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SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Bevacizumab and biosimilars

A52370

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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
A52370
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Bevacizumab and biosimilars
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
04/01/2023
Revision Ending Date
06/30/2023
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

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Article Guidance

Article Text

This article contains billing and coding guidelines that complement the Local Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and Off-Label Uses.

Coding Information:

When billing for metastatic (secondary) disease, only use the code for the primary malignancy if still present, and only use the related “personal history of” Z code if not. 

For claims submitted to the Part B MAC:

NON-OPHTHALMOLOGIC GUIDELINES

Bevacizumab should be reported with HCPCS code J9035 (injection, bevacizumab, 10 mg). The number of services should reflect multiples of 10 mg provided.

Bevacizumab-awwb should be reported with HCPCS code Q5107 (injection, bevacizumab-awwb, biosimilar, (MVASI), 10 mg).

Bevacizumab-bvzr should be reported with HCPCS code Q5118 (injection, bevacizumab-bvzr, biosimilar, (ZIRABEV), 10 mg).

Effective 01/01/2023, HCPCS code Q5126 should be used to report bevacizumab-maly, biosimilar, (ALYMSYS1®), 10 mg. Effective 10/01/2022 through 12/31/2022, bevacizumab-maly should be reported with HCPCS code C9142 (injection, bevacizumab-maly, biosimilar, (ALYMSYS®), 10 mg).

Effective 04/01/2023, HCPCS code Q5129 should be used to report bevacizumab-adcd (Vegzelma®). Effective 09/27/2022 through 03/31/2023 HCPCS code J3590 should be reported.

OPHTHALMOLOGIC GUIDELINES

Claims for small dose bevacizumab and biosimilars for the treatment of approved ophthalmologic indications, for providers who bill the Part B MAC, should be submitted using HCPCS code C9142, J9035, Q5107 or Q5118 (bill one unit per eye).

HCPCS code C9257 (injection, bevacizumab, 0.25 mg) should be reported for treatment of approved ophthalmologic indications when billed in an ambulatory surgical center setting.

The claim for the intravitreal injection should be coded using CPT code 67028. The appropriate site modifier (RT, LT or 50) must be appended to indicate if the service was performed unilaterally or bilaterally. Claims without a modifier will be returned to the provider unprocessed.

If the drug is denied as not reasonable and necessary, the associated injection code will also be denied.

For claims submitted to the Part A MAC:

NON-OPHTHALMOLOGIC GUIDELINES

Bevacizumab should be reported with HCPCS code J9035 (injection, bevacizumab, 10 mg). The number of services should reflect multiples of 10 mg provided.

Bevacizumab-awwb should be reported with HCPCS code Q5107 (injection, bevacizumab-awwb, biosimilar, (MVASI), 10 mg).

Bevacizumab-bvzr should be reported with HCPCS code Q5118 (injection, bevacizumab-bvzr, biosimilar, (ZIRABEV), 10 mg).

Effective 01/01/2023, HCPCS code Q5126 should be used to report bevacizumab-maly, biosimilar, (ALYMSYS1®), 10 mg. Effective 10/01/2022 through 12/31/2022, bevacizumab-maly should be reported with HCPCS code C9142 (injection, bevacizumab-maly, biosimilar, (ALYMSYS®), 10 mg).

Effective 04/01/2023, HCPCS code Q5129 should be used to report bevacizumab-adcd (Vegzelma®). Effective 09/27/2022 through 03/31/2023 HCPCS code J3590 should be reported.

OPHTHALMOLOGIC GUIDELINES

For providers who bill the Part A MAC, claims for bevacizumab should be reported using HCPCS code C9257 (injection, bevacizumab, 0.25 mg) for treatment of approved ophthalmologic indications.

Bevacizumab-awwb should be reported with HCPCS code Q5107 (injection, bevacizumab-awwb, biosimilar, (MVASI), 10 mg).

Bevacizumab-bvzr should be reported with HCPCS code Q5118 (injection, bevacizumab-bvzr, biosimilar, (ZIRABEV), 10 mg).

