bilateral pelvic sidewall
N80.361 Superficial endometriosis of the right pelvic brim
N80.362 Superficial endometriosis of the left pelvic brim
N80.363 Superficial endometriosis of bilateral pelvic brim
N80.371 Deep endometriosis of the right pelvic brim
N80.372 Deep endometriosis of the left pelvic brim
N80.373 Deep endometriosis of bilateral pelvic brim
N80.3A1 Superficial endometriosis of the right uterosacral ligament
N80.3A2 Superficial endometriosis of the left uterosacral ligament
N80.3A3 Superficial endometriosis of the bilateral uterosacral ligament(s)
N80.3B1 Deep endometriosis of the right uterosacral ligament
N80.3B2 Deep endometriosis of the left uterosacral ligament
N80.3B3 Deep endometriosis of bilateral uterosacral ligament(s)
N80.391 Superficial endometriosis of the pelvic peritoneum, other specified sites
N80.392 Deep endometriosis of the pelvic peritoneum, other specified sites
N80.40 Endometriosis of rectovaginal septum, unspecified involvement of vagina
N80.41 Endometriosis of rectovaginal septum without involvement of vagina
N80.42 Endometriosis of rectovaginal septum with involvement of vagina
N80.511 Superficial endometriosis of the rectum
N80.512 Deep endometriosis of the rectum
N80.521 Superficial endometriosis of the sigmoid colon
N80.522 Deep endometriosis of the sigmoid colon
N80.531 Superficial endometriosis of the cecum
N80.532 Deep endometriosis of the cecum
N80.541 Superficial endometriosis of the appendix
N80.542 Deep endometriosis of the appendix
N80.551 Superficial endometriosis of other parts of the colon
N80.552 Deep endometriosis of other parts of the colon
N80.561 Superficial endometriosis of the small intestine
N80.562 Deep endometriosis of the small intestine
N80.6 Endometriosis in cutaneous scar
N80.A1 Superficial endometriosis of bladder
N80.A2 Deep endometriosis of bladder
N80.A41 Superficial endometriosis of right ureter
N80.A42 Superficial endometriosis of left ureter
N80.A43 Superficial endometriosis of bilateral ureters
N80.A51 Deep endometriosis of right ureter
N80.A52 Deep endometriosis of left ureter
N80.A53 Deep endometriosis of bilateral ureters
N80.B1 Endometriosis of pleura
N80.B2 Endometriosis of lung
N80.B31 Superficial endometriosis of diaphragm
N80.B32 Deep endometriosis of diaphragm
N80.B4 Endometriosis of the pericardial space
N80.B5 Endometriosis of the mediastinal space
N80.B6 Endometriosis of cardiothoracic space
N80.C10 Endometriosis of the anterior abdominal wall, subcutaneous tissue
N80.C11 Endometriosis of the anterior abdominal wall, fascia and muscular layers
N80.C2 Endometriosis of the umbilicus
N80.C3 Endometriosis of the inguinal canal
N80.C4 Endometriosis of extra-pelvic abdominal peritoneum
N80.C9 Endometriosis of other site of abdomen
N80.D1 Endometriosis of the sacral splanchnic nerves
N80.D2 Endometriosis of the sacral nerve roots
N80.D3 Endometriosis of the obturator nerve
N80.D4 Endometriosis of the sciatic nerve
N80.D5 Endometriosis of the pudendal nerve
N80.D6 Endometriosis of the femoral nerve
N80.D9 Endometriosis of other pelvic nerve
N80.8 Other endometriosis
N80.9 Endometriosis, unspecified

Group 2

(178 Codes)
Group 2 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

These ICD-10-CM codes are applicable for J9217 and J1954.

