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State Medicare Guidelines / CMS 1500
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| Legal Notice: This document is presented for informational purposes only and is not intended to provide reimbursement or legal advice. Laws, regulations and policies concerning reimbursement are complex and are updated frequently. While we have made an effort to be current as of the issue date of this document the information may not be as current or comprehensive when you view it. Please consult with your counsel or reimbursement specialist for any reimbursement or billing questions. |
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Please refer to the National Coverage Determination (NCD) for additional information that may supercede the Medicare guidelines provided by your local Medicare Carrier, Fiscal Intermediary, or Medicare Administrative Contractor (MAC).
Summary - Part A
- Updated August 01, 2010
For additional information on Medicare covered indications for your specific state, please see the appropriate Part A Local Coverage Determinations/Supporting Documentation which may be accessed through the link above or by clicking here - Part A.
Your state has two Medicare contractors which process claims for Part A providers.
If you use WPS (formerly Mutual of Omaha), please select it now.
WPS
If you do not use WPS, the Medicare guideline summary is below.
| Indication |
ICD-9-CM |
HCPCS |
Starting Labs |
Ending Labs |
GFR/Serum Creatinine |
Allowable Dosage |
Post Chemo |
| Cancer (chemo) |
284.89 or 285.3 and V58.11 or V58.12 and 140.0-149.9, 150.0-159.9, 160.0-165.9, 170.0-176.9, 179-189.9, 190.0-199.1, 199.2, 200.00-202.98, 203.00-203.81, 203.82, 204.00-204.91, 204.92, 209.00-209.30, 209.31, 209.32, 209.33, 209.34, 209.35, 209.36, 233.30, 233.31, 233.32, 233.39, 235.0-235.9, 236.0-236.99, 237.0-237.9, 238.0, 238.1, 238.2, 238.3, 238.5, 238.6, 238.77, 238.79-238.9, 239.0-239.8, 239.81, 239.89, 239.9 or 273.3
Link |
J0885
Link |
HCT < 30% or Hb < 10 g/dL
Link |
HCT 30% or Hb 10 g/dL
Link |
SC: Not Applicable
GFR: Not Applicable |
Starting dose 150 U/kg 3x/wk
Link |
8 weeks
Link |
| AIDS/AZT |
284.89 and 042 or 079.53
Link |
J0885
Link |
Not Stated |
HCT 30-36% or Hb 10-12 g/dL
Link |
SC: Not Applicable
GFR: Not Applicable |
Not Stated |
Not Applicable |
| Renal |
285.21 and 403.00, 403.01, 403.10, 403.11, 403.90, 403.91, 404.00, 404.01, 404.02, 404.03, 404.10, 404.11, 404.12, 404.13, 404.90, 404.91, 404.92, 404.93, 585.3, 585.4 or 585.5
Link |
J0885
Link |
Not Stated |
HCT 30-36% or Hb 10-12 g/dL
Link |
Serum creatinine > 2.5, creatinine clearance < 60 mL/min (not required for stage I or II), or GFR < 60 mL/min/1.73m^2 (not required for stage I or II)
Link
Link |
Not Stated |
Not Applicable |
| Surgery (hip or knee) |
285.29 or 285.9 and V07.8
Link |
J0885
Link |
Hb between 10 and 13 g/dL
Link |
Not Stated |
SC: Not Applicable
GFR: Not Applicable |
Not Stated |
Not Applicable |
These summaries have been prepared using the Medicare guidelines. If you would like to receive the Medicare guidelines, you can call PROCRITline® at 1-800-553-3851 or you can contact the Medicare contractor directly at the web address in the State Medicare Payers box above.
R146
Please refer to the National Coverage Determination (NCD) for additional information that may supercede the Medicare guidelines provided by your local Medicare Carrier, Fiscal Intermediary, or Medicare Administrative Contractor (MAC).
Summary - Part B
- Updated July 22, 2010
For additional information on Medicare covered indications for your specific state, please see the appropriate Medicare carrier Part B Local Coverage Determinations/Supporting Documentation which may be accessed through the link above or by clicking here - Part B.
| Indication |
ICD-9-CM |
HCPCS |
Starting Labs |
Ending Labs |
GFR/Serum Creatinine |
Allowable Dosage |
Post Chemo |
| Cancer (chemo) |
284.89 or 285.3 and V58.11 or V58.12 and 140.0-149.9, 150.0-159.9, 160.0-165.9, 170.0-176.9, 179-189.9, 190.0-199.1, 199.2, 200.00-202.98, 203.00-203.81, 203.82, 204.00-204.91, 204.92, 209.00-209.30, 209.31, 209.32, 209.33, 209.34, 209.35, 209.36, 233.30, 233.31, 233.32, 233.39, 235.0-235.9, 236.0-236.99, 237.0-237.9, 238.0, 238.1, 238.2, 238.3, 238.5, 238.6, 238.77, 238.79-238.9, 239.0-239.8, 239.81, 239.89, 239.9 or 273.3
Link
Link |
J0885
Link
Link |
HCT < 30% or Hb < 10 g/dL
Link
Link |
HCT 30%
Link
Link |
SC: Not Applicable
GFR: Not Applicable |
Starting dose 150 U/kg 3x/wk.
Link
Link |
8 weeks
Link
Link |
| AIDS/AZT |
284.89 and 042 or 079.53
Link
Link |
J0885
Link
Link |
Not Stated |
HCT 30-36% or Hb 10-12 g/dL
Link
Link |
SC: Not Applicable
GFR: Not Applicable |
Not Stated |
Not Applicable |
| Renal |
285.21 and 403.00, 403.01, 403.10, 403.11, 403.90, 403.91, 404.00, 404.01, 404.02, 404.03, 404.10, 404.11, 404.12, 404.13, 404.90, 404.91, 404.92, 404.93, 585.3, 585.4 or 585.5
Link
Link |
J0885
Link
Link |
Not Stated |
HCT 30-36% or Hb 10-12 g/dL
Link
Link |
Serum creatinine > 2.5, creatinine clearance < 60 mL/min (not required for stage I or II), or GFR < 60 mL/min/1.73m^2 (not required for stage I or II)
Link
Link
Link
Link |
Not Stated |
Not Applicable |
| Surgery (hip or knee) |
285.29 or 285.9 and V07.8
Link
Link |
J0885
Link
Link |
Hb between 10 and 13 g/dL
Link
Link |
Not Stated |
SC: Not Applicable
GFR: Not Applicable |
Not Stated |
Not Applicable |
These summaries have been prepared using the Medicare guidelines. If you would like to receive the Medicare guidelines, you can call PROCRITline® at 1-800-553-3851 or you can contact the Medicare contractor directly at the web address in the State Medicare Payers box above.
R145
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