Effective 01/01/2023, HCPCS code Q5126 should be used to report bevacizumab-maly, biosimilar, (ALYMSYS1®), 10 mg. Effective 10/01/2022 through 12/31/2022, bevacizumab-maly should be reported with HCPCS code C9142 (injection, bevacizumab-maly, biosimilar, (ALYMSYS®), 10 mg).

The claim for the intravitreal injection should be coded using CPT code 67028. The appropriate site modifier (RT, LT or 50) must be appended to indicate if the service was performed unilaterally or bilaterally. Claims without a modifier will be returned to the provider unprocessed.

If the drug is denied as not reasonable and necessary, the associated injection code will also be denied.

Utilization:

Dose and frequency should be in accordance with the FDA label or recognized compendia (for off-label uses). When services are performed in excess of established parameters, they may be subject to review for medical necessity.

FDA and Compendia Review

American Society of Health-System Pharmacists, Inc. AHFS Drug Information®. Bethesda, MD:2007.

Clinical Pharmacology Web site. http://www.clinicalpharmacology.com. Accessed 03/13/2023.

Lexi-Drugs Web site. http://online.lexi.com. Accessed 03/13/2023.

Micromedex DrugDex®. http://www.micromedexsolutions.com/home/dispatch. Accessed 03/13/2023.

National Comprehensive Cancer Network Web site. http://www.nccn.org/index.asp. Accessed 03/08/2023.

U.S. Food and Drug Administration (FDA) Web site. http://www.accessdata.fda.gov/scripts/cder/daf/. Accessed 08/07/2019.

United States Pharmacopoeia (USP), Volume I; Drug Information for the Health Care Professional, 2007.

Response To Comments

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Coding Information

Bill Type Codes

Code Description
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Revenue Codes

Code Description
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CPT/HCPCS Codes

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Group 1

(7 Codes)
Group 1 Paragraph

Effective 04/01/2023, HCPCS code Q5129 should be used to report bevacizumab-adcd (Vegzelma®). Effective 09/27/2022 through 03/31/2023 HCPCS code J3590 should be reported.

Effective 01/01/2023, HCPCS code Q5126 should be reported for bevacizumab-maly, biosimilar, (ALYMSYS1®), 10 mg. Effective 10/01/2022 through 12/31/2022, HCPCS code C9142 Injection, bevacizumab-maly, biosimilar, (ALYMSYS®), 10 mg has been added for services billed to the Part A MAC. HCPCS code J3590 should be reported for the Part B MAC.

HCPCS code C9142, C9257, Q5107, Q5118 or Q5126 should be reported for treatment of approved ophthalmologic indications billed to the Part A MAC.

HCPCS code C9142, J9035, Q5107, Q5118 or Q5126 (bill one unit per eye) should be reported for the treatment of approved ophthalmologic indications billed to the Part B MAC.

 Group 1 Codes
Code Description
C9257 INJECTION, BEVACIZUMAB, 0.25 MG
J3590 UNCLASSIFIED BIOLOGICS
J9035 INJECTION, BEVACIZUMAB, 10 MG
Q5107 INJECTION, BEVACIZUMAB-AWWB, BIOSIMILAR, (MVASI), 10 MG
Q5118 INJECTION, BEVACIZUMAB-BVZR, BIOSIMILAR, (ZIRABEV), 10 MG
Q5126 INJECTION, BEVACIZUMAB-MALY, BIOSIMILAR, (ALYMSYS), 10 MG
Q5129 INJECTION, BEVACIZUMAB-ADCD (VEGZELMA), BIOSIMILAR, 10 MG

Group 2

(1 Code)
Group 2 Paragraph

Intravitreal injection code

Group 2 Codes
Code Description
67028 INTRAVITREAL INJECTION OF A PHARMACOLOGIC AGENT (SEPARATE PROCEDURE)
N/A

CPT/HCPCS Modifiers

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

(213 Codes)
Group 1 Paragraph

Effective 04/01/2023, HCPCS code Q5129 should be used to report bevacizumab-adcd (Vegzelma®). Effective 09/27/2022 through 03/31/2023 HCPCS code J3590 should be reported.

HCPCS code C9142*, J9035, Q5107, Q5118 or Q5126 and the ICD-10-CM codes listed below should be reported for non-ophthalmologic indications.

