Revised Policies

The following are revised policies. To view the new policies on the WPS Medicare Website, use the left hand navigation to go to the Local Policies (LCD). Be sure to note the effective date of the revision, as the revision will not appear in the Active policy until the effective date. Prior to the effective date, the revision can be found by selecting the link "Display Future Effective Documents" within the CMS Medicare Coverage Database (MCD).

February 2012

POLICIES WILL BE AVAILABLE ON THE CMS WEBSITE 01/26/12 AND ON THE WPS MEDICARE WEBSITE 02/07/12.

Policy Title MCD Policy # WPS Policy # Effective Date
Application of Bioengineered Skin Substitutes L30135 GSURG-052 02/01/2012
Removed information regarding Medicare Physician Fee Schedule Database.
Botulinum Toxin Type A & Type B L28555 INJ-018 02/01/2012
Removed information regarding Medicare Physician Fee Schedule Database.
Chemotherapy Drugs and their Adjuncts L28576 HONC-010 02/01/2012

Indications and Limitations of Coverage and/or Medical Necessity

E. Monoclonal Antibodies that are useful in chemotherapeutic regimens:
  1. Rituximab (Rituxan) 100 mg, (J9310)
    Acquired coagulation factor deficiency 286.7
Circulating Tumor Cell Marker Assays L32218 PATH-033 02/15/2012
Annual code updates: Added codes 0279T and 0280T and removed code 86849.
Magnetic Resonance Imaging L28723 RAD-024 01/01/2012
Inadvertent omission of new for 2012 HCPCS code A9585. Effective 01/01/2012.
Optometrist Services L32001 OPHTH-503 04/01/2011
Correction of typographical error listed under LCD Attachments; Billing and Coding Guidelines for Optometrist Service (OPHTH-503).

January 2012

POLICIES WILL BE AVAILABLE ON THE CMS WEBSITE 12/30/11 AND ON THE WPS MEDICARE WEBSITE 01/06/12.
Policy Title MCD Policy # WPS Policy # Effective Date
2012 CPT/HCPCS Code Update Various Various New Codes: 01/01/2012
Deleted Codes: 12/31/2011
The following Procedure Codes have been added or deleted from the listed Local Coverage Determination (LCD) polices for 2011. The new codes are effective for services performed on or after 01/01/2012; the deleted are effective until 12/31/2011 and will not include a 90-day grace period.

*Editor's Note: J3490, J9999, C9399, and A4641 are valid codes to identify not otherwise classified (NOC) drugs and radiopharmaceuticals that have not been assigned a true CPT/HCPCS code. They are listed in the table below to indicate that the NOC code is no longer valid to use for the drugs and radiopharmaceutical listed below which now have true HCPCS codes.
Policy Name & Number Added Codes Deleted Codes Description Changed
Application of Bioengineered Skin Substitutes
GSURG-052
L30135
15271 - 15278, Q4122 - Q4130 15340, 15431, G0440, G0441  
Automatic Implantable Cardioverter Defibrillator (AICD or ICD)
CV-014
33230, 33231, 33262, 33263, 33264   33224, 33225, 33240, 33241, 33249
Bone Mass Measurement
MS-004
L31620
  77079  
Botulinum Toxin Type A & Type B
INJ-018
L28555
J0588 Q2040  
Chemotherapy Drugs and their Adjuncts
HONC-010
L28576
C9287, J9043, J9179, J9228 C9276, *C9399, *J9999  
Computerized Tomography (CAT Scans)
RAD-033
L28544
74174   74176, 74177, 74178
Drugs and Biologics (Non-chemotherapy)
INJ-041
L32013
J0257   J0129, J0256
Epidural, Subarachnoid and Transforaminal Epidural Injections
NEURO-007
L30481
    62310, 62311, 62318, 62319, 77003
Hemophilia Clotting Factors
INJ-003
L31078
J7180, J7183 Q2041  
Immune Globulins
INJ-012
L30147
J1557 C9270 J1561
Injections-Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma
MS-007
L30153
26341, 20527    
Intra-articular Injections of Hyaluronan
INJ-033
L30149
J7326    
Optometrist Services
OPHTH-503
L32001
(Table I) 92071 and 92072   (Table I) 92070
Nerve Conduction Studies and Electromyography
NEURO-005
L31346
95885, 95886, 95887    
Paravertebral Facet Joint Block and Facet Joint Denervation
NEURO-008
L30483
64633, 64634, 64635, 64636 64622, 64623, 64626, 64627
Removed codes 77003 and 77012 - no longer apply to this LCD
 
Radiopharmaceutical Agents
RAD-026
L31361
A9584 C9406, *A4641  
Sacroiliac Joint Injections
MS-009
L31359
  73542
Removed codes 77003 and 77012 - no longer apply to this LCD
27096
Application of Bioengineered Skin Substitutes L30135 GSURG-052 01/01/2012
Added Q4121 TheraSkin®, per square centimeter for all dates of service, claims submitted on and after January 1, 2012.

