CSHCN 2009 > Physician > Benefits, Limitations, and Authorization Requirements

   
 

29.2.37 Therapeutic Apheresis

Therapeutic apheresis does not require authorization. Reimbursement for procedure codes 36511, 36512, 36513, and 36514 is limited to the following diagnosis codes:

Diagnosis Code
Description

20300

Multiple myeloma, without mention of having achieved remission

20302

Multiple myeloma, in relapse

20310

Plasma cell leukemia, without mention of having achieved remission

20311

Plasma cell leukemia in remission

20312

Plasma cell leukemia, in relapse

20380

Other immunoproliferative neoplasms, without mention of having achieved remission

20381

Other immunoproliferative neoplasms in remission

20382

Other immunoproliferative neoplasms, in relapse

20400

Acute lymphoid leukemia, without mention of having achieved remission

20401

Acute lymphoid leukemia in remission

20402

Acute lymphoid leukemia, in relapse

20410

Chronic lymphoid leukemia, without mention of having achieved remission

20411

Acute lymphoid leukemia in remission

20412

Chronic lymphoid leukemia, in relapse

20420

Subacute lymphoid leukemia, without mention of having achieved remission

20421

Subacute lymphoid leukemia in remission

20422

Subacute lymphoid leukemia, in relapse

20480

Other lymphoid leukemia, without mention of having achieved remission

20481

Other lymphoid leukemia in remission

20482

Other lymphoid leukemia, in relapse

20490

Unspecified lymphoid leukemia, without mention of having achieved remission

20492

Unspecified lymphoid leukemia, in relapse

20491

Unspecified lymphoid leukemia, in remission

20500

Acute myeloid leukemia, without mention of having achieved remission

20501

Acute myeloid leukemia in remission

20502

Acute myeloid leukemia, in relapse

20510

Chronic myeloid leukemia, without mention of having achieved remission

20511

Chronic myeloid leukemia in remission

20512

Chronic myeloid leukemia, in relapse

20520

Subacute myeloid leukemia, without mention of having achieved remission

20521

Subacute myeloid leukemia in remission

20522

Subacute myeloid leukemia, in relapse

20530

Myeloid sarcoma, without mention of remission

20531

Myeloid sarcoma in remission

20532

Myeloid sarcoma, in relapse

20580

Other myeloid leukemia, without mention of having achieved remission

20581

Other myeloid leukemia in remission

20582

Other myeloid leukemia, in relapse

20590

Unspecified myeloid leukemia, without mention of having achieved remission

20591

Unspecified myeloid leukemia in remission

20592

Unspecified myeloid leukemia, in relapse

20600

Acute monocytic leukemia, without mention of having achieved remission

20601

Monocytic leukemia, acute, in remission

20602

Acute monocytic leukemia, in relapse

20610

Chronic monocytic leukemia, without mention of having achieved remission

20611

Chronic monocytic leukemia in remission

20612

Chronic monocytic leukemia, in relapse

20620

Subacute monocytic leukemia, without mention of having achieved remission

20621

Subacute monocytic leukemia in remission

20622

Subacute monocytic leukemia, in relapse

20680

Other monocytic leukemia, without mention of having achieved remission

20681

Other monocytic leukemia in remission

20682

Other monocytic leukemia, in relapse

20690

Unspecified monocytic leukemia, without mention of having achieved remission

20691

Unspecified monocytic leukemia, in remission

20692

Unspecified monocytic leukemia, in relapse

20700

Acute erythremia and erythroleukemia, without mention of having achieved remission

20701

Acute erythremia and erythroleukemia in remission

20702

Acute erythremia and erythroleukemia, in relapse

20710

Chronic erythremia, without mention of having achieved remission

20711

Chronic erythremia in remission

20712

Chronic erythremia, in relapse

20720

Megakaryocytic leukemia, without mention of having achieved remission

20721

Megakaryocytic leukemia in remission

20722

Megakaryocytic leukemia, in relapse

20780

Other specified leukemia, without mention of having achieved remission

20781

Other specified leukemia in remission

20782

Other specified leukemia, in relapse

20800

Acute leukemia of unspecified cell type, without mention of having achieved remission

