Thursday, December 17, 2015

Ferrlecit® and Venofer – J2916 Coding Information and covered DX

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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

13 Hospital Outpatient
72 Clinic - Hospital Based or Independent Renal Dialysis Center
85 Critical Access Hospital

Revenue Codes
Code Description
0636 Pharmacy - Drugs Requiring Detailed Coding

CPT/HCPCS Codes
Group 1 Paragraph
N/A

Group 1 Codes
J1756 Iron sucrose injection
J2916 Na ferric gluconate complex
ICD-9 Codes that Support Medical Necessity
N/A
ICD-9 Codes that DO NOT Support Medical Necessity
N/A
ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph
Part A: For procedure code J2916 (Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg)
Group 1 Codes
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D50.1 Sideropenic dysphagia
D50.8 Other iron deficiency anemias
D50.9 Iron deficiency anemia, unspecified
N18.4* Chronic kidney disease, stage 4 (severe)
N18.5* Chronic kidney disease, stage 5
N18.6* End stage renal disease
Group 2 Paragraph
For procedure code J1756 (Injection, iron sucrose, 1mg)
Group 2 Codes
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D50.1 Sideropenic dysphagia
D50.8 Other iron deficiency anemias
D50.9 Iron deficiency anemia, unspecified
N18.3 Chronic kidney disease, stage 3 (moderate)
N18.4 Chronic kidney disease, stage 4 (severe)
N18.5 Chronic kidney disease, stage 5
N18.6 End stage renal disease
N18.9* Chronic kidney disease, unspecified
Group 3 Paragraph
Part B: For procedure code J2916 (Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg) and J1756 (Injection, iron sucrose, 1 mg)
Group 3 Codes
D50.0* Iron deficiency anemia secondary to blood loss (chronic)
D50.1* Sideropenic dysphagia
D50.8* Other iron deficiency anemias
D50.9* Iron deficiency anemia, unspecified
N18.1* Chronic kidney disease, stage 1
N18.2 Chronic kidney disease, stage 2 (mild)
N18.3 Chronic kidney disease, stage 3 (moderate)
N18.4 Chronic kidney disease, stage 4 (severe)
N18.5 Chronic kidney disease, stage 5
N18.6 End stage renal disease
N18.9* Chronic kidney disease, unspecified
*The billing of Ferrlecit® and Venofer® requires a dual diagnosis. ICD-10-CM codes N18.1-N18.9 and one of the secondary codes for iron deficiency anemia (ICD-10 codes D50.0, D50.1, D50.8, or D50.9) must be billed on the claim.
ICD-10 Codes that DO NOT Support Medical Necessity
N/A

Documentation Requirements

Medical record documentation maintained by the performing provider must substantiate the medical necessity for the use of Ferrlecit® and Venofer® by clearly indicating the condition for which this drug is being used. The documentation must support the criteria as set forth in the "Indications and Limitation of Coverage and/or Medical Necessity" section of this Local Coverage Determination (LCD). The managing physician’s target values for hemoglobin, hematocrit, transferrin saturation and/or serum ferritin levels must be recorded. Laboratory results must be maintained. In addition, documentation that the service was performed must be included in the patient’s medical record. This documentation is normally found in the history and physical or in the office/facility progress notes. The medical record documentation should support that dialysis dependent chronic kidney disease patients receiving Ferrlecit® are also receiving supplemental Epo therapy.

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