Group 2 Codes
Code Description
C08.0 Malignant neoplasm of submandibular gland
C08.1 Malignant neoplasm of sublingual gland
C08.9 Malignant neoplasm of major salivary gland, unspecified
C48.0 Malignant neoplasm of retroperitoneum
C48.1 Malignant neoplasm of specified parts of peritoneum
C48.2 Malignant neoplasm of peritoneum, unspecified
C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum
C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.019 Malignant neoplasm of nipple and areola, unspecified female breast
C50.021 Malignant neoplasm of nipple and areola, right male breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.029 Malignant neoplasm of nipple and areola, unspecified male breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.119 Malignant neoplasm of central portion of unspecified female breast
C50.121 Malignant neoplasm of central portion of right male breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.129 Malignant neoplasm of central portion of unspecified male breast
C50.211 Malignant neoplasm of upper-inner quadrant of right female breast
C50.212 Malignant neoplasm of upper-inner quadrant of left female breast
C50.219 Malignant neoplasm of upper-inner quadrant of unspecified female breast
C50.221 Malignant neoplasm of upper-inner quadrant of right male breast
C50.222 Malignant neoplasm of upper-inner quadrant of left male breast
C50.229 Malignant neoplasm of upper-inner quadrant of unspecified male breast
C50.311 Malignant neoplasm of lower-inner quadrant of right female breast
C50.312 Malignant neoplasm of lower-inner quadrant of left female breast
C50.319 Malignant neoplasm of lower-inner quadrant of unspecified female breast
C50.321 Malignant neoplasm of lower-inner quadrant of right male breast
C50.322 Malignant neoplasm of lower-inner quadrant of left male breast
C50.329 Malignant neoplasm of lower-inner quadrant of unspecified male breast
C50.411 Malignant neoplasm of upper-outer quadrant of right female breast
C50.412 Malignant neoplasm of upper-outer quadrant of left female breast
C50.419 Malignant neoplasm of upper-outer quadrant of unspecified female breast
C50.421 Malignant neoplasm of upper-outer quadrant of right male breast
C50.422 Malignant neoplasm of upper-outer quadrant of left male breast
C50.429 Malignant neoplasm of upper-outer quadrant of unspecified male breast
C50.511 Malignant neoplasm of lower-outer quadrant of right female breast
C50.512 Malignant neoplasm of lower-outer quadrant of left female breast
C50.519 Malignant neoplasm of lower-outer quadrant of unspecified female breast
C50.521 Malignant neoplasm of lower-outer quadrant of right male breast
C50.522 Malignant neoplasm of lower-outer quadrant of left male breast
C50.529 Malignant neoplasm of lower-outer quadrant of unspecified male breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.619 Malignant neoplasm of axillary tail of unspecified female breast
C50.621 Malignant neoplasm of axillary tail of right male breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.629 Malignant neoplasm of axillary tail of unspecified male breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.819 Malignant neoplasm of overlapping sites of unspecified female breast
C50.821 Malignant neoplasm of overlapping sites of right male breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
C50.829 Malignant neoplasm of overlapping sites of unspecified male breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
C50.919 Malignant neoplasm of unspecified site of unspecified female breast
C50.921 Malignant neoplasm of unspecified site of right male breast
C50.922 Malignant neoplasm of unspecified site of left male breast
C50.929 Malignant neoplasm of unspecified site of unspecified male breast
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C56.3 Malignant neoplasm of bilateral ovaries
C56.9 Malignant neoplasm of unspecified ovary
C57.00 Malignant neoplasm of unspecified fallopian tube
C57.01 Malignant neoplasm of right fallopian tube
C57.02 Malignant neoplasm of left fallopian tube
C61 Malignant neoplasm of prostate
D05.00 Lobular carcinoma in situ of unspecified breast
D05.01 Lobular carcinoma in situ of right breast
D05.02 Lobular carcinoma in situ of left breast
D05.10 Intraductal carcinoma in situ of unspecified breast
D05.11 Intraductal carcinoma in situ of right breast
D05.12 Intraductal carcinoma in situ of left breast
D05.80 Other specified type of carcinoma in situ of unspecified breast
D05.81 Other specified type of carcinoma in situ of right breast
D05.82 Other specified type of carcinoma in situ of left breast
D05.90 Unspecified type of carcinoma in situ of unspecified breast
D05.91 Unspecified type of carcinoma in situ of right breast
D05.92 Unspecified type of carcinoma in situ of left breast
D07.5 Carcinoma in situ of prostate
D25.0 Submucous leiomyoma of uterus
D25.1 Intramural leiomyoma of uterus