*C9142 is being deleted 12/31/2022 and being replaced with HCPCS code Q5126

ICD-10-CM code I67.89 should be used to report symptomatic post-radiation necrosis of the central nervous system.

 Group 1 Codes
Code Description
C17.0 Malignant neoplasm of duodenum
C17.1 Malignant neoplasm of jejunum
C17.2 Malignant neoplasm of ileum
C17.3 Meckel's diverticulum, malignant
C17.8 Malignant neoplasm of overlapping sites of small intestine
C17.9 Malignant neoplasm of small intestine, unspecified
C18.0 Malignant neoplasm of cecum
C18.1 Malignant neoplasm of appendix
C18.2 Malignant neoplasm of ascending colon
C18.3 Malignant neoplasm of hepatic flexure
C18.4 Malignant neoplasm of transverse colon
C18.5 Malignant neoplasm of splenic flexure
C18.6 Malignant neoplasm of descending colon
C18.7 Malignant neoplasm of sigmoid colon
C18.8 Malignant neoplasm of overlapping sites of colon
C18.9 Malignant neoplasm of colon, unspecified
C19 Malignant neoplasm of rectosigmoid junction
C20 Malignant neoplasm of rectum
C21.2 Malignant neoplasm of cloacogenic zone
C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal
C22.0 Liver cell carcinoma
C22.3 Angiosarcoma of liver
C22.8 Malignant neoplasm of liver, primary, unspecified as to type
C22.9 Malignant neoplasm of liver, not specified as primary or secondary
C24.1 Malignant neoplasm of ampulla of Vater
C33 Malignant neoplasm of trachea
C34.00 - C34.92 Malignant neoplasm of unspecified main bronchus - Malignant neoplasm of unspecified part of left bronchus or lung
C38.4 Malignant neoplasm of pleura
C45.0 Mesothelioma of pleura
C45.1 Mesothelioma of peritoneum
C45.2 Mesothelioma of pericardium
C45.7 Mesothelioma of other sites
C46.0 - C46.4 Kaposi's sarcoma of skin - Kaposi's sarcoma of gastrointestinal sites
C46.51 Kaposi's sarcoma of right lung
C46.52 Kaposi's sarcoma of left lung
C46.7 Kaposi's sarcoma of other sites
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
C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck
C49.10 Malignant neoplasm of connective and soft tissue of unspecified upper limb, including shoulder
C49.11 Malignant neoplasm of connective and soft tissue of right upper limb, including shoulder
C49.12 Malignant neoplasm of connective and soft tissue of left upper limb, including shoulder
C49.20 Malignant neoplasm of connective and soft tissue of unspecified lower limb, including hip
C49.21 Malignant neoplasm of connective and soft tissue of right lower limb, including hip
C49.22 Malignant neoplasm of connective and soft tissue of left lower limb, including hip
C49.3 Malignant neoplasm of connective and soft tissue of thorax
C49.4 Malignant neoplasm of connective and soft tissue of abdomen
C49.5 Malignant neoplasm of connective and soft tissue of pelvis
C49.6 Malignant neoplasm of connective and soft tissue of trunk, unspecified
C49.8 Malignant neoplasm of overlapping sites of connective and soft tissue
C49.9 Malignant neoplasm of connective and soft tissue, unspecified
C50.011 - C50.929 Malignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of unspecified site of unspecified male breast
C51.0 Malignant neoplasm of labium majus
C51.1 Malignant neoplasm of labium minus
C51.2 Malignant neoplasm of clitoris
C51.8 Malignant neoplasm of overlapping sites of vulva
C53.0 Malignant neoplasm of endocervix
C53.1 Malignant neoplasm of exocervix
C53.8 Malignant neoplasm of overlapping sites of cervix uteri
C53.9 Malignant neoplasm of cervix uteri, unspecified
C54.0 Malignant neoplasm of isthmus uteri
C54.1 Malignant neoplasm of endometrium
C54.2 Malignant neoplasm of myometrium
C54.3 Malignant neoplasm of fundus uteri
C54.8 Malignant neoplasm of overlapping sites of corpus uteri
