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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 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 March 07, 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 (on chemo, non-myeloid malignancies) |
285.3
Link |
J0885
Link |
Hb < 10 g/dL or HCT < 30% w/in last 30 days
Link
Link |
See NCD
Link
Link |
SC: Not Applicable
GFR: Not Applicable |
See NCD
Link
Link |
8 weeks
Link
Link |
| AIDS/AZT |
285.8 or 285.9 and 042 or 079.53
Link |
J0885
Link |
HCT < 30% or Hb < 10 g/dL within the past 30 days, AZT < 4200 mg/wk; endogenous EPO < 500 mU/mL
Link
Link |
HCT 30-36% or Hb 10-12 g/dL
Link |
SC: Not Applicable
GFR: Not Applicable |
Not Stated |
Not Applicable |
| Renal |
285.21 and 585.3, 585.4, 585.5 or 585.9
Link |
J0885
Link |
HCT < 30% or Hb < 10 g/dL
Link |
HCT 30-36% or Hb 10-12 g/dL
Link |
Serum creatinine > 3, creatinine clearance < 60 mL/min or GFR < 60 mL/min/1.73m^2
Link |
Not Stated |
Not Applicable |
| Surgery (hip or knee) |
285.8 or 285.9 and V07.8
Link |
J0885
Link |
Hb between 10 and 13 g/dL at least 3 wks prior to surgery
Link |
Not Stated |
SC: Not Applicable
GFR: Not Applicable |
Weekly dosage starting 3 weeks prior to surgery (on days 21, 14, 7) and day of surgery).
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.
R141
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