SUPERSEDED LCD Reference Article Article

Intravenous Immune Globulin - Policy Article

A52509

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Draft Article
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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Source Article ID
N/A
Article ID
A52509
Original ICD-9 Article ID
Not Applicable
Article Title
Intravenous Immune Globulin - Policy Article
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
07/01/2023
Revision Ending Date
12/31/2023
Retirement Date
N/A

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CMS National Coverage Policy

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NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

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

Intravenous immune globulin used for the treatment of primary immunodeficiency is covered under the Intravenous Immune Globulin benefit. (IOM 100-2, Ch. 15, §50.6) In order for a beneficiary’s equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.

Intravenous immune globulin (IVIG) is covered if all of the following criteria are met:

  1. It is an approved pooled plasma derivative for the treatment of primary immune deficiency disease; and
  2. The patient has a diagnosis of primary immune deficiency disease (See Diagnosis Codes that Support Medical Necessity section below); and
  3. The IVIG is administered in the home; and
  4. The treating practitioner has determined that administration of the IVIG in the patient’s home is medically appropriate.

If all of the criteria are not met and the IVIG is not administered with an infusion pump, the IVIG will be denied as noncovered - no benefit category.

If the criteria are not met and the IVIG is administered with an infusion pump, refer to the Intravenous Immune Globulin LCD.

Coverage under the IVIG benefit is limited to the IVIG itself, not to related supplies and services. If the IVIG is not administered with an infusion pump, related supplies will be denied as noncovered – no benefit category.

Codes J1573 and J2791 are non-covered. They are not indicated for the treatment of primary immune deficiency disease (#2 above).

Refer to the External Infusion Pumps LCD for information concerning coverage of subcutaneous immune globulin.

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

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.

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

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

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

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

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

The supplier must enter a diagnosis code corresponding to the patient's diagnosis on each claim.

MODIFIERS

JW AND JZ MODIFIERS

Effective for claims with dates of service on or after January 1, 2017, the JW modifier is required when billing for unused and discarded amounts of drugs and biologicals from single-dose containers that are administered by the supplier.

Effective for claims with dates of service on or after July 1, 2023, the JZ modifier is required when billing for drugs and biologicals from single-dose containers that are administered by the supplier but have no unused and discarded amounts.

The JW and JZ modifiers are not required for drugs dispensed by the supplier and self-administered by the patient or caregiver in the patient’s home.

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

The DME MACs expect rare use of the JW or JZ modifiers on claims due to HCPCS code descriptors and their associated Units of Service (UOS) for DMEPOS in addition to the limited instructions for use.

There are two scenarios that can occur when billing with the JW modifier:

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

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

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

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

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

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

CODING GUIDELINES

If the IVIG is not administered through an infusion pump and if supplies are billed, code A4223 (INFUSION SUPPLIES NOT USED WITH EXTERNAL INFUSION PUMP, PER CASSETTE OR BAG (LIST DRUGS SEPARATELY) must be used for the supplies.

If the IVIG is administered through an infusion pump refer to the External Infusion Pump LCD and Policy Article for additional information.

Claims for Panzyga for dates of service from August 2, 2018 to June 30, 2023 must be submitted using the HCPCS code J1599 (INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG). One UOS equals five hundred (500) milligrams (mg).

Claims for Panzyga for dates of service on or after July 1, 2023 must be submitted using HCPCS code J1576 (INJECTION, IMMUNE GLOBULIN (PANZYGA), INTRAVENOUS, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID, 500 MG). One UOS equals five hundred (500) mg.

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

Response To Comments

Number Comment Response
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Coding Information

Bill Type Codes

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(25 Codes)
Group 1 Paragraph

The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the Non-Medical Necessity Coverage and Payment Rules section for other coverage criteria and payment information.

Group 1 Codes
Code Description
D80.0 Hereditary hypogammaglobulinemia
D80.2 Selective deficiency of immunoglobulin A [IgA]
D80.3 Selective deficiency of immunoglobulin G [IgG] subclasses
D80.4 Selective deficiency of immunoglobulin M [IgM]
D80.5 Immunodeficiency with increased immunoglobulin M [IgM]
D80.6 Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia
D80.7 Transient hypogammaglobulinemia of infancy
D81.0 Severe combined immunodeficiency [SCID] with reticular dysgenesis
D81.1 Severe combined immunodeficiency [SCID] with low T- and B-cell numbers
D81.2 Severe combined immunodeficiency [SCID] with low or normal B-cell numbers
D81.5 Purine nucleoside phosphorylase [PNP] deficiency
D81.6 Major histocompatibility complex class I deficiency
D81.7 Major histocompatibility complex class II deficiency
D81.82 Activated Phosphoinositide 3-kinase Delta Syndrome [APDS]
D81.89 Other combined immunodeficiencies
D81.9 Combined immunodeficiency, unspecified
D82.0 Wiskott-Aldrich syndrome
D82.1 Di George's syndrome
D82.4 Hyperimmunoglobulin E [IgE] syndrome
D83.0 Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function
D83.1 Common variable immunodeficiency with predominant immunoregulatory T-cell disorders
D83.2 Common variable immunodeficiency with autoantibodies to B- or T-cells
D83.8 Other common variable immunodeficiencies
D83.9 Common variable immunodeficiency, unspecified
G11.3 Cerebellar ataxia with defective DNA repair
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

All codes not listed in the previous section.

Group 1 Codes

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ICD-10-PCS Codes

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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

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
07/01/2023 R11

Revision Effective Date: 07/01/2023
CODING GUIDELINES:
Added: Direction for billing Panzyga

06/22/2023: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2023 R10

Revision Effective Date: 01/01/2023
MODIFIERS:
Revised: JW and JZ modifier instructions to align with the CMS 2023 Physician Fee Schedule final rule

06/15/2023: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2023 R9

Revision Effective Date: 01/01/2023
MODIFIERS:
Added: JZ modifier instructions

01/12/2023: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

10/01/2022 R8

Revision Effective Date: 10/01/2022
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Added: ICD-10-CM code D81.82 to Group 1 codes per update to Medicare Benefit Policy Manual, Chapter 15, section 50.6 

11/24/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2020 R7

Revision Effective Date: 01/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list

04/14/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2020 R6

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “physician” to “practitioner”
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”

02/06/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

08/13/2019 R5

Revision Effective Date: 08/13/2019
ICD-10 CODES THAT ARE COVERED:
Added: Codes D80.2, D80.3, D80.4, D80.6, D80.7, D81.5, D82.1, D82.4, D83.1 and G11.3 per update to Medicare Benefit Policy Manual, Chapter 15, section 50.6

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

01/01/2017 R4

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

01/01/2017 R3 Revision History Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Modifier requirements
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article
07/01/2016 R2 Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.
10/01/2015 R1 Revision Effective Date: 10/01/2015
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: Diagnosis codes from this section
Added: Reference to diagnosis codes section

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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