C54.9 Malignant neoplasm of corpus uteri, unspecified
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 - C57.22 Malignant neoplasm of unspecified fallopian tube - Malignant neoplasm of left round ligament
C57.3 Malignant neoplasm of parametrium
C57.4 Malignant neoplasm of uterine adnexa, unspecified
C57.7 Malignant neoplasm of other specified female genital organs
C57.8 Malignant neoplasm of overlapping sites of female genital organs
C57.9 Malignant neoplasm of female genital organ, unspecified
C64.1 Malignant neoplasm of right kidney, except renal pelvis
C64.2 Malignant neoplasm of left kidney, except renal pelvis
C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis
C65.1 Malignant neoplasm of right renal pelvis
C65.2 Malignant neoplasm of left renal pelvis
C65.9 Malignant neoplasm of unspecified renal pelvis
C70.0 Malignant neoplasm of cerebral meninges
C70.1 Malignant neoplasm of spinal meninges
C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles
C71.1 Malignant neoplasm of frontal lobe
C71.2 Malignant neoplasm of temporal lobe
C71.3 Malignant neoplasm of parietal lobe
C71.4 Malignant neoplasm of occipital lobe
C71.5 Malignant neoplasm of cerebral ventricle
C71.6 Malignant neoplasm of cerebellum
C71.7 Malignant neoplasm of brain stem
C71.8 Malignant neoplasm of overlapping sites of brain
C71.9 Malignant neoplasm of brain, unspecified
C72.0 Malignant neoplasm of spinal cord
C72.9 Malignant neoplasm of central nervous system, unspecified
C83.30 Diffuse large B-cell lymphoma, unspecified site
C83.31 Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
C83.39 Diffuse large B-cell lymphoma, extranodal and solid organ sites
C83.80 Other non-follicular lymphoma, unspecified site
C83.81 Other non-follicular lymphoma, lymph nodes of head, face, and neck
C83.89 Other non-follicular lymphoma, extranodal and solid organ sites
C85.89 Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites
D19.1 Benign neoplasm of mesothelial tissue of peritoneum
D32.0 Benign neoplasm of cerebral meninges
D32.1 Benign neoplasm of spinal meninges
D42.0 Neoplasm of uncertain behavior of cerebral meninges
D42.1 Neoplasm of uncertain behavior of spinal meninges
D43.0 Neoplasm of uncertain behavior of brain, supratentorial
D43.1 Neoplasm of uncertain behavior of brain, infratentorial
D43.2 Neoplasm of uncertain behavior of brain, unspecified
D43.4 Neoplasm of uncertain behavior of spinal cord
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
G93.6 Cerebral edema
G96.89* Other specified disorders of central nervous system
I67.89 Other cerebrovascular disease
I78.0 Hereditary hemorrhagic telangiectasia
T66.XXXA* Radiation sickness, unspecified, initial encounter
T66.XXXD* Radiation sickness, unspecified, subsequent encounter
T66.XXXS* Radiation sickness, unspecified, sequela
Y84.2 Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
Z85.038 Personal history of other malignant neoplasm of large intestine
Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus
Z85.068 Personal history of other malignant neoplasm of small intestine
Z85.118 Personal history of other malignant neoplasm of bronchus and lung
Z85.3 Personal history of malignant neoplasm of breast
Z85.41 Personal history of malignant neoplasm of cervix uteri
Z85.43 Personal history of malignant neoplasm of ovary
Z85.44 Personal history of malignant neoplasm of other female genital organs
Z85.528 Personal history of other malignant neoplasm of kidney
Z85.53 Personal history of malignant neoplasm of renal pelvis
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*ICD-10-CM code G96.89 must be billed with ICD-10-CM code T66.XXXA, T66.XXXD or T66.XXXS.