D25.2 Subserosal leiomyoma of uterus
D25.9 Leiomyoma of uterus, unspecified
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D62 Acute posthemorrhagic anemia
E22.8 Other hyperfunction of pituitary gland
N80.01 Superficial endometriosis of the uterus
N80.02 Deep endometriosis of the uterus
N80.03 Adenomyosis of the uterus
N80.111 Superficial endometriosis of right ovary
N80.112 Superficial endometriosis of left ovary
N80.113 Superficial endometriosis of bilateral ovaries
N80.121 Deep endometriosis of right ovary
N80.122 Deep endometriosis of left ovary
N80.123 Deep endometriosis of bilateral ovaries
N80.211 Superficial endometriosis of right fallopian tube
N80.212 Superficial endometriosis of left fallopian tube
N80.213 Superficial endometriosis of bilateral fallopian tubes
N80.219 Superficial endometriosis of unspecified fallopian tube
N80.221 Deep endometriosis of right fallopian tube
N80.222 Deep endometriosis of left fallopian tube
N80.223 Deep endometriosis of bilateral fallopian tubes
N80.229 Deep endometriosis of unspecified fallopian tube
N80.311 Superficial endometriosis of the anterior cul-de-sac
N80.312 Deep endometriosis of the anterior cul-de-sac
N80.321 Superficial endometriosis of the posterior cul-de-sac
N80.322 Deep endometriosis of the posterior cul-de-sac
N80.331 Superficial endometriosis of the right pelvic sidewall
N80.332 Superficial endometriosis of the left pelvic sidewall
N80.333 Superficial endometriosis of bilateral pelvic sidewall
N80.341 Deep endometriosis of the right pelvic sidewall
N80.342 Deep endometriosis of the left pelvic sidewall
N80.343 Deep endometriosis of the bilateral pelvic sidewall
N80.361 Superficial endometriosis of the right pelvic brim
N80.362 Superficial endometriosis of the left pelvic brim
N80.363 Superficial endometriosis of bilateral pelvic brim
N80.371 Deep endometriosis of the right pelvic brim
N80.372 Deep endometriosis of the left pelvic brim
N80.373 Deep endometriosis of bilateral pelvic brim
N80.3A1 Superficial endometriosis of the right uterosacral ligament
N80.3A2 Superficial endometriosis of the left uterosacral ligament
N80.3A3 Superficial endometriosis of the bilateral uterosacral ligament(s)
N80.3B1 Deep endometriosis of the right uterosacral ligament
N80.3B2 Deep endometriosis of the left uterosacral ligament
N80.3B3 Deep endometriosis of bilateral uterosacral ligament(s)
N80.391 Superficial endometriosis of the pelvic peritoneum, other specified sites
N80.392 Deep endometriosis of the pelvic peritoneum, other specified sites
N80.40 Endometriosis of rectovaginal septum, unspecified involvement of vagina
N80.41 Endometriosis of rectovaginal septum without involvement of vagina
N80.42 Endometriosis of rectovaginal septum with involvement of vagina
N80.511 Superficial endometriosis of the rectum
N80.512 Deep endometriosis of the rectum
N80.521 Superficial endometriosis of the sigmoid colon
N80.522 Deep endometriosis of the sigmoid colon
N80.531 Superficial endometriosis of the cecum
N80.532 Deep endometriosis of the cecum
N80.541 Superficial endometriosis of the appendix
N80.542 Deep endometriosis of the appendix
N80.551 Superficial endometriosis of other parts of the colon
N80.552 Deep endometriosis of other parts of the colon
N80.561 Superficial endometriosis of the small intestine
N80.562 Deep endometriosis of the small intestine
N80.6 Endometriosis in cutaneous scar
N80.A1 Superficial endometriosis of bladder
N80.A2 Deep endometriosis of bladder
N80.A41 Superficial endometriosis of right ureter
N80.A42 Superficial endometriosis of left ureter
N80.A43 Superficial endometriosis of bilateral ureters
N80.A51 Deep endometriosis of right ureter
N80.A52 Deep endometriosis of left ureter
N80.A53 Deep endometriosis of bilateral ureters
N80.B1 Endometriosis of pleura
N80.B2 Endometriosis of lung
N80.B31 Superficial endometriosis of diaphragm
N80.B32 Deep endometriosis of diaphragm
N80.B4 Endometriosis of the pericardial space
N80.B5 Endometriosis of the mediastinal space
N80.B6 Endometriosis of cardiothoracic space
N80.C10 Endometriosis of the anterior abdominal wall, subcutaneous tissue
N80.C11 Endometriosis of the anterior abdominal wall, fascia and muscular layers
N80.C2 Endometriosis of the umbilicus
N80.C3 Endometriosis of the inguinal canal
N80.C4 Endometriosis of extra-pelvic abdominal peritoneum
N80.C9 Endometriosis of other site of abdomen
N80.D1 Endometriosis of the sacral splanchnic nerves
N80.D2 Endometriosis of the sacral nerve roots
N80.D3 Endometriosis of the obturator nerve
N80.D4 Endometriosis of the sciatic nerve
N80.D5 Endometriosis of the pudendal nerve
N80.D6 Endometriosis of the femoral nerve
N80.D9 Endometriosis of other pelvic nerve
N80.8 Other endometriosis
N80.9 Endometriosis, unspecified
Z85.3 Personal history of malignant neoplasm of breast
Z85.46 Personal history of malignant neoplasm of prostate

