 |
|
|
|
State Medicare Guidelines / CMS 1500
|
|
|
|
|
|
|
|
|
| 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. |
|
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 December 16, 2009
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) |
285.3 and V67.2 or V58.11
Link |
J0885
Link |
Not Stated
Link |
Not Stated |
SC: Not Applicable
GFR: Not Applicable |
Not Stated |
Not Stated |
| AIDS/AZT |
285.9 and 042
Link |
J0885
Link |
HCT < 30% w/in one wk of initial treatment & anemia must be symptomatic
Link |
Hb 12 g/dL or HCT 36%
Link |
SC: Not Applicable
GFR: Not Applicable |
Per FDA
Link |
Not Applicable |
| Renal |
285.21 and 403.01, 403.11, 403.91, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93, 585.3, 585.4, 585.5, 585.9 or V42.0
Link |
J0885
Link |
HCT < 30% w/in one wk of the initial injection, or higher if anemia is symptomatic
Link |
HCT 36%
Link |
SC: Not Stated
GFR: GFR < 60 mL/min/1.73m^2
Link |
Not Stated |
Not Applicable |
| Surgery (hip or knee) |
284.81, 284.89, 284.9, 285.21, 285.22, 285.29, 285.8, or 285.9 and V07.8
Link |
J0885
Link |
Hb between 10 and 13 g/dL w/in one wk of initial injection
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.
R138
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 October 01, 2009
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) |
285.3. Or, V58.11 and malignancy code
Link |
J0885
Link |
HCT < 30% or Hb < 10 g/dL
Link |
HCT 30%
Link |
SC: Not Applicable
GFR: Not Applicable |
Recommended starting dose 150 U/kg 3x/wk
Link |
8 weeks
Link |
| AIDS/AZT |
042
Link |
J0885
Link |
HCT < 33%; endogenous serum EPO < 500 mU/mL prior to therapy.
Link
Link |
HCT 36%. For HCT > 34%+/- 2%, retain documentation to support necessity in medical record.
Link |
SC: Not Applicable
GFR: Not Applicable |
Usual dose 40,000 units in single or divided doses, maximum dose 60,000 units in single or divided doses.
Link |
Not Applicable |
| Renal |
285.21 and 585.2, 585.3, 585.4, 585.5 or 585.9
Link |
J0885
Link |
HCT < 33%
Link |
HCT 36%. Or, for HCT > 34%+/- 2%, retain documentation to support necessity in medical record.
Link |
SC: Most recent serum creatinine or estimated creatinine clearance within the last month. Values not stated.
Link
GFR: Not Stated |
Usual dose 40,000 units in single or divided doses, maximum dose 60,000 units in single or divided doses.
Link |
Not Applicable |
| Surgery (elective, non-cardiac, non-vascular) |
V72.83 and condition for which the patient is undergoing surgery
Link |
J0885
Link |
HCT < 33%
Link |
HCT 36%. Or, for HCT > 34%+/- 2%, retain documentation to support necessity in medical record.
Link |
SC: Not Applicable
GFR: Not Applicable |
Usual dose 40,000 units/wk given in single or divided doses. Maximum dose 60,000 units/wk in single or divided doses.
Link |
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.
R135
|
