LCD, Billing and Coding Article Updates for August 2023

New LCDs and Articles (Effective 8/1/2023)

Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell Origin (L39513 A59311)

The CMS National Coverage Determination (NCD 110.23) for Stem Cell Transplantation describes nationally covered indications for SCT, the details of which will not be repeated within this policy. This policy describes additional locally covered indications for allogeneic hematopoietic cell transplants for primary refractory or relapsed Hodgkin and non-Hodgkin lymphoma with B-cell or T-cell origin, that are medically necessary for beneficiaries with no other curative intent options.

Revised LCDs and Billing and Coding Articles

Molecular Pathology (L35000)

Effective for services rendered on or after August 6, 2023, based upon the receipt of two reconsideration requests, chronic lymphocytic leukemia was added to the following Indications of Coverage:

TP53 (tumor protein 53) (e.g. tumor samples), targeted sequence analysis of 2-5 exons, and CPT code 81405 TP53 (tumor protein 53) (e.g. Li-Fraumeni syndrome, tumor samples), full gene sequence or targeted sequence analysis of >5 exons are considered medically necessary in individuals who have Acute Myelogenous Leukemia, CLL, or Myelodysplastic Disease to guide therapeutic decision-making.

IGH@ (Immunoglobulin heavy chain locus) is considered medically necessary for acute ALL, CLL and lymphoma, B-cell to guide therapeutic decision making.

Corrected the LCD number referenced in the following paragraph from L36376 to L37810:
Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, and RNA analysis when performed, 5–50 genes (EG, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed is considered not medically necessary except when used to guide treatment decision making in individuals with non-small cell lung cancer (please refer to LCD L37810).

Billing and Coding: Molecular Pathology Procedures (A56199)

The following changes are effective for services rendered on or after August 6, 2023.

Deleted CPT code 81352 from CPT/HCPCS Section Group 2

• Established Group 35 under the “ICD-10-CM Codes that Support Medical Necessity” section for CPT codes 81261-81264, effective for services rendered on or after August 1, 2023.
• Added Modifier 91 to the CPT/HCPCS Modifier section. The 91 modifier is used for laboratory tests paid under the clinical laboratory fee schedule, as stated in the Medicare Claims Processing Manual, Chapter 16, Laboratory Services, Section 100.5.1.
• Added the following Modifier 91 information to the article text:

Modifier 91

Please use Modifier 91 as appropriate, based on the Medicare Claims Processing Manual, Chapter 16, Laboratory Services, Section 100.5.1. Modifier 91 may be is used “to indicate that a test was performed more than once on the same day for the same patient, only when it is necessary to obtain multiple results in the course of treatment.”

Billing and Coding: Nonvascular Extremity Ultrasound (A56787)

The following ICD-10 codes were added to Group 1: Codes in the ICD-10-CM Codes that Support Medical Necessity section payable only for CPT 76882: K40.00, K40.01, K40.10, K40.11, K40.20, K40.21, K40.30, K40.31, K40.40, K40.41, K40.90 and K40.91.

These codes were also added to Group 1: Medical Necessity ICD-10-CM Codes Asterisk Explanation; only payable for CPT 76882.

Billing and Coding: Peripheral Nerve Blocks (A57452)

The following ICD-10 codes were added to Group 2 of the “ICD-10-CM Codes that Support Medical Necessity” section; G57.81, G57.82, G57.83.

Billing and Coding: Stem Cell Transplantation (A52879)

The article has been revised to remove all references to allogeneic stem cell transplantation. Please refer to LCD L39513 for Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin.

Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (A56874)

The following ICD-10 codes have been added to Group 2 in the ICD-10-CM Codes that Support Medical Necessity section: C54.0, C54.1 and C54.9.

Posted 7/27/2023