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87635 | SARS-COV-2 COVID-19 AMP PRB | HCPCS | The World Health Organization (WHO) has already added code U07.1 (2019-nCoV acute respiratory disease) to the international ICD-10, and the CDC recently announced(www.cdc.gov) that the same code would be added to the U.S. ICD-10-CM list effective April 1. Starting on that day, U07.1 should be used to report a patient who has tested positive for COVID-19. Until then, the CDC has published the following interim guidance on coding for this condition: For a diagnosis of COVID-19, report the code for the patient condition that is related to the COVID-19 (e.g., J12.89, “Other viral pneumonia”) and B97.29, “Other coronavirus as the cause of diseases classified elsewhere.”
Diagnostic code “87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19], amplified probe technique” 87635 is under parent code 87471. https://www.aapc.com/blog/49987-new-cpt-code-for-reporting-covid-19-test/ There are also two new HCPCS Level II testing codes for reporting Medicare beneficiaries being tested for COVID-19,
Question: Should CPT code 87635, a HCPCS Level II code, or both be reported if the test for COVID-19 is performed? Answer: The appropriate code to be reported is dependent upon the payer to which the claim is being submitted. If the claim is submitted to a payer that requires CPT codes, then code 87635 should be reported. |
87471 | HC IADNA BARTONELLA AMPLIFIED PROBE TECHNIQUE | HCPCS | Until then, the CDC has published the following interim guidance on coding for this condition: For a diagnosis of COVID-19, report the code for the patient condition that is related to the COVID-19 (e.g., J12.89, “Other viral pneumonia”) and B97.29, “Other coronavirus as the cause of diseases classified elsewhere.”
Diagnostic code “87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19], amplified probe technique” 87635 is under parent code 87471. https://www.aapc.com/blog/49987-new-cpt-code-for-reporting-covid-19-test/ There are also two new HCPCS Level II testing codes for reporting Medicare beneficiaries being tested for COVID-19,
Question: Should CPT code 87635, a HCPCS Level II code, or both be reported if the test for COVID-19 is performed? Answer: The appropriate code to be reported is dependent upon the payer to which the claim is being submitted. If the claim is submitted to a payer that requires CPT codes, then code 87635 should be reported. Conversely, if the payer requires use of the HCPCS Level II code, the HCPCS Level II code should be reported. CPT and HCPCS codes should not both be reported on the same claim. |
87635 | SARS-COV-2 COVID-19 AMP PRB | HCPCS | Until then, the CDC has published the following interim guidance on coding for this condition: For a diagnosis of COVID-19, report the code for the patient condition that is related to the COVID-19 (e.g., J12.89, “Other viral pneumonia”) and B97.29, “Other coronavirus as the cause of diseases classified elsewhere.”
Diagnostic code “87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19], amplified probe technique” 87635 is under parent code 87471. https://www.aapc.com/blog/49987-new-cpt-code-for-reporting-covid-19-test/ There are also two new HCPCS Level II testing codes for reporting Medicare beneficiaries being tested for COVID-19,
Question: Should CPT code 87635, a HCPCS Level II code, or both be reported if the test for COVID-19 is performed? Answer: The appropriate code to be reported is dependent upon the payer to which the claim is being submitted. If the claim is submitted to a payer that requires CPT codes, then code 87635 should be reported. Conversely, if the payer requires use of the HCPCS Level II code, the HCPCS Level II code should be reported. CPT and HCPCS codes should not both be reported on the same claim. |
87635 | SARS-COV-2 COVID-19 AMP PRB | HCPCS | Answer: The appropriate code to be reported is dependent upon the payer to which the claim is being submitted. If the claim is submitted to a payer that requires CPT codes, then code 87635 should be reported. Conversely, if the payer requires use of the HCPCS Level II code, the HCPCS Level II code should be reported. CPT and HCPCS codes should not both be reported on the same claim. https://isalushealthcare.com/blog/covid-19-coding-guidelines/ So, now you know why there is so much confusion over what is reported as COVID-19. |
87635 | SARS-COV-2 COVID-19 AMP PRB | HCPCS | If the claim is submitted to a payer that requires CPT codes, then code 87635 should be reported. Conversely, if the payer requires use of the HCPCS Level II code, the HCPCS Level II code should be reported. CPT and HCPCS codes should not both be reported on the same claim. https://isalushealthcare.com/blog/covid-19-coding-guidelines/ So, now you know why there is so much confusion over what is reported as COVID-19. And why it is easy to count someone twice. |
G6015 | Radiation tx delivery imrt | HCPCS | Policy description and statement updated to change "radiation therapy" to "radiotherapy" throughout policy. Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. |
77386 | HC IMRT COMPLEX | HCPCS | Policy description and statement updated to change "radiation therapy" to "radiotherapy" throughout policy. Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. |
77385 | HC IMRT SIMPLE | HCPCS | Policy description and statement updated to change "radiation therapy" to "radiotherapy" throughout policy. Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Policy description and statement updated to change "radiation therapy" to "radiotherapy" throughout policy. Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. |
