LCD Reference Article Billing and Coding Article

Billing and Coding: Therapeutic Apheresis for Familial Hypercholesterolemia

A56289

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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.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56289
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Therapeutic Apheresis for Familial Hypercholesterolemia
Article Type
Billing and Coding
Original Effective Date
12/01/2018
Revision Effective Date
02/01/2024
Revision Ending Date
N/A
Retirement Date
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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.

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CMS National Coverage Policy

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Article Guidance

Article Text

Apheresis Therapeutic Pheresis National Coverage Determination (NCD) (110.14) allows Medicare Administrative Contractor coverage discretion in the use of therapeutic apheresis in the treatment of refractory familial hypercholesterolemia.

Note: CMS Medicare Learning Network (MLN) (MM) 4250 does not apply to or restrict this use.

 

CGS will cover plasma apheresis for the treatment of familial hypercholesterolemia that is resistant to appropriate lifestyle changes combined with maximal use of statin agents with or without the use of ezetimibe in:

  1. Functional homozygotes with a LDL cholesterol greater than 500mg/dl;
  2. Functional heterozygotes with no known cardiovascular disease but a LDL cholesterol greater than 300mg/dl;
  3. Functional heterozygotes with known cardiovascular disease and a LDL cholesterol greater than 200mg/dl;
  4. Familial hypercholesterolemia in pregnancy when the physician feels usual therapy is inadequate to assure uteroplacental perfusion.

 

All such claims are subject to either pre- or post-pay review by CGS or any of the authorized Medicare auditors. The need for this procedure must be clearly documented in the medical records for each visit including which pharmacologic agents are/have been used and what lifestyle changes have been made and, if a beneficiary was intolerant of statins, the actual findings and symptoms reported. Be sure that the clinical notes are properly signed by the treating provider and dated for the date of service.

Response To Comments

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Coding Information

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CPT/HCPCS Codes

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Code Description
36516 THERAPEUTIC APHERESIS; WITH EXTRACORPOREAL IMMUNOADSORPTION, SELECTIVE ADSORPTION OR SELECTIVE FILTRATION AND PLASMA REINFUSION
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ICD-10-CM Codes that Support Medical Necessity

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Code Description
E78.01 Familial hypercholesterolemia
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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.

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Other Coding Information

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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
02/01/2024 R7

Revision Effective: 02-01-2024

Revision Explanation: Annual review, no changes were made.

11/16/2023 R6

Revision Effective: 11/16/2023

Revision Explanation: Updated LCD Reference Article section.

02/02/2023 R5

Revision Effective: 02/02/2023

Revision Explanation: Annual Review, no changes were made.

02/03/2022 R4

Revision Effective: 02/03/2022

Revision Explanation: Annual Review, no changes were made.

02/04/2021 R3

Revision Effective: 02/04/2021

Revision Explanation: Annual Review, no changes were made.

01/01/2020 R2

Revision Effective: N/A

Revision Explanation: Annual Review, no changes made.

01/01/2020 R1

R1

Revision Effective: 01/01/2020

Revision Explanation: Converted to new billing and coding article format.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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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
01/25/2024 02/01/2024 - N/A Currently in Effect You are here
11/07/2023 11/16/2023 - 01/31/2024 Superseded View
01/27/2023 02/02/2023 - 11/15/2023 Superseded View
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