Group 3

(3 Codes)
Group 3 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

These ICD-10-CM codes are applicable for J9219.

Group 3 Codes
Code Description
C61 Malignant neoplasm of prostate
D07.5 Carcinoma in situ of prostate
Z85.46 Personal history of malignant neoplasm of prostate

Group 4

(177 Codes)
Group 4 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

These ICD-10-CM codes are applicable for J9202.

Group 4 Codes
Code Description
C08.0 Malignant neoplasm of submandibular gland
C08.1 Malignant neoplasm of sublingual gland
C08.9 Malignant neoplasm of major salivary gland, unspecified
C48.0 Malignant neoplasm of retroperitoneum
C48.1 Malignant neoplasm of specified parts of peritoneum
C48.2 Malignant neoplasm of peritoneum, unspecified
C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum
C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.019 Malignant neoplasm of nipple and areola, unspecified female breast
C50.021 Malignant neoplasm of nipple and areola, right male breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.029 Malignant neoplasm of nipple and areola, unspecified male breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.119 Malignant neoplasm of central portion of unspecified female breast
C50.121 Malignant neoplasm of central portion of right male breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.129 Malignant neoplasm of central portion of unspecified male breast
C50.211 Malignant neoplasm of upper-inner quadrant of right female breast
C50.212 Malignant neoplasm of upper-inner quadrant of left female breast
C50.219 Malignant neoplasm of upper-inner quadrant of unspecified female breast
C50.221 Malignant neoplasm of upper-inner quadrant of right male breast
C50.222 Malignant neoplasm of upper-inner quadrant of left male breast
C50.229 Malignant neoplasm of upper-inner quadrant of unspecified male breast
C50.311 Malignant neoplasm of lower-inner quadrant of right female breast
C50.312 Malignant neoplasm of lower-inner quadrant of left female breast
C50.319 Malignant neoplasm of lower-inner quadrant of unspecified female breast
C50.321 Malignant neoplasm of lower-inner quadrant of right male breast
C50.322 Malignant neoplasm of lower-inner quadrant of left male breast
C50.329 Malignant neoplasm of lower-inner quadrant of unspecified male breast
C50.411 Malignant neoplasm of upper-outer quadrant of right female breast
C50.412 Malignant neoplasm of upper-outer quadrant of left female breast
C50.419 Malignant neoplasm of upper-outer quadrant of unspecified female breast
C50.421 Malignant neoplasm of upper-outer quadrant of right male breast
C50.422 Malignant neoplasm of upper-outer quadrant of left male breast
C50.429 Malignant neoplasm of upper-outer quadrant of unspecified male breast
C50.511 Malignant neoplasm of lower-outer quadrant of right female breast
C50.512 Malignant neoplasm of lower-outer quadrant of left female breast
C50.519 Malignant neoplasm of lower-outer quadrant of unspecified female breast
C50.521 Malignant neoplasm of lower-outer quadrant of right male breast
C50.522 Malignant neoplasm of lower-outer quadrant of left male breast
C50.529 Malignant neoplasm of lower-outer quadrant of unspecified male breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.619 Malignant neoplasm of axillary tail of unspecified female breast