20801

Acute leukemia of unspecified cell type in remission

20802

Acute leukemia of unspecified cell type, in relapse

20810

Chronic leukemia of unspecified cell type, without mention of having achieved remission

20811

Chronic leukemia of unspecified cell type in remission

20812

Chronic leukemia of unspecified cell type, in relapse

20820

Subacute leukemia of unspecified cell type, without mention of having achieved remission

20821

Subacute leukemia of unspecified cell type in remission

20822

Subacute leukemia of unspecified cell type, in relapse

20880

Other leukemia of unspecified cell type, without mention of having achieved remission

20881

Other leukemia of unspecified cell type in remission

20882

Other leukemia of unspecified cell type, in relapse

20890

Unspecified leukemia, without mention of having achieved remission

20891

Unspecified leukemia in remission

20892

Unspecified leukemia, in relapse

2384

Neoplasm of uncertain behavior of polycythemia vera

23871

Essential thrombocythemia

2720

Pure Hypercholesterolemia

2730

Polyclonal hypergammaglobulinemia

2731

Monoclonal paraproteinemia

2733

Macroglobulinemia

28260

Sickle-cell disease, unspecified

28261

Hb-SS disease without crisis

28262

Hb-SS disease with crisis

28263

Sickle-cell/Hb-C disease without crisis

28264

Sickle-cell/Hb-C disease with crisis

28268

Other sickle-cell disease without crisis

28269

Other sickle-cell disease with crisis

2828

Other specified hereditary hemolytic anemias

2830

Autoimmune hemolytic anemias

28310

Unspecified non-autoimmune hemolytic anemia

28311

Hemolytic-uremic syndrome

28319

Other non-autoimmune hemolytic anemias

2863

Congenital deficiency of other clotting factors

2866

Defibrination syndrome

2870

Allergic purpura

2871

Qualitative platelet defects

2872

Other nonthrombocytopenic purpura

28730

Primary thrombocytopenia, unspecified

28731

Immune thrombocytopenic purpura

28732

Evans' syndrome

28733

Congenital and hereditary thrombocytopenic purpura

28739

Other primary thrombocytopenia

2874

Secondary thrombocytopenia

2875

Unspecified thrombocytopenia

2878

Other specified hemorrhagic conditions

2879

Unspecified hemorrhagic conditions

2884

Hemophagocytic syndromes

28869

Other elevated white blood cell count

2890

Polycythemia, secondary

28951

Chronic congestive splenomegaly

28952

Splenic sequestration

2896

Familial polycythemia

2897

Methemoglobinemia

28981

Primary hypercoagulable state

28989

Other specified diseases of blood and blood-forming organs

2899

Unspecified diseases of blood and blood-forming organs

3564

Idiopathic progressive polyneuropathy

3570

Acute infective polyneuritis

3571

Polyneuropathy in collagen vascular disease

3572

Polyneuropathy in diabetes

3573

Polyneuropathy in malignant disease

3574

Polyneuropathy in other diseases classified elsewhere

3575

Alcoholic polyneuropathy

3576

Polyneuropathy due to drugs

3577

Polyneuropathy due to other toxic agents

35781

Chronic inflammatory demyelinating polyneuritus

35782

Critical illness polyneuropathy

35789

Other inflammatory and toxic neuropathy

35800

Myasthenia gravis without (acute) exacerbation

390

Rheumatic fever without mention of heart involvement

3918

Other acute rheumatic heart disease

44620

Unspecified hypersensitivity angiitis

44621

Goodpasture's syndrome

44629

Other specified hypersensitivity angiitis

4466

Thrombotic microangiopathy

4476

Unspecified arteritis

4478

Other specified disorders of arteries and arterioles

570

Acute and subacute necrosis of liver

5718

Other chronic nonalcoholic liver disease

5724

Hepatorenal syndrome

5731

Hepatitis in viral diseases classified elsewhere

5732

Hepatitis in other infectious diseases classified elsewhere

5733

Unspecified hepatitis

57431

Calculus of bile duct with acute cholecystitis and obstruction

57441

Calculus of bile duct with other cholecystitis and obstruction

5800