G6015 | Radiation tx delivery imrt | HCPCS | Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. |
77386 | HC IMRT COMPLEX | HCPCS | Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. |
77385 | HC IMRT SIMPLE | HCPCS | Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. |
G6015 | Radiation tx delivery imrt | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. |
77386 | HC IMRT COMPLEX | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. |
77385 | HC IMRT SIMPLE | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. |
G6015 | Radiation tx delivery imrt | HCPCS | Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. Policy Guidelines updated to add medically necessary and investigative definitions. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. Policy Guidelines updated to add medically necessary and investigative definitions. |
0100 | Med-Surg | RC | Given that lipedema is thought to affect 11% of the adult female population (7), it is vital that more research funding be allocated and larger scale studies take place. "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. |
0200 | INTENSIVE CARE UNIT - GENERAL CLASSIFICATION | RC | Given that lipedema is thought to affect 11% of the adult female population (7), it is vital that more research funding be allocated and larger scale studies take place. "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. |
0129 | ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - OTHER | RC | Given that lipedema is thought to affect 11% of the adult female population (7), it is vital that more research funding be allocated and larger scale studies take place. "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. |
1002 | HC ASAM LEVEL 3.7WM INPATIENT WITHDRAW MANAGEMENT | RC | Given that lipedema is thought to affect 11% of the adult female population (7), it is vital that more research funding be allocated and larger scale studies take place. "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. |
0100 | Med-Surg | RC | "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. |
0200 | INTENSIVE CARE UNIT - GENERAL CLASSIFICATION | RC | "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. |
0129 | ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - OTHER | RC | "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. |
1002 | HC ASAM LEVEL 3.7WM INPATIENT WITHDRAW MANAGEMENT | RC | "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. |
0100 | Med-Surg | RC | We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. |
0200 | INTENSIVE CARE UNIT - GENERAL CLASSIFICATION | RC | We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. |
0129 | ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - OTHER | RC | We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. |
1002 | HC ASAM LEVEL 3.7WM INPATIENT WITHDRAW MANAGEMENT | RC | We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. |
0100 | Med-Surg | RC | E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. Chronic Oedema, 2010; 10-16
4) Schmeller W, Meier-Vollrath I, Chapter 7 Lipedema, http://www.hanse-klinik.com/englisch/Lipoedema.pdf
5) Allen E V, Hines E A, Lipoedema of the legs. A syndrome characterized by fat legs and edema. |
0200 | INTENSIVE CARE UNIT - GENERAL CLASSIFICATION | RC | E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. Chronic Oedema, 2010; 10-16
4) Schmeller W, Meier-Vollrath I, Chapter 7 Lipedema, http://www.hanse-klinik.com/englisch/Lipoedema.pdf
5) Allen E V, Hines E A, Lipoedema of the legs. A syndrome characterized by fat legs and edema. |
0129 | ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - OTHER | RC | E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. Chronic Oedema, 2010; 10-16
4) Schmeller W, Meier-Vollrath I, Chapter 7 Lipedema, http://www.hanse-klinik.com/englisch/Lipoedema.pdf
5) Allen E V, Hines E A, Lipoedema of the legs. A syndrome characterized by fat legs and edema. |
1002 | HC ASAM LEVEL 3.7WM INPATIENT WITHDRAW MANAGEMENT | RC | E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. Chronic Oedema, 2010; 10-16
4) Schmeller W, Meier-Vollrath I, Chapter 7 Lipedema, http://www.hanse-klinik.com/englisch/Lipoedema.pdf
5) Allen E V, Hines E A, Lipoedema of the legs. A syndrome characterized by fat legs and edema. |
32856 | Prepare donor lung double | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. |
S2061 | Donor lobectomy (lung) for transplantation, living donor | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. |
32855 | Prepare donor lung single | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. |
S2060 | LOBAR LUNG TRANSPLANTATION | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. |
S2152 | SOLID ORGAN TRANSPL PKG | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. |
32856 | Prepare donor lung double | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. |
S2061 | Donor lobectomy (lung) for transplantation, living donor | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. |
32855 | Prepare donor lung single | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. |
S2060 | LOBAR LUNG TRANSPLANTATION | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. |
S2152 | SOLID ORGAN TRANSPL PKG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. |
32856 | Prepare donor lung double | HCPCS | Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. CPT4 2006 revisions added to policy. 9/20/2007: Code Reference section updated. |
