LCD/Billing and Coding Article Updates – December 2024–January 2025
Mass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG) (L39189) – Effective 12/15/2024
Under the Indications of Coverage, added the following language: "The use of serum mass spectrometry (MS) in monoclonal gammopathies (MGs) and the concurrent use of serum or urine immunofixation electrophoresis (sIFE) is considered medically necessary for:
Under the Limitations of Coverage, removed "Concurrent (sIFE)" limitation and Urine MS Testing.
Billing and Coding: Mass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG) (A58921) – Effective 12/15/2024
Removed Specific Documentation Requirements from article text.
Under Utilization Guidelines, removed "Serum immunofixation electrophoresis (CPT code 86334) will be denied when submitted with PLA code 0077U", and "PLA code 0077U shall only be billed twice per date of service." from the Article Text.
Under Coding Information-Paragraph - Group 1, removed "Serum immunofixation electrophoresis (CPT code 86334) will be denied when submitted with PLA code 0077U", and "PLA code 0077U shall only be billed twice per date of service."
The following diagnosis codes have been added to the "ICD-10-CM That Supports Medical Necessity" section: D63.8, D64.9, N18.1, N18.2, N18.30, N18.31, N18.32, N18.4, N18.5, N18.6, N18.9, N04.0, N04.1, N04.20, N04.9, N03.8, N05.5, N05.8, N05.9, R80.9, D86.85, I11.0, I13.0, I13.10, I13.2, I42.1-I42.9, I50.1, I50.20-I50.23, I50.30-I50.33, I50.40-I50.43, I50.810-I50.814, I50.82, I50.83, I50.84, I50.89, I50.9, C83.00, C91.10, G62.9, M54.50, M79.7, M81.0, R20.2, R53.82, R53.83
Billing and Coding Articles
Billing and Coding: Bevacizumab and biosimilars (A52370)
Added HCPCS code Q5129 to the "ICD-10-CM Codes that Support Medical Necessity" Paragraph- Group 2, effective for services rendered on or after 10/1/2024.
Billing and Coding: Eculizumab (A54548)
Effective 1/1/2025, due to the annual HCPCS update, added HCPCS code Q5139.
Billing and Coding: Facet Joint Interventions for Pain Management (A57826)
Effective 1/1/2025, in the Article Text, under Coding Guidance Diagnostic and Therapeutic injections, added “For unilateral paravertebral facet injection of the T12-L1 and L1-L2 levels or nerves innervating that joint, use 64490 and 64494 once.”
Under Levels: added clarifying language that CPT code 64491 should be reported in conjunction with CPT code 64490 and CPT code 64494 should be reported in conjunction with CPT code 64490 or 64493. Added “Billing contiguous facet interventions in the thoraco-lumbar T12-L1 and lumbar segments (L1-2) during one session will be allowed and considered to be one spine (lumbar) region.”
Under Laterality: added “For bilateral paravertebral facet injection of the T12-L1 and L1–L2 levels or nerves innervating that joint, use 64490 with modifier 50 and 64494 with modifier 50.”
Deleted 083x from Bill Type Codes.
Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms (A56867)
Added C56.3 which was inadvertently omitted from the "ICD-10-CM Codes That Support Medical Necessity" section-Group 3.
Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM) (A58116)
Effective 1/1/2025, per Annual HCPCS/CPT Updates, HCPCS codes G0564 and G0565 were added to the "CPT/HCPCS Codes" section- Group 1 for the new 365-day implantable interstitial glucose sensor. Additional instructions added to clarify coding for 90, 180 and 365-day implantable interstitial glucose sensors.
Billing and Coding: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Tremor (A57435)
Effective 1/1/2025, due to the annual CPT/HCPCs code updates, 0398T has been deleted and 61715 has been added.
