SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Octreotide Acetate for Injectable Suspension (Sandostatin® LAR Depot)

A56531

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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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Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56531
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Octreotide Acetate for Injectable Suspension (Sandostatin® LAR Depot)
Article Type
Billing and Coding
Original Effective Date
05/09/2019
Revision Effective Date
07/18/2024
Revision Ending Date
09/30/2024
Retirement Date
N/A

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

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. 100-08, Medicare Program Integrity Manual, Chapter 3, §3.4.1.3 Diagnosis Code Requirements

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §50.3 Incident to Requirements, §50.4.3 Examples of Not Reasonable and Necessary, §50.4.4 Payment for Antigens and Immunizations, §50.4.4.2 Immunizations, §50.4.5 Off-Label Use of Drugs and Biologicals in an Anti-Cancer Chemotherapeutic Regimen, §50.4.5.1 Process for Amending the List of Compendia for Determination of Medically-Accepted Indications for Off-Label Uses of Drugs and Biologicals in an Anti-Cancer Chemotherapeutic Regimen, §50.4.6 Less Than Effective Drug and §50.4.7 Denial of Medicare Payment for Compounded Drugs Produced in Violation of Federal Food, Drug, and Cosmetic Act

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Octreotide Acetate for Injectable Suspension (Sandostatin® LAR Depot) L33438. 

When ICD-10-CM codes T38.895A, T38.895D, T38.895S, T43.215A, T43.215D, T43.215S, T43.225A, T43.225D, T43.225S, T50.995A, T50.995D or T50.995S is submitted for chemotherapy induced diarrhea (CID); the medical record must document the covered chemotherapy agent(s) causing the CID and the previous antidiarrheal treatments that have become ineffective.

  • If ICD-10-CM codes C25.4, C26.0, D13.7, D13.91 and D13.99 are submitted on the claim, the medical record must document that the patient’s diagnosis is VIPoma.
  • If ICD-10-CM code R79.89 is submitted on the claim, the patient’s record must document abnormal findings leading to suspicion of VIPoma.
  • If ICD-10-CM code R94.7 is submitted on the claim, the patient’s record must document an abnormal octreotide scan leading to suspicion of VIPoma.

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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N/A

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

(24 Codes)
Group 1 Paragraph

Use of these codes does not guarantee reimbursement. The patient’s medical record must document that the coverage criteria in this policy have been met.

Group 1 Codes
Code Description
C7A.010 Malignant carcinoid tumor of the duodenum
C7A.011 Malignant carcinoid tumor of the jejunum
C7A.012 Malignant carcinoid tumor of the ileum
C7A.019 Malignant carcinoid tumor of the small intestine, unspecified portion
C7A.020 Malignant carcinoid tumor of the appendix
C7A.021 Malignant carcinoid tumor of the cecum
C7A.022 Malignant carcinoid tumor of the ascending colon
C7A.023 Malignant carcinoid tumor of the transverse colon
C7A.024 Malignant carcinoid tumor of the descending colon
C7A.025 Malignant carcinoid tumor of the sigmoid colon
C7A.026 Malignant carcinoid tumor of the rectum
C7A.029 Malignant carcinoid tumor of the large intestine, unspecified portion
C7A.090 Malignant carcinoid tumor of the bronchus and lung
C7A.091 Malignant carcinoid tumor of the thymus
C7A.092 Malignant carcinoid tumor of the stomach
C7A.093 Malignant carcinoid tumor of the kidney
C7A.094 Malignant carcinoid tumor of the foregut, unspecified
C7A.095 Malignant carcinoid tumor of the midgut, unspecified
C7A.096 Malignant carcinoid tumor of the hindgut, unspecified
C7A.098 Malignant carcinoid tumors of other sites
C7A.1 Malignant poorly differentiated neuroendocrine tumors
C7A.8 Other malignant neuroendocrine tumors
E22.0 Acromegaly and pituitary gigantism
E34.0 Carcinoid syndrome

Group 2

(25 Codes)
Group 2 Paragraph

NOTE: For K52.1, per ICD-10-CM coding conventions, use an additional code for adverse effect, if applicable, to identify the drug (toxic substance).

For chemotherapy induced diarrhea (CID) use:

Group 2 Codes
Code Description
K52.1 Toxic gastroenteritis and colitis
T38.895A Adverse effect of other hormones and synthetic substitutes, initial encounter
T38.895D Adverse effect of other hormones and synthetic substitutes, subsequent encounter
T38.895S Adverse effect of other hormones and synthetic substitutes, sequela
T43.215A Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, initial encounter
T43.215D Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, subsequent encounter
T43.215S Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, sequela
T43.225A Adverse effect of selective serotonin reuptake inhibitors, initial encounter
T43.225D Adverse effect of selective serotonin reuptake inhibitors, subsequent encounter
T43.225S Adverse effect of selective serotonin reuptake inhibitors, sequela
T43.641A Poisoning by ecstasy, accidental (unintentional), initial encounter
T43.641D Poisoning by ecstasy, accidental (unintentional), subsequent encounter
T43.641S Poisoning by ecstasy, accidental (unintentional), sequela
T43.642A Poisoning by ecstasy, intentional self-harm, initial encounter
T43.642D Poisoning by ecstasy, intentional self-harm, subsequent encounter
T43.642S Poisoning by ecstasy, intentional self-harm, sequela
T43.643A Poisoning by ecstasy, assault, initial encounter
T43.643D Poisoning by ecstasy, assault, subsequent encounter
T43.643S Poisoning by ecstasy, assault, sequela
T43.644A Poisoning by ecstasy, undetermined, initial encounter
T43.644D Poisoning by ecstasy, undetermined, subsequent encounter
T43.644S Poisoning by ecstasy, undetermined, sequela
T50.995A Adverse effect of other drugs, medicaments and biological substances, initial encounter
T50.995D Adverse effect of other drugs, medicaments and biological substances, subsequent encounter
T50.995S Adverse effect of other drugs, medicaments and biological substances, sequela

