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J9201 | INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38209 | Wash harvest stem cells | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9202 | ZOLADEX IMPLANT 3.6MG | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9214 | interferon alfa-2b per 1000000 Units | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9310 | RITUXIMAB INJECTION SOLUTION 10 MG/ML (FOR DESENSITIZATION) | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38204 | PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9185 | Injection, fludarabine phosphate, 50 mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9110 | Cytarabine hcl 500 MG inj | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9264 | PACLITAX-PROTEIN1MGINJJW Injectable Drugs Not on Fee Schedule | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9350 | MOSUNETUZUMB AXGB 1MG 30MG 30MLSNIV | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9150 | Injection, daunorubicin, 10 mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38208 | Thaw preserved stem cells | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9208 | Injection, ifosfamide, 1 gram | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9261 | Nelarabine injection | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9225 | Vantas implant | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9050 | Injection, carmustine, 100 mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
Q0085 | Chemotherapy administration by both infusion technique and other technique(s) (e.g., subcutaneous, intramuscular, push), per visit | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9212 | Interferon alfacon-1 inj | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9001 | DOXORUBICIN PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9370 | VINCRISTINE SULFATE 2MG Injectable Drugs Not on Fee Schedule | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9209 | mesna per 200 mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9092 | Cyclophosphamide 2.0 grm inj | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9017 | Injection, arsenic trioxide, 1 mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9090 | Cyclophosphamide 500 MG inj | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9190 | INJECTION, FLUOROURACIL, 500 MG | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9245 | melphalan HCl 50 mg recon soln 1 each Vial | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
G0267 | Bone marrow or psc harvest | CPT | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9098 | Injection, cytarabine liposome, 10 mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9091 | Cyclophosphamide 1.0 grm inj | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9080 | Cyclophosphamide 200 MG inj | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9170 | Docetaxel injection | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9270 | Plicamycin (mithramycin) inj | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9070 | HC Cyclophosphamide Inj Bu100mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
S2150 | Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; m | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9120 | Injection, dactinomycin, 0.5 mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9200 | Injection, floxuridine, 500 mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9266 | PEGASPARGASE VIAL 3750U 5ML SNIJ | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
30243G0 | Transfusion of Autologous Bone Marrow into Central Vein, Percutaneous Approach Tandem Autologous Allogeneic Unrelated Non ICU | ICD | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38211 | Tumor cell deplete of harvst | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9093 | CYCLOPHOSPHAMIDE LYOPHILIZED 100 MG | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9305 | pemetrexed per 10 mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38232 | PR BONE MARROW HARVEST TRANSPLANTATION AUTOLOGOUS | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9027 | Injection, clofarabine, 1 mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9355 | trastuzumab per 10 mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9357 | Valrubicin injection | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9216 | Interferon gamma 1-b inj | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9260 | METHOTREXATE SODIUM (PF) 50 MG/2ML INJ SOLUTION | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9211 | Injection, idarubicin hydrochloride, 5 mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9215 | Interferon alfa-n3 inj | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9340 | Thiotepa injection | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9290 | Mitomycin 20 MG inj | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9025 | INJECTION, AZACITIDINE, 1 MG | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9300 | QUINACRINE HCL 10 CC/200 MGM | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9219 | Leuprolide acetate implant, 65 mg | HCPCS | |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. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J7188 | Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7189 | NOVOSEVEN RT 5 MG INJ Injectable Drugs Not on Fee Schedule | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7190 | HC Monoclate P/F-Tc/Phsa Home | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7192 | HC Recombinate-Tc/Phsa Home | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7187 | Injection, von willebrand factor complex (humate-p), per iu vwf:rco | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7191 | HC FACTOR VIII (PORCINE) PER IU | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7180 | Injection, factor xiii (antihemophilic factor, human), 1 i.u. | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7186 | Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7181 | Injection, factor xiii a-subunit, (recombinant), per iu | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7175 | Inj, factor x, (human), 1iu | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
Q9995 | INJ. EMICIZUMAB-KXWH, 0.5 MG | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7185 | Xyntha inj | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7182 | Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7183 | Wilate injection | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7179 | VON WILLEBRAND FACTOR (RECOMB) 650 UNITS IV SOLR | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7170 | Inj., emicizumab-kxwh 0.5 mg | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7195 | Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7194 | HC Profilnine Sd Phs Home | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7193 | HC Mononine-Tc/Phsa Home Phs | HCPCS | - D66 Hereditary factor VIII deficiency
- D67 Hereditary factor IX deficiency
- D68.0 Von Willebrand’s disease
