SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Intravenous Immune Globulin (IVIg)-NCD 250.3

A54641

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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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To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A54641
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Intravenous Immune Globulin (IVIg)-NCD 250.3
Article Type
Billing and Coding
Original Effective Date
11/07/2015
Revision Effective Date
11/07/2015
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

CMS National Coverage Determination Manual, 250.3

Article Guidance

Article Text

This article describes CMS national coverage effective on/after October 1, 2001. Please see the Noridian Local Coverage Determination for additional indications.

Patient must meet at least one of the following criteria:

• Failed conventional therapy. Contractors have the discretion to define what constitutes failure of conventional therapy;
• Conventional therapy is contraindicated. Contractors have the discretion to define what constitutes contraindications to conventional therapy; or
• Have rapidly progressive disease in which a clinical response could not be affected quickly enough using conventional agents. In these situations, IVIg therapy would be give along with conventional treatment(s) and the IVIg would be used only until conventional therapy could take effect.

Note: In addition, IVIg for the treatment of autoimmune mucocutaneous blistering disease must be used only for short term therapy and not as a maintenance therapy. Again, contractors have the discretion to decide what constitutes short-term therapy.

Response To Comments

Number Comment Response
1
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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

Group 1

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Group 1 Codes

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CPT/HCPCS Modifiers

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(14 Codes)
Group 1 Paragraph

The following diagnosis codes are appropriate. Intravenous immune globulin (IVIg) is covered nationally for the treatment of the following biopsy-proven conditions:

Group 1 Codes
Code Description
L10.0 Pemphigus vulgaris
L10.1 Pemphigus vegetans
L10.2 Pemphigus foliaceous
L10.3 Brazilian pemphigus [fogo selvagem]
L10.4 Pemphigus erythematosus
L10.5 Drug-induced pemphigus
L10.81 Paraneoplastic pemphigus
L10.89 Other pemphigus
L10.9 Pemphigus, unspecified
L12.0 Bullous pemphigoid
L12.1 Cicatricial pemphigoid
L12.8 Other pemphigoid
L12.9 Pemphigoid, unspecified
L13.8 Other specified bullous disorders
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

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Group 1 Codes

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ICD-10-PCS Codes

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
N/A

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
11/07/2015 R2

As required by CR 10901, article is converted to a formal billing and coding type article. There is no change in coverage.

11/07/2015 R1 Diagnosis L14 is deleted effective 5/20/2015 per CR 9252, dated 12/3/2015. The Part A article (A54640) is retired and Part A contract numbers are added to the Part B article.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L34314 - Immune Globulin Intravenous (IVIg)
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
11/17/2023 11/07/2015 - N/A Currently in Effect View
05/07/2020 11/07/2015 - N/A Superseded You are here
01/18/2017 11/07/2015 - N/A Superseded View
09/01/2015 11/07/2015 - N/A Superseded View

Keywords

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