C50.621 Malignant neoplasm of axillary tail of right male breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.629 Malignant neoplasm of axillary tail of unspecified male breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.819 Malignant neoplasm of overlapping sites of unspecified female breast
C50.821 Malignant neoplasm of overlapping sites of right male breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
C50.829 Malignant neoplasm of overlapping sites of unspecified male breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
C50.919 Malignant neoplasm of unspecified site of unspecified female breast
C50.921 Malignant neoplasm of unspecified site of right male breast
C50.922 Malignant neoplasm of unspecified site of left male breast
C50.929 Malignant neoplasm of unspecified site of unspecified male breast
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C56.3 Malignant neoplasm of bilateral ovaries
C56.9 Malignant neoplasm of unspecified ovary
C57.00 Malignant neoplasm of unspecified fallopian tube
C57.01 Malignant neoplasm of right fallopian tube
C57.02 Malignant neoplasm of left fallopian tube
C61 Malignant neoplasm of prostate
D05.00 Lobular carcinoma in situ of unspecified breast
D05.01 Lobular carcinoma in situ of right breast
D05.02 Lobular carcinoma in situ of left breast
D05.10 Intraductal carcinoma in situ of unspecified breast
D05.11 Intraductal carcinoma in situ of right breast
D05.12 Intraductal carcinoma in situ of left breast
D05.80 Other specified type of carcinoma in situ of unspecified breast
D05.81 Other specified type of carcinoma in situ of right breast
D05.82 Other specified type of carcinoma in situ of left breast
D05.90 Unspecified type of carcinoma in situ of unspecified breast
D05.91 Unspecified type of carcinoma in situ of right breast
D05.92 Unspecified type of carcinoma in situ of left breast
D07.5 Carcinoma in situ of prostate
D25.0 Submucous leiomyoma of uterus
D25.1 Intramural leiomyoma of uterus
D25.2 Subserosal leiomyoma of uterus
D25.9 Leiomyoma of uterus, unspecified
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D62 Acute posthemorrhagic anemia
N80.01 Superficial endometriosis of the uterus
N80.02 Deep endometriosis of the uterus
N80.03 Adenomyosis of the uterus
N80.111 Superficial endometriosis of right ovary
N80.112 Superficial endometriosis of left ovary
N80.113 Superficial endometriosis of bilateral ovaries
N80.121 Deep endometriosis of right ovary
N80.122 Deep endometriosis of left ovary
N80.123 Deep endometriosis of bilateral ovaries
N80.211 Superficial endometriosis of right fallopian tube
N80.212 Superficial endometriosis of left fallopian tube
N80.213 Superficial endometriosis of bilateral fallopian tubes
N80.219 Superficial endometriosis of unspecified fallopian tube
N80.221 Deep endometriosis of right fallopian tube
N80.222 Deep endometriosis of left fallopian tube
N80.223 Deep endometriosis of bilateral fallopian tubes
N80.229 Deep endometriosis of unspecified fallopian tube
N80.311 Superficial endometriosis of the anterior cul-de-sac
N80.312 Deep endometriosis of the anterior cul-de-sac
N80.321 Superficial endometriosis of the posterior cul-de-sac
N80.322 Deep endometriosis of the posterior cul-de-sac
N80.331 Superficial endometriosis of the right pelvic sidewall
N80.332 Superficial endometriosis of the left pelvic sidewall
N80.333 Superficial endometriosis of bilateral pelvic sidewall