- D68.1 Hereditary factor XI deficiency
- D68.3 Hemorrhagic disorder due to circulating anticoagulants
- D68.311 Acquired hemophilia
- D68.312 Antiphospholipid antibody with hemorrhagic disorder
- D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
- D68.4 Acquired coagulation factor deficiency
People also use self-injectable medications to reduce the frequency of bleeding episodes. HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. |
J7188 | Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7189 | NOVOSEVEN RT 5 MG INJ Injectable Drugs Not on Fee Schedule | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7190 | HC Monoclate P/F-Tc/Phsa Home | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7192 | HC Recombinate-Tc/Phsa Home | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7187 | Injection, von willebrand factor complex (humate-p), per iu vwf:rco | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7191 | HC FACTOR VIII (PORCINE) PER IU | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7180 | Injection, factor xiii (antihemophilic factor, human), 1 i.u. | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7186 | Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7181 | Injection, factor xiii a-subunit, (recombinant), per iu | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7175 | Inj, factor x, (human), 1iu | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
Q9995 | INJ. EMICIZUMAB-KXWH, 0.5 MG | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7185 | Xyntha inj | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7182 | Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7183 | Wilate injection | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7179 | VON WILLEBRAND FACTOR (RECOMB) 650 UNITS IV SOLR | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7170 | Inj., emicizumab-kxwh 0.5 mg | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7195 | Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7194 | HC Profilnine Sd Phs Home | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7193 | HC Mononine-Tc/Phsa Home Phs | HCPCS | HEMLIMBRA is one such approved prophylactic medicine for adults and children with congenital factor VIII deficiency hemophilia A with factor VIII inhibitors and the drug is self-administered subcutaneously, weekly. Usage of this drug can be reported using HCPCS code. - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. |
J7188 | Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. | HCPCS | - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. Physicians treating COVID-19, hemophilia or any bleeding disorders can consider partnering with an experienced medical billing and coding company to assign the correct codes on medical claims. |
J7189 | NOVOSEVEN RT 5 MG INJ Injectable Drugs Not on Fee Schedule | HCPCS | - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. Physicians treating COVID-19, hemophilia or any bleeding disorders can consider partnering with an experienced medical billing and coding company to assign the correct codes on medical claims. |
J7190 | HC Monoclate P/F-Tc/Phsa Home | HCPCS | - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. Physicians treating COVID-19, hemophilia or any bleeding disorders can consider partnering with an experienced medical billing and coding company to assign the correct codes on medical claims. |
J7192 | HC Recombinate-Tc/Phsa Home | HCPCS | - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. Physicians treating COVID-19, hemophilia or any bleeding disorders can consider partnering with an experienced medical billing and coding company to assign the correct codes on medical claims. |
J7187 | Injection, von willebrand factor complex (humate-p), per iu vwf:rco | HCPCS | - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. Physicians treating COVID-19, hemophilia or any bleeding disorders can consider partnering with an experienced medical billing and coding company to assign the correct codes on medical claims. |
J7191 | HC FACTOR VIII (PORCINE) PER IU | HCPCS | - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. Physicians treating COVID-19, hemophilia or any bleeding disorders can consider partnering with an experienced medical billing and coding company to assign the correct codes on medical claims. |
J7180 | Injection, factor xiii (antihemophilic factor, human), 1 i.u. | HCPCS | - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. Physicians treating COVID-19, hemophilia or any bleeding disorders can consider partnering with an experienced medical billing and coding company to assign the correct codes on medical claims. |
J7186 | Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. | HCPCS | - Q9995 Injection, emicizumab-kxwh, 0.5 mg
Other HCPCS codes for blood-clotting factors and injections are
- J7170 Injection, emicizumab-kxwh, 0.5 mg
- J7175 Injection, factor X, (human), 1 IU
- J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo
- J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
- J7181 Injection, factor XIII A-subunit, (recombinant), per IU
- J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU
- J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo
- J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha®), per IU
- J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per
factor VIII IU
- J7187 Injection, von Willebrand factor complex (Humate-P®), per IU VWF:RCO
- J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU
- J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg
- J7190 Factor VIII (antihemophilic factor, human), per IU
- J7191 Factor VIII (antihemophilic factor (porcine)), per IU
- J7192 Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified
- J7193 Factor IX (antihemophilic factor, purified, non-recombinant), per IU
- J7194 Factor IX, complex, per IU
- J7195 Injection, factor IX (antihemophilic factor, recombinant) per IU, not otherwise
- Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified)
COVID-19 and Hemophilia
Hemophilia News Today has pointed out that individuals of any age with blood disorders such as hemophilia, porphyria, and sickle cell disease are at increased risk of developing serious COVID-19 symptoms and they should take extra precautions to minimize the risk of getting COVID-19. It is recommended that such patients keep their blood pressure in check and follow general guidelines to keep their immune system strong. To avoid getting infected by COVID-19, they should follow preventive measures such as stocking up on necessary medications and supplies that can last for a few weeks, avoid crowds and unnecessary travel, stay at home as much as possible and consult their healthcare providers in case of any COVID-19-like symptoms. Physicians treating COVID-19, hemophilia or any bleeding disorders can consider partnering with an experienced medical billing and coding company to assign the correct codes on medical claims. |
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