Group 2

(187 Codes)
Group 2 Paragraph

HCPCS code C9142*, C9257, Q5107, Q5118 or Q5126 and the ICD-10-CM codes listed below should be reported for treatment of approved ophthalmologic indications billed to the Part A MAC.

HCPCS code C9142*, J9035, Q5107, Q5118 or Q5126 (bill one unit per eye) should be reported for treatment of approved ophthalmologic indications billed to the Part B MAC.
*C9142 is being deleted 12/31/2022 and being replaced with HCPCS code Q5126



 Group 2 Codes
Code Description
E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with 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
E08.3311 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
E08.3411 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
E08.3511 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
E08.3521 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
E08.3531 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
E08.3541 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
E08.3551 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
E08.3591 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
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with 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
E09.3311 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
E09.3411 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
E09.3511 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
E09.3521 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
E09.3531 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
E09.3541 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
E09.3551 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
E09.3591 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
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with 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
E10.3311 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
E10.3411 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
E10.3511 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
E10.3521 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
E10.3531 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
E10.3541 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
E10.3551 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
E10.3591 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
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with 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
E11.3311 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
E11.3411 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
E11.3511 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
E11.3521 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
E11.3531 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
E11.3541 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
E11.3551 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
E11.3591 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
E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with 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
E13.3311 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
E13.3411 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
E13.3511 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
E13.3521 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
E13.3531 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
E13.3541 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
E13.3551 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
E13.3591 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
H21.1X1 Other vascular disorders of iris and ciliary body, right eye
H21.1X2 Other vascular disorders of iris and ciliary body, left eye
H21.1X3 Other vascular disorders of iris and ciliary body, bilateral
H21.1X9 Other vascular disorders of iris and ciliary body, unspecified eye
H34.8110 Central retinal vein occlusion, right eye, with macular edema
H34.8111 Central retinal vein occlusion, right eye, with retinal neovascularization
H34.8112 Central retinal vein occlusion, right eye, stable
H34.8120 Central retinal vein occlusion, left eye, with macular edema
H34.8121 Central retinal vein occlusion, left eye, with retinal neovascularization
H34.8122 Central retinal vein occlusion, left eye, stable
H34.8130 Central retinal vein occlusion, bilateral, with macular edema
H34.8131 Central retinal vein occlusion, bilateral, with retinal neovascularization
H34.8132 Central retinal vein occlusion, bilateral, stable
H34.8310 Tributary (branch) retinal vein occlusion, right eye, with macular edema
H34.8311 Tributary (branch) retinal vein occlusion, right eye, with retinal neovascularization
H34.8312 Tributary (branch) retinal vein occlusion, right eye, stable
H34.8320 Tributary (branch) retinal vein occlusion, left eye, with macular edema
H34.8321 Tributary (branch) retinal vein occlusion, left eye, with retinal neovascularization
H34.8322 Tributary (branch) retinal vein occlusion, left eye, stable
H34.8330 Tributary (branch) retinal vein occlusion, bilateral, with macular edema
H34.8331 Tributary (branch) retinal vein occlusion, bilateral, with retinal neovascularization
H34.8332 Tributary (branch) retinal vein occlusion, bilateral, stable
H35.051 Retinal neovascularization, unspecified, right eye
H35.052 Retinal neovascularization, unspecified, left eye
H35.053 Retinal neovascularization, unspecified, bilateral
H35.059 Retinal neovascularization, unspecified, unspecified eye
H35.3210 Exudative age-related macular degeneration, right eye, stage unspecified
H35.3211 Exudative age-related macular degeneration, right eye, with active choroidal neovascularization
H35.3212 Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularization
H35.3213 Exudative age-related macular degeneration, right eye, with inactive scar
H35.3220 Exudative age-related macular degeneration, left eye, stage unspecified
H35.3221 Exudative age-related macular degeneration, left eye, with active choroidal neovascularization
H35.3222 Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularization
H35.3223 Exudative age-related macular degeneration, left eye, with inactive scar
H35.3230 Exudative age-related macular degeneration, bilateral, stage unspecified
H35.3231 Exudative age-related macular degeneration, bilateral, with active choroidal neovascularization
H35.3232 Exudative age-related macular degeneration, bilateral, with inactive choroidal neovascularization
H35.3233 Exudative age-related macular degeneration, bilateral, with inactive scar
H35.351 Cystoid macular degeneration, right eye
H35.352 Cystoid macular degeneration, left eye
H35.353 Cystoid macular degeneration, bilateral
H35.359 Cystoid macular degeneration, unspecified eye
H35.81 Retinal edema
H40.89 Other specified glaucoma
H44.2A1 Degenerative myopia with choroidal neovascularization, right eye
H44.2A2 Degenerative myopia with choroidal neovascularization, left eye
H44.2A3 Degenerative myopia with choroidal neovascularization, bilateral eye
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph

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 Group 1 Codes

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ICD-10-PCS Codes

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Group 1

Group 1 Paragraph

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 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

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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
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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
04/01/2023 R33

Based on Transmittal 11848 (CR 13092) - Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2023 Update, HCPCS code Q5129 has been added for Bevacizumab-adcd (Vegzelma®). Based on compendia review, ICD-10 codes D19.1 and Z85.41 have been added to the Group 1 ICD-10 code list effective 04/01/2023.