N80.341 Deep endometriosis of the right pelvic sidewall
N80.342 Deep endometriosis of the left pelvic sidewall
N80.343 Deep endometriosis of the bilateral pelvic sidewall
N80.361 Superficial endometriosis of the right pelvic brim
N80.362 Superficial endometriosis of the left pelvic brim
N80.363 Superficial endometriosis of bilateral pelvic brim
N80.371 Deep endometriosis of the right pelvic brim
N80.372 Deep endometriosis of the left pelvic brim
N80.373 Deep endometriosis of bilateral pelvic brim
N80.3A1 Superficial endometriosis of the right uterosacral ligament
N80.3A2 Superficial endometriosis of the left uterosacral ligament
N80.3A3 Superficial endometriosis of the bilateral uterosacral ligament(s)
N80.3B1 Deep endometriosis of the right uterosacral ligament
N80.3B2 Deep endometriosis of the left uterosacral ligament
N80.3B3 Deep endometriosis of bilateral uterosacral ligament(s)
N80.391 Superficial endometriosis of the pelvic peritoneum, other specified sites
N80.392 Deep endometriosis of the pelvic peritoneum, other specified sites
N80.40 Endometriosis of rectovaginal septum, unspecified involvement of vagina
N80.41 Endometriosis of rectovaginal septum without involvement of vagina
N80.42 Endometriosis of rectovaginal septum with involvement of vagina
N80.511 Superficial endometriosis of the rectum
N80.512 Deep endometriosis of the rectum
N80.521 Superficial endometriosis of the sigmoid colon
N80.522 Deep endometriosis of the sigmoid colon
N80.531 Superficial endometriosis of the cecum
N80.532 Deep endometriosis of the cecum
N80.541 Superficial endometriosis of the appendix
N80.542 Deep endometriosis of the appendix
N80.551 Superficial endometriosis of other parts of the colon
N80.552 Deep endometriosis of other parts of the colon
N80.561 Superficial endometriosis of the small intestine
N80.562 Deep endometriosis of the small intestine
N80.6 Endometriosis in cutaneous scar
N80.A1 Superficial endometriosis of bladder
N80.A2 Deep endometriosis of bladder
N80.A41 Superficial endometriosis of right ureter
N80.A42 Superficial endometriosis of left ureter
N80.A43 Superficial endometriosis of bilateral ureters
N80.A51 Deep endometriosis of right ureter
N80.A52 Deep endometriosis of left ureter
N80.A53 Deep endometriosis of bilateral ureters
N80.B1 Endometriosis of pleura
N80.B2 Endometriosis of lung
N80.B31 Superficial endometriosis of diaphragm
N80.B32 Deep endometriosis of diaphragm
N80.B4 Endometriosis of the pericardial space
N80.B5 Endometriosis of the mediastinal space
N80.B6 Endometriosis of cardiothoracic space
N80.C10 Endometriosis of the anterior abdominal wall, subcutaneous tissue
N80.C11 Endometriosis of the anterior abdominal wall, fascia and muscular layers
N80.C2 Endometriosis of the umbilicus
N80.C3 Endometriosis of the inguinal canal
N80.C4 Endometriosis of extra-pelvic abdominal peritoneum
N80.C9 Endometriosis of other site of abdomen
N80.D1 Endometriosis of the sacral splanchnic nerves
N80.D2 Endometriosis of the sacral nerve roots
N80.D3 Endometriosis of the obturator nerve
N80.D4 Endometriosis of the sciatic nerve
N80.D5 Endometriosis of the pudendal nerve
N80.D6 Endometriosis of the femoral nerve
N80.D9 Endometriosis of other pelvic nerve
N80.8 Other endometriosis
N80.9 Endometriosis, unspecified
Z85.3 Personal history of malignant neoplasm of breast
Z85.46 Personal history of malignant neoplasm of prostate