Group 3

(7 Codes)
Group 3 Paragraph

The following ICD-10-CM diagnoses codes must be used to designate VIPoma or suspected VIPoma:

Group 3 Codes
Code Description
C25.4 Malignant neoplasm of endocrine pancreas
C26.0 Malignant neoplasm of intestinal tract, part unspecified
D13.7 Benign neoplasm of endocrine pancreas
D13.91 Familial adenomatous polyposis
D13.99 Benign neoplasm of ill-defined sites within the digestive system
R79.89 Other specified abnormal findings of blood chemistry
R94.7 Abnormal results of other endocrine function studies

Group 4

(2 Codes)
Group 4 Paragraph

The diagnosis for VIPoma or suspected VIPoma must also be accompanied by:

Group 4 Codes
Code Description
K52.89 Other specified noninfective gastroenteritis and colitis
R19.7 Diarrhea, unspecified

Group 5

(9 Codes)
Group 5 Paragraph

Severe Liver Disease

Group 5 Codes
Code Description
I85.00 Esophageal varices without bleeding
I85.01 Esophageal varices with bleeding
I85.10 Secondary esophageal varices without bleeding
I85.11 Secondary esophageal varices with bleeding
K76.7 Hepatorenal syndrome
K91.82 Postprocedural hepatic failure
K91.83 Postprocedural hepatorenal syndrome
O90.41 Hepatorenal syndrome following labor and delivery
O90.49 Other postpartum acute kidney failure

Group 6

(2 Codes)
Group 6 Paragraph

Sulfa urea induced hypoglycemia

Group 6 Codes
Code Description
E13.641 Other specified diabetes mellitus with hypoglycemia with coma
E13.649 Other specified diabetes mellitus with hypoglycemia without coma

Group 7

(1 Code)
Group 7 Paragraph

Thymoma advanced

NOTE: Approved for use as a second line therapy when disease progression occurs despite treatment with first line therapies.

Group 7 Codes
Code Description
C37 Malignant neoplasm of thymus
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

All other ICD-10-CM codes not listed under Covered ICD-10-CM Codes will be denied as not medically necessary.

Group 1 Codes

N/A

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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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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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N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

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
07/18/2024 R7

Under CMS National Coverage Policy the following regulation was added: CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, §3.4.1.3 Diagnosis Code Requirements.

10/01/2023 R6

Under Article Text from the first bullet point and under ICD-10 Codes that Support Medical Necessity Group 3: Codes deleted D13.9 and added D13.91 and D13.99. Under ICD-10 Codes that Support Medical Necessity Group 5: Codes deleted O90.4 and added O90.41 and O90.49. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/23.

05/26/2022 R5

Under Coverage Indications, Limitations and/or Medical Necessity updated regulation section headings. Formatting and punctuation was corrected throughout the article.

06/24/2021 R4

Under Article Title and Article Text deleted registered symbol from LAR and added registered symbol to Sandostatin. Under CMS National Coverage Policy added regulation Title XVIII of the Social Security Act, §1833(e), moved regulation CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §50 Drugs and Biologicals, §50.1 Definition of Drug or Biological, §50.2 Determining Self-Administration of Drug or Biological, §50.4 Reasonableness and Necessity, §50.4.1 Approved Use of Drug, §50.4.2 Unlabeled Use of Drug and §50.4.4.1 Antigens to the related LCD, and updated regulation headings. Formatting and punctuation were corrected throughout the article.

10/01/2020 R3

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes deleted K59.8. This revision is due to the Annual ICD-10 Code Update and is effective on 10/1/20.

10/17/2019 R2

This article is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual. CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §§50-50.4.7 was removed from the CMS National Coverage Policy section of the related Octreotide Acetate for Injectable Suspension (Sandostatin LAR® depot) L33438 and placed in this article. Under Article Text deleted the subheading Documentation Requirements.

05/29/2019 R1

All coding located in the Coding Information section has been removed from the related Octreotide Acetate for Injectable Suspension (Sandostatin LAR® depot) L33438 LCD and added to this article. Under Covered ICD-10 Codes Group 1: Codes added C7A.8.

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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
08/12/2024 10/01/2024 - N/A Currently in Effect View
07/12/2024 07/18/2024 - 09/30/2024 Superseded You are here
08/23/2023 10/01/2023 - 07/17/2024 Superseded View
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Keywords

  • Octreotide
  • Sandostatin