01/01/2023 R32

The reference for Bevacizumab-adcd (Vegzelma®) listed under the OPHTHALMOLOGIC GUIDELINES section of the article has been removed. The reference for Bevacizumab-adcd (Vegzelma®) has also been removed from the Group 2 ICD-10 code Paragraph section. This drug is only approved for non-ophthalmologic indications.

01/01/2023 R31

Based on Transmittal 11738 (CR 12998) January 2023 Integrated Outpatient Code Editor (I/OCE) Specifications Version 24.0, HCPCS code C9142 has been deleted and replaced with Q5126. Bevacizumab-adcd (Vegzelma®) should be reported using HCPCS code J3590. Reference to this drug has been added throughout the article.
10/01/2022 R30

Based on Transmittal 11594, (CR 12885) October 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS), HCPCS code C9142 has been added to the CPT/HCPCS Codes paragraph section and through out the article. Based on compendia review, ICD-10 code Z85.068 has been added to the Group 1 ICD-10 code list effective for dates of service on or after 10/01/2022.
07/01/2022 R29

Based on compendia review, ICD-10 code C45.2 has been added to the Group 1 ICD-10 code list effective for dates of service on or after 07/01/2022.
04/01/2022 R28

Based on compendia review, ICD-10 code C45.7 has been added to Group 1 ICD-10 code list effective for dates of service on or after 04/01/2022.
10/01/2021 R27

Based on the annual ICD-10 code update, ICD-10 code C56.3 has been added to Group 1.
08/01/2021 R26

Based on compendia review, ICD-10 codes G93.6 and Y84.2 have been added to the Group 1 ICD-10 code list effective for dates of service on or after 08/01/2021. 
05/01/2021 R25

Based on compendia review, ICD-10 codes C17.3 and C24.1 have been added to the Group 1 ICD-10 code list effective for dates of service on or after 05/01/2021.
01/01/2021 R24

Based on compendia review, ICD-10 code C22.3 has been added to Group 1 ICD-10 code list effective for dates of service on or after 1/1/2021.
10/01/2020 R23

Based on the annual ICD-10 code update, ICD-10 code G96.8 has been deleted in Group 1 and replaced with G96.89.
08/01/2020 R22

ICD-10-CM codes C22.0, C22.8 and C22.9 were inadvertently added with an incorrect effective date. The effective date has been corrected to 5/29/2020 based on the FDA label.

The following language has been added to the ICD-10 Codes that Support Medical Necessity Group 1 paragraph section:

The annual ICD-10 CM updates, 2020-2021 were applied to the Article Databases. Based on this ICD-10-CM code G96.8 has been deleted from the Group 1 Codes but is effective until 9/30/2020.

Based on a Part B provider comment, ICD-10-CM code Z80.49 has been removed from the Group 1 ICD-10 code list and replaced with Z85.44. 
08/01/2020 R21

Based on compendia review, ICD-10-CM codes C22.0, C22.8 and C22.9 have been added effective for dates of service on or after 08/01/2020.
05/01/2020 R20

Based on compendia review, ICD-10-CM codes G96.8, T66.XXXA, T66.XXXD and T66.XXXS have been added effective for dates of service on or after 05/01/2020. The following has been added to the ICD-10 Codes Asterisk Explanation section: ICD-10-CM code G96.8 must be billed with ICD-10-CM code T66.XXXA, T66.XXXD or T66.XXXS.
11/07/2019 R19