New 2012 CPT codes dates of service on and after 01/01/2012:
15271 Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
15272 Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)
15273 Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
15274 Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary
15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
15276 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)
15277 Application of skin substitute graft to face, scalp, eyelids, mouth, neck ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
15278 Application of skin substitute graft to face, scalp, eyelids, mouth, neck ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure)
Effective dates of service after 12/31/2011:
15340 Deleted To report, see 15271-15278)
15341 Deleted To report, see 15271-15278)
15360 Deleted To report, see 15271-15274)
15361 Deleted To report, see 15271-15274)
15365 Deleted To report, see 15275-15278)
15366 Deleted To report, see 15275-15278)
15400 Deleted To report, see 15271-15274)
15401 Deleted To report, see 15271-15274)
15420 Deleted To report, see 15275-15278)
15421 Deleted To report, see 15275-15278)
15430 Deleted To report, see 15271-15278)
15431 Deleted To report, see 15271-15278)
G0440 Discontinued
G0441 Discontinued
Immune Globulins L30147 INJ-012 01/01/2012
2. Specific hyperimmune serum globulin includes several different disease-specific drugs.
  1. Crotalidae polyvalent immune FAB (OVINE), (CroFab) (J0840) CroFab is indicated for the management of patients with minimal or moderate North American rattlesnake envenomation. Early use of CroFab (within 6 hours of snakebite) is advised to prevent clinical deterioration and the occurrence of systemic coagulation abnormalities (989.5)

December 2011

POLICIES WILL BE AVAILABLE ON THE CMS WEBSITE 11/30/11 AND ON THE WPS MEDICARE WEBSITE 12/08/11.

Policy Title MCD Policy # WPS Policy # Effective Date
Cardiovascular Stress Testing L28563 CV-004 Retroactive 02/16/2009
ICD-9 Codes that Support Medical Necessity
*425.0-425.9 Cardiomyopathy
This is a correction to the previous policy update.
Chemotherapy Drugs and their Adjuncts & Billing and Coding Guidelines L28576 HONC-010 12/01/2011
Indications and Limitations of Coverage and/or Medical Necessity
E. Monoclonal Antibodies that are useful in chemotherapeutic regimens:
  1. Rituximab (Rituxan) 100 mg, (J9310)
    Dermatomyositis 710.3
    Acquired hemophilia 286.52
Billing and Coding Guidelines:

Coverage for PROVENGE®, Q2043, for asymptomatic or minimally symptomatic metastatic castrate-resistant
(hormone refractory) prostate cancer is limited to one (1) treatment regimen in a patient's lifetime, consisting of
three (3) doses with each dose administered approximately two (2) weeks apart for a total treatment period not to
exceed 30 weeks from the first administration.

Contractors shall not pay separately for routine costs associated with PROVENGE®, HCPCS Q2043, except for
the cost of administration. (Q2043 is all-inclusive and represents all routine costs except for its cost of administration)

Computerized Tomography (CAT Scans) L28544 RAD-033 10/01/2011
ICD-9-CM 2012 update; CHEST AND THORAX (71250-71270) ICD-9 code 998.0 truncated to 998.00, 998.01, 998.02 and 998.09. LOWER EXTREMITY (73700-73706) ICD-9 code 718.60 deleted, effective 10/01/2011.
Drugs and Biologics (Non-chemotherapy) L32013 INJ-041 12/01/2011
J1300 Eculizumab, 10 mg (SolirisTM)
For the treatment of patients with atypical hemolytic uremic syndrome (aHUS) (283.11) to inhibit complement-mediated thrombotic microangiopathy. Effective 09/23/2011-FDA approval date.
Magnetic Resonance Angiography L31355 RAD-023 10/01/2011
Inadvertent omission from ICD-9 list for CPT code 71555, new ICD-9 code V12.55. Effective 10/01/2011.
Magnetic Resonance Imaging L28723 RAD-024 10/01/2011
Inadvertent omission of 726.13, new ICD-9 code for 2012 for CPT procedure UPPER EXTREMITY (73218-73223). ICD-9 code 718.60 invalid with 2012 revisions for CPT procedures LOWER EXTREMITY (73718-73723) effective 10/01/2011.
Radiation Oncology Including Intensity Modulated Radiation Therapy (IMRT) L30316 RAD-014 12/01/2011
Added ICD-9 code 527.7 and removed reference to Proton beam therapy.

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Page Last Updated: Sunday, 29-Jan-2012 09:21:11 CST