FIRST COAST SERVICE OPTIONS
LOCAL COVERAGE DETERMINATION
CODING GUIDELINES
Contractor’s
Determination Number
J1459
Contractor Name
First Coast Service
Options, Inc.
Contractor
Number
09102 – Florida
09202 – Puerto Rico
09302 – Virgin Islands
LCD Title
Intravenous Immune
Globulin
Coding Guidelines
When administering IVIG for Thrombocytopenia, documentation must be on
file and available to Medicare. Documentation should include a copy of the
laboratory results showing platelet counts.
Documentation should include the history of the active bleeding
source. This documentation should
include the source, the duration, and the intensity of the episode of bleeding
being treated.
For patients with HIV disease and ITP the medical record must
specifically reflect that the patient has a platelet count of less than 30,000
and is actively bleeding. This must be
supported by applicable lab results. There is a dual diagnosis requirement for
administering IVIG for thrombocytopenia associated with HIV disease.
Dual Diagnosis requirement:
Pediatric HIV: For all children <13 years of age, claims must include dual
diagnoses listed:
042 Human
immunodeficiency virus [HIV] disease
plus
V15.9 Unspecified
personal history presenting hazards to health
OR
042 Human immunodeficiency virus [HIV] disease
plus
V49.89
Other specified conditions influencing health status
Adult HIV: For
adults ≥ 13 there is a dual diagnosis requirement for administering IVIG
for thrombocytopenia associated with HIV disease;
·
Primary
diagnosis of 287.5, Thrombocytopenia, unspecified and
·
Secondary
diagnosis of 042, Human immunodeficiency virus [HIV] disease.
The type / brand of Immune
Globulin must be indicated in Item 19 CMS 1500 form or electronic equivalent.
Other Comments
N/A
Revision History
|
Date |
Revision |
|
02/02/2009 –
Florida |
Original |
Document formatted:
12/12/2007 (JM/st)