This article was converted to the new Billing and Coding Article format. The Coding Information section has been revised to remove the indications which can be found on the FDA Web site and in the approved compendia. The “Sources of Information” has been revised to “FDA and Compendia Review.” Sources of information other than the FDA and compendia have been moved to a PDF file attached to LCD L33394. The Bill type codes have been removed from this article. Guidance on these codes is available in the Bill type code section.
10/01/2019 R18

Bevacizumab-awwb and HCPCS code Q5107 have been added to the CPT/HCPCS code section and throughout the article effective for dates of service on or after 07/18/2019. Based on Transmittal 4367 (CR 11422 - Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update), HCPCS code Q5118 for bevacizumab-bvzr has been added to the CPT/HCPCS paragraph code section and throughout the article effective for dates of service on or after 10/1/2019. Based on compendia review, ICD-10-CM code C45.1 has been added to the Group 1 code list effective for dates of service on or after 10/1/2019.
08/01/2019 R17

Based on compendia review, ICD-10-CM code C85.89 has been added to the Group 1 code list effective for dates of service on or after 08/01/2019.
02/01/2019 R16

Based on compendia review, ICD-10-CM codes C51.0, C51.1, C51.2 and C51.8 have been added to the Group 1 code list and an indication for vulvar cancer has been added effective for dates of service on or after 02/01/2019.
10/01/2018 R15

Based on compendia review, ICD-10-CM codes D32.0, D32.1, D42.0 and D42.1 have been added to the “Group 1 Covered ICD-10 Codes” section of the article effective for dates of service on and after 10/01/2018.
07/01/2018 R14

Based on a provider/practitioner request, the following indication for central nervous system cancers has been updated to add: 

Central nervous system cancers – consider short-course single agent therapy for management of symptoms driven by RT necrosis poorly controlled vasogenic edema or mass effect: 

  • Adult low-grade (WHO grade II) infiltrative supratentorial astrocytoma/oligodendroglioma;
  • Adult medulloblastoma;
  • Meningiomas;
  • Metastatic spine tumors;
  • Primary central nervous system lymphoma;

An indication for Avastin for epithelial ovarian, fallopian tube or primary peritoneal cancer for persistent disease or recurrence in combination with carboplatin and paclitaxel, followed by Avastin as a single agent, for stage III or IV disease following initial surgical resection (Effective June 13, 2018 based on (FDA) approval) has also been added to the Indications section of the article. ICD-10-CM codes C70.0, C70.1, C83.30, C83.31, C83.39, C83.80, C83.81 and C83.89, have been added effective for dates of service on or after 07/01/2018.
03/01/2018 R13

Based on a Part B provider comment and review of NCCN, the following ICD-10-CM codes have been added to the Group 1 list of Covered ICD-10 Codes effective for dates of service on or after 03/01/2018: C46.0 – C46.4, C46.51, C46.52, C46.7, C54.0 and C54.8. The following ICD-10-CM codes are being removed from the Group 1 list as they were added in error: C49.A0, C49.A1, C49.A2, C49.A3, C49.A4, C49.A5 and C49.A9.

    The “NON-OPHTHALMOLOGIC INDICATIONS” section of the article has been updated to add the following:

AIDS-related Kaposi sarcoma - subsequent systemic therapy given with antiretroviral therapy (ART) for relapsed/refractory advanced, cutaneous, oral, visceral, or nodal disease that has progressed on or not responded to first-line systemic therapy, and progressed on alternate first-line systemic therapy.

The coding information for metastatic malignancy has been revised. The brand name, Avastin™, has been removed from the title of the article.
11/01/2017 R12

Based on a Part B provider comment, ICD-10-CM codes H44.2A1, H44.2A2 and H44.2A3 have been added effective for dates of service on or after 10/01/2017.
11/01/2017 R11

An indication for recurrent adult intracranial and spinal ependymoma (excluding subependymoma) has been added to the “NON-OPHTHALMOLOGIC INDICATIONS” section of the article. The indication for glioblastoma multiforme of brain has been revised to add “recurrent anaplastic gliomas” and “as a single agent or in combination with irinotecan, carmustine/lomustine or temozolomide.” ICD-10-CM code C72.0 has been added to Group 1 effective for dates of service on or after 11/01/2017.