Acute glomerulonephritis with lesion of proliferative glomerulonephritis

5804

Acute glomerulonephritis with lesion of rapidly progressive glomerulonephritis

5810

Nephrotic syndrome with lesion of proliferative glomerulonephritis

5811

Nephrotic syndrome with lesion of membranous glomerulonephritis

5812

Nephrotic syndrome with lesion of membranoproliferative glomerulonephritis

5813

Nephrotic syndrome with lesion of minimal change glomerulonephritis

58181

Nephrotic syndrome in diseases classified elsewhere

58189

Other nephrotic syndrome with other specified pathological lesion in kidney

5819

Nephrotic syndrome with unspecified pathological lesion in kidney

5820

Chronic glomerulonephritis with lesion of proliferative glomerulonephritis

5821

Chronic glomerulonephritis with lesion of membranous glomerulonephritis

5822

Chronic glomerulonephritis with lesion of membranoproliferative glomerulonephritis

5824

Chronic glomerulonephritis with lesion of rapidly progressive glomerulonephritis

5830

Nephritis and nephropathy, not specified as acute or chronic, with lesion of proliferative glomerulonephritis

5831

Nephritis and nephropathy, not specified as acute or chronic, with lesion of membranous glomerulonephritis

5832

Nephritis and nephropathy, not specified as acute or chronic, with lesion of membranoproliferative glomerulonephritis

5834

Nephritis and nephropathy, not specified as acute or chronic, with lesion of rapidly progressive glomerulonephritis

5836

Nephritis and nephropathy, not specified as acute or chronic, with lesion of renal cortical necrosis

5837

Nephritis and nephropathy, not specified as acute or chronic, with lesion of renal medullary necrosis

58381

Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere

58389

Nephritis and nephropathy, not specified as acute or chronic, with other specified pathological lesion in kidney, other

5839

Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney

6944

Pemphigus

7010

Circumscribed scleroderma

7100

Systemic lupus erythematosus

7101

Systemic sclerosis

7103

Dermatomyositis

7104

Polymyositis

7140

Rheumatoid arthritis

7141

Felty's syndrome

7142

Other rheumatoid arthritis with visceral or systemic involvement

71430

Polyarticular juvenile rheumatoid arthritis, chronic or unspecified

71431

Polyarticular juvenile rheumatoid arthritis, acute

71432

Pauciarticular juvenile rheumatoid arthritis

71433

Monoarticular juvenile rheumatoid arthritis

Reimbursement for procedure codes 36515 and 36516 are limited to the following diagnosis codes:

Diagnosis
Description

2720

Hypercholesterolemia

28730

Primary thrombocytopenia, unspecified

28731

Immune thrombocytopenic purpura

28732

Evans' syndrome

28733

Congenital and hereditary thrombocytopenic purpura

28739

Other primary thrombocytopenia

7140

Rheumatoid arthritis

7141

Felty's syndrome

7142

Other rheumatoid arthritis with visceral or systemic involvement

Other diagnoses may be considered upon appeal with documentation of medical necessity.

Therapeutic apheresis with extracorporeal affinity column adsorption and plasma reinfusion may be considered for reimbursement when billed for the low density lipoprotein (LDL) apheresis or the protein A immunoadsorption columns.

Claims for apheresis services must be coded 36511, 36512, 36513, 36514, 36515, and 36516, as appropriate. This procedure represents one 30-minute time interval of personal physician involvement in the apheresis. Apheresis is limited to three 30-minute time intervals per procedure. If the time is not indicated, payment is based on one 30-minute time interval.

Procedure codes for therapeutic apheresis may be reimbursed at the lower of the billed amount or the amount allowed by CMS, when available, or the amount allowed by Texas Medicaid.


Texas Medicaid & Healthcare Partnership
CPT only copyright 2008 American Medical Association. All rights reserved.
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