S2061 | Donor lobectomy (lung) for transplantation, living donor | HCPCS | Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. CPT4 2006 revisions added to policy. 9/20/2007: Code Reference section updated. |
32855 | Prepare donor lung single | HCPCS | Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. CPT4 2006 revisions added to policy. 9/20/2007: Code Reference section updated. |
S2060 | LOBAR LUNG TRANSPLANTATION | HCPCS | Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. CPT4 2006 revisions added to policy. 9/20/2007: Code Reference section updated. |
S2152 | SOLID ORGAN TRANSPL PKG | HCPCS | Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. CPT4 2006 revisions added to policy. 9/20/2007: Code Reference section updated. |
J9020 | Injection, asparaginase, not otherwise specified, 10,000 units | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9041 | INJECTION, BORTEZOMIB, 0.1 MG | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9055 | INJECTION, CETUXIMAB, 10 MG | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9062 | Cisplatin 50 MG injection | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9045 | INJECTION, CARBOPLATIN, 50 MG | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9263 | oxaliplatin per 0.5 mg | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9060 | INJECTION, CISPLATIN, POWDER OR SOLUTION, 10 MG | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
G0265 | Cryopresevation Freeze+stora | CPT | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9151 | Injection, daunorubicin citrate, liposomal formulation, 10 mg | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9230 | Mechlorethamine hcl inj | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
38221 | PR DIAGNOSTIC BONE MARROW BIOPSIES | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9140 | Dacarbazine 200 MG inj | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9100 | INJECTION, CYTARABINE, 100 MG | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9010 | DOXORUBICIN HCL, 50 MG | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
38240 | Transplt allo hct/donor | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9015 | Injection, aldesleukin, per single use vial | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
38210 | T-cell depletion of harvest | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9303 | panitumumab per 10 mg | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9213 | Interferon alfa-2a inj | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9380 | TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
38212 | Rbc depletion of harvest | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9268 | Pentostatin injection | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
38220 | PR DIAGNOSTIC BONE MARROW ASPIRATIONS | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9130 | dacarbazine per 200 mg | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9160 | INJ DENILEUKIN DIFTITOX 300 MCG | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9375 | Vincristine sulfate 2 MG inj | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9291 | Mitomycin 40 MG inj | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9094 | CYCLOPHOSPHAMIDE LYOPHILIZED 200 MG | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9265 | Paclitaxel injection | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
Q0083 | Chemotherapy administration by other than infusion technique only (e.g., subcutaneous, intramuscular, push), per visit | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9095 | CYCLOPHOSPHAMIDE LYOPHILIZED 500 MG | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9165 | Injection, diethylstilbestrol diphosphate, 250 mg | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9390 | vinorelbine tartrate per 10 mg | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9250 | METHOTREXATE SODIUM (PF) NON-ONCOLOGY USE 25 MG/ML INJ SOLN | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9218 | LEUPROLIDE ACETATE, PER 1 MG | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9175 | Injection, elliotts'' b solution, 1 ml | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
G0266 | Thawing + expansion froz cel | CPT | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9178 | Inj, epirubicin hcl, 2 mg | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
38215 | PR TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9226 | Supprelin LA implant | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9097 | CYCLOPHOSPHAMIDE LYOPHILIZED 2.0 GM | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
30243Y0 | Transfusion of Autologous Hematopoietic Stem Cells into Central Vein, Percutaneous Approach Tandem Autologous Allogeneic Unrelated Non ICU | ICD | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
30243X0 | Transfusion of Autologous Cord Blood Stem Cells into Central Vein, Percutaneous Approach Tandem Autologous Allogeneic Unrelated Non ICU | ICD | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9360 | Vinblastine sulfate inj | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9217 | LUPRON DEPOT IM 1 MONTH PWD FOR SUSP 7.5 | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9065 | Injection, cladribine, per 1 mg | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
J9600 | Porfimer sodium injection | HCPCS | 2007;49(1):34-40. - National Comprehensive Cancer Network (NCCN). Central Nervous System Cancers 2014; http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. |
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