 
07/15/2017 R10

 

The Indication for metastatic renal cell carcinoma has been revised to add the following bulleted item:

  • in combination with erlotinib or everolimus for selected patients with advanced papillary renal cell carcinoma including hereditary leiomyomatosis and renal cell cancer (HLRCC)
07/15/2017 R9

Based on a provider request, symptomatic post-radiation necrosis of the central nervous system has been added to the “Non-Ophthalmologic Indications” section of the article and ICD-10 code I67.89 has been added to the Group 1 Codes effective for dates of service on or after 07/15/2017. The following statement has been added to the Group 1 Codes paragraph section: 

      ICD-10-CM code I67.89 should be used to report symptomatic post-radiation necrosis of the central nervous system 

Additional sources have been added to the “Sources of Information” section of the article.
02/01/2017 R8 The indication for metastatic renal cell carcinoma has been revised to add the following bulleted items:
  • in combination with interferon alfa-2b as first-line therapy for predominant clear cell histology; or
  • as a single-agent systemic therapy for non-clear cell histology
The indication for epithelial ovarian, fallopian tube or primary peritoneal cancer for persistent disease or recurrence has been revised to add :
  • in combination with carboplatin and paclitaxel or in combination with carboplatin and gemcitabine, followed by Avastin as a single agent for the treatment of patients with platinum-sensitive disease (Effective December 06, 2016 based on (FDA) approval).
ICD-10-CM codes C57.7, C57.8, C57.9 have been added to the Group 1 ICD-10 code list effective for dates of service on or after 02/01/2017.
01/01/2017 R7 CPT code 67028 has been removed from the CPT/HCPCS Group 1 code list and has been added to the CPT/HCPCS Group 2 code list. An “Ophthalmologic Limitations” section has been added which includes the following paragraph:
    If the drug is denied as not reasonable and necessary, the associated injection code will also be denied.
10/01/2016 R6 The Group 1 and Group 2 Codes have been revised based on the annual ICD-10-CM code update.
10/01/2015 R5 ICD-10-CM code C49.5 has been added to the Group 1 Codes effective for dates of service on or after 10/01/2015.
10/01/2015 R4 The article has been revised to add single agent treatment for persistent or recurrent ovarian cancer. ICD-10-CM code C21.2 has been added to the Group 1 Codes and ICD-10-CM codes H21.1X9, H34.819, H34.839, H35.059, and H35.359 have been added to the Group 2 Codes effective for dates of service on or after 10/01/2015. HCPC codes J3490 and J3590 have been removed from the CPT/HCPCS section of the article. Out-dated information has been removed.
10/01/2015 R3 An indication for malignant pleural mesothelioma has been added to the “NON-OPHTHALMOLOGIC INDICATIONS” section of the article. The following ICD-10-CM codes have been added to the Group 1: Codes: C34.00, C34.10, C34.30, C34.80, C34.90, C38.4, C45.0, C49.10, C49.20, C49.3, C50.019, C50.029, C50.119, C50.129, C50.219, C50.229, C50.319, C50.329, C50.419, C50.429, C50.519, C50.529, C50.619, C50.629, C50.819, C50.829, C50.919, C50.929, C56.9, C57.00, C57.10, C57.20, C64.9, C65.9 and Z85.43. The following ICD-10.CM codes have been put into ranges C34.00 – C34.92, C50.011 – C50.929 and C57.00 – C57.22. ICD-9-CM code V10.43 is being added effective for dates of service on or after 07/01/2014.
10/01/2015 R2 The following ICD-10 codes have been removed from the Group 1: code list: C21.2, C45.1, C47.0, C47.11, C47.12, C47.21, C47.22, C47.4 and C47.8. The following ICD-10 codes have been added to the Group 1: code list: C53.9, C57.4, C72.9 and D43.2. The place of service guideline for the Part B MAC has been removed. The dosing information has been removed and replaced with the following Utilization guideline: Dose and frequency should be in accordance with the FDA label or recognized compendia (for off-label uses). When services are performed in excess of established parameters, they may be subject to review for medical necessity.
10/01/2015 R1 Updated to include revisions made since April 2014. ICD-10-CM codes C54.9 and I78.0 have been added to the Group 1 Covered ICD-10 Codes.
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