Group 5

(2 Codes)
Group 5 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

These ICD-10-CM codes are applicable for J3315.

Group 5 Codes
Code Description
C61 Malignant neoplasm of prostate
Z85.46 Personal history of malignant neoplasm of prostate

Group 6

(1 Code)
Group 6 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

These ICD-10-CM codes are applicable for J9225.

Group 6 Codes
Code Description
E22.8 Other hyperfunction of pituitary gland

Group 7

(2 Codes)
Group 7 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

These ICD-10-CM codes are applicable for J1952.

Group 7 Codes
Code Description
C61 Malignant neoplasm of prostate
Z85.46 Personal history of malignant neoplasm of prostate
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

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Additional ICD-10 Information

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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.

Code Description
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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.

Code Description
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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
03/15/2024 R4

Under ICD-10-CM Codes that Support Medical Necessity Group 1, 2 and 4: Codes added C08.0, C08.1, C08.9, C48.0, C48.1, C48.2, C48.8, C56.1, C56.2, C56.3, C56.9, C57.00, C57.01 and C57.02.

04/01/2023 R3

Under CPT/HCPCS Codes Group 2: Codes the description was revised for J1954. This revision is due to the 2023 Q2 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 4/1/23.

Acronyms and registered marks were inserted where appropriate throughout the article. Punctuation errors were corrected throughout the article. This revision is retroactive effective for dates of service on or after 4/1/23.

02/19/2023 R2

Under ICD-10-CM Codes that Support Medical Necessity Group 1: Codes added E22.8. Under ICD-10-CM Codes that Support Medical Necessity Group 2: Codes added E22.8.

02/19/2023 R1

Under Article Text added J1954 to the verbiage, “Administration code 96402 should be billed with HCPCS codes J1950, J9217, J9202, J3315 and J1952”. Under CPT/HCPCS Codes Group 2: Codes added J1954. Under CPT/HCPCS Modifiers Group 1: Codes added JZ. This revision is due to the 2023 Annual/Q1 CPT/HCPCS Code Update.

Under CPT/HCPCS Codes Group 1: Paragraph added the verbiage, “Administration code 96402 should be billed with HCPCS code J1950”. Under CPT/HCPCS Codes Group 1: Codes added 96402. Under CPT/HCPCS Codes Group 2: Paragraph added the verbiage, “Administration code 96402 should be billed with HCPCS codes J9217 and J1954”. Under CPT/HCPCS Codes Group 2: Codes added 96402. Under CPT/HCPCS Codes Group 3: Paragraph added the verbiage, “Administration codes 11981, 11982, and 11983 may be billed with HCPCS code J9219”. Under CPT/HCPCS Codes Group 3: Codes added 11981,11982 and 11983. Under CPT/HCPCS Codes Group 4: Paragraph added the verbiage, “Administration code 96402 should be billed with HCPCS code J9202”. Under CPT/HCPCS Codes Group 4: Codes added 96402. Under CPT/HCPCS Codes Group 5: Paragraph added the verbiage, “Administration code 96402 should be billed with HCPCS code J3315”. Under CPT/HCPCS Codes Group 5: Codes added 96402. Under CPT/HCPCS Codes Group 6: Paragraph added the verbiage, “Administration codes 11981, 11982, and 11983 may be billed with HCPCS code J9225”. Under CPT/HCPCS Codes Group 6: Codes added 11981, 11982 and 11983. Under CPT/HCPCS Codes Group 7: Paragraph added the verbiage, “Administration code 96402 should be billed with HCPCS code J1952”. Under CPT/HCPCS Codes Group 7: Codes added 96402. Under CPT/HCPCS Modifiers Group 1: Paragraph added the verbiage, “These modifiers are applicable to all codes listed in CPT/HCPCS Codes Groups 1-7”. Under CPT/HCPCS Modifiers Group 1: Codes added JW. Under ICD-10 Codes that Support Medical Necessity Group 1: Paragraph added the verbiage, “These ICD-10 codes are applicable for J1950”. Under ICD-10 Codes that Support Medical Necessity Group 2: Paragraph added the verbiage, “These ICD-10 codes are applicable for J9217 and J1954”. Under ICD-10 Codes that Support Medical Necessity Group 3: Paragraph added the verbiage, “These ICD-10 codes are applicable for J9219”. Under ICD-10 Codes that Support Medical Necessity Group 4: Paragraph added the verbiage, “These ICD-10 codes are applicable for J9202”. Under ICD-10 Codes that Support Medical Necessity Group 5: Paragraph added the verbiage, “These ICD-10 codes are applicable for J3315”. Under ICD-10 Codes that Support Medical Necessity Group 6: Paragraph added the verbiage, “These ICD-10 codes are applicable for J9225”. Under ICD-10 Codes that Support Medical Necessity Group 7: Paragraph added the verbiage, “These ICD-10 codes are applicable for J1952”.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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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
02/07/2024 03/15/2024 - N/A Currently in Effect You are here
04/06/2023 04/01/2023 - 03/14/2024 Superseded View
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Keywords

  • LHRH
  • Luteinizing Hormone