FIRST COAST SERVICE OPTIONS
LOCAL COVERAGE DETERMINATION
CODING GUIDELINES

Contractor’s Determination Number

J1459

LCD Database ID Number

L29205 – Florida
L29356 – Puerto Rico/Virgin Islands

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.

For claims processed on or after October 4, 2010, for dates of service on or after October 1, 2010 use HCPCS code C9270 only when

For claims processed on or after October 4, 2010, for dates of service on or after October 1, 2010 use HCPCS code C9270 only when billed in an Ambulatory Surgical Center.

Other Comments

N/A

Revision History

Date

Revision

10/01/2010

1-Added information related to HCPCS code C9270 for use by Ambulatory Surgical Centers only.  The effective date of this revision is based on date of service.

02/02/2009 – Florida
03/02/2009 – Puerto Rico/Virgin Islands

Original

Document formatted: 09/23/10 (SS/mp)