Billing and Coding: Molecular Pathology Procedures (A56199)
Under Tier 1 Non-covered Codes - Group 3: Effective 1/1/2025, due to the annual CPT/HCPCS update, CPT codes 81433, 81436, and 81438 have been deleted. To report, please use 81479. Also, the descriptors have changed for CPT codes, 81432, 81434, 81435, and 81437.
Billing and Coding: Non-Invasive Vascular Studies (A56758)
Effective 1/1/2025, due to the annual CPT/HCPCS codes updates, 93890 has been deleted from Group 2 in the CPT/HCPCS Codes section. The following codes have been added to Group 2: 93896, 93897 and 93898 as well as the Group 2 paragraph in the ICD-10 codes that support medical necessity section.
Either the short and/or long code description was changed for code 93893.
Billing and Coding: Off-Label Use of Intravenous Immune Globulin (IVIG) (A59105)
Added ICD-10-CM diagnosis code G93.49 to the "ICD-10-CM Codes that Support Medical Necessity" section, effective for services rendered on or after 1/1/2025.
Billing and Coding: Paclitaxel (e.g., Taxol®/Abraxane ™) (A52450)
Effective 1/1/2025, due to the annual CPT/HCPCS update, HCPCS code J9259 was deleted from Group 1.
The CPT/HCPCS section- Group 1 Paragraph has been revised to read: "Effective for dates of service from 7/1/2023 through 12/31/2024, HCPCS code J9259 should be used to report Injection, paclitaxel protein-bound particles (American regent)."
Billing and Coding: Psychiatric Partial Hospitalization Programs (A56850)
The 10/1/2024 update (R6) added codes F50.83 (Purging disorder) and F50.84 (Night Eating Syndrome) to Group 1, and deleted code F50.81 from the list of ICD-10-CM Codes that Support Medical Necessity Group 1, though these changes were not mentioned in the revision history note. On 10/8/2024, code F50.82 was removed from Group 1 due to its inadvertent addition.
Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (A56874)
Effective 1/1/2025, due to annual HCPCs updates, G0563 has been added to Groups 1 and 2 in the ICD-10-CM Codes that Support Medical Necessity section.
Effective 1/1/2025, ICD-10 code C41.3 has been added to Group 1 in the ICD-10 Codes that Support Medical Necessity section and the following codes have been added to Group 2: C66.1, C66.2, C79.11, C77.2, and C78.6.
The following language has been updated in the Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation: ICD-10-CM codes C7B.03, C7B.8, C79.31-C79.52, C79.89-C79.9, D35.6, D42.0-D43.2, D43.4, D44.6-D44.7, D49.6-D49.7, G52.0-G53, Q28.2-Q28.3, that could not be safely treated by conventional methods (record must describe why other radiation therapy measures are not appropriate or safe for the particular patient).
Either the short and/or long code description was changed for CPT code 77373 in Groups 1 and 2.
Self-Administered Drug Exclusion List: Medical Policy Article (A53021, A53022)
Effective on 1/1/2025, due to the 2025 annual HCPCS update, HCPCS codes Q5131 and Q5132 (adalimumab-aacf (idacio), biosimilar, 20 mg and adalimumab-afzb (abrilada), biosimilar, 10 mg) have been deleted and replaced by HCPCS codes Q5140, Q5141, Q5142, Q5143, Q5144, and Q5145 biosimilars. The previous miscellaneous codes C9399, J3490, and J3590 have been end-dated.
Effective on 1/1/2025, due to the annual HCPCS update, HCPCS code J0135 (Injection, adalimumab, 20 mg) has been deleted and replaced by HCPCS code J0139 (Injection, adalimumab, 1 mg).
Effective on 1/1/2025, due to the annual HCPCS update, HCPCS codes Q9996 and Q9998 (Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mg and Injection, ustekinumab-aekn (selarsdi), 1 mg) have been added to the SAD exclusion table.
Retired
Computed Tomographic (CT) Colonography for Diagnostic Uses (L33562) (A57026) – Effective 12/31/2024
Posted 12/26/2024