CSHCN Services Program 2010 >30.2.24.8 Immune Globulins

Immune and gamma globulins and the administration of immune and gamma globulins are benefits of the CSHCN Services Program.

The following procedure codes may be used to submit claims for immune and gamma globulin injections:

Unless otherwise indicated, the immune and gamma globulin procedure codes in the above table may be reimbursed with one of the following diagnosis codes:


Diagnosis Code	Description
03812	Methicillin resistant Staphylococcus aureus septicemia
04112	Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site
042	Human immunodeficiency virus (HIV)
20312	Plasma cell leukemia, in relapse
20402	Acute lymphoid leukemia, in relapse
20410	Lymphoid leukemia, chronic, without mention of remission
20412	Chronic lymphoid leukemia, in relapse
20422	Subacute lymphoid leukemia, in relapse
20482	Other lymphoid leukemia, in relapse
20492	Unspecified lymphoid leukemia, in relapse
20502	Acute myeloid leukemia, in relapse
20512	Chronic myeloid leukemia, in relapse
20522	Subacute myeloid leukemia, in relapse
20532	Myeloid sarcoma, in relapse
20582	Other myeloid leukemia, in relapse
20592	Unspecified myeloid leukemia, in relapse
20602	Acute monocytic leukemia, in relapse
20612	Chronic monocytic leukemia, in relapse
20622	Subacute monocytic leukemia, in relapse
20682	Other monocytic leukemia, in relapse
20692	Unspecified monocytic leukemia, in relapse
20702	Acute erythremia and erythroleukemia, in relapse
20712	Chronic erythremia, in relapse
20722	Megakaryocytic leukemia, in relapse
20782	Other specified leukemia, in relapse
20802	Acute leukemia of unspecified cell type, in relapse
20812	Chronic leukemia of unspecified cell type, in relapse
20822	Subacute leukemia of unspecified cell type, in relapse
20882	Other leukemia of unspecified cell type, in relapse
20892	Unspecified leukemia, in relapse
27789	Other specified disorders of metabolism
27900	Unspecified hypogammaglobulinemia
27901	Selective IgA immunodeficiency
27902	Selective IgM immunodeficiency
27903	Other selective immunoglobulin deficiencies
27904	Congenital hypogammaglobulinemia
27905	Immunodeficiency with increased IgM
27906	Common variable immunodeficiency
27909	Deficiency of humoral immunity
27910	Unspecified immunodeficiency with predominant T-cell defect
27911	DiGeorge's syndrome
27912	Wiskott-Aldrich syndrome
27913	Nezelof's syndrome
27919	Other deficiency of cell-mediated immunity
2792	Combined immunity deficiency
2793	Unspecified immunity deficiency
27941	Autoimmune lymphoproliferative syndrome
27949	Autoimmune disease, not elsewhere classified
28409	Other constitutional aplastic anemia
28489	Other specified aplastic anemias
28730	Primary thrombocytopenia,unspecified
28731	Immune thrombocytopenic purpura
28732	Evan's syndrome
28733	Congenital and hereditary thrombocytopenic purpura
28739	Other primary thrombocytopenia
28984	Heparin-induced thrombocytopenia (HIT)
3348	Other spinocerebellar diseases
33700	Idiopathic peripheral autonomic neuropathy, unspecified
33709	Other idiopathic peripheral autonomic neuropathy
340	Multiple sclerosis
34541	Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy
3530	Brachial plexus lesions
3570	Acute infective polyneuritis
35781	Chronic inflammatory demyelinating polyneuritis
35782	Critical illness polyneuropathy
35800	Myasthenia gravis without (acute) exacerbation
35801	Myasthenia gravis with (acute) exacerbation
3929	Rheumatic chorea without mention of heart involvement
4461	Acute febrile mucocutaneous lymph node syndrome (MCLS)
57142	Autoimmune hepatitis
5855	Chronic kidney disease, stage V
5856	End-stage renal disease
5859	Chronic kidney disease, unspecified
586	Unspecified renal failure
7103	Dermatomyositis
7104	Polymyositis
7140	Rheumatoid arthritis
79579	Other and unspecified nonspecific immunological findings
9895	Toxic effect of venom
V0179	Contact or exposure to other viral diseases
V0189	Contact with or exposure to other communicable diseases
V0253	Carrier or suspected carrier of Methicillin susceptible Staphylococcus aureus
V0254	Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus
V0260	Unspecified viral hepatitis carrier
V08	Asymptomatic human immunodeficiency virus (HIV) infection status
V1204	Personal history of Methicillin resistant Staphylococcus aureus
V4281	Bone marrow replaced by transplant
V4282	Peripheral stem cells replaced by transplant
V4283	Pancreas replaced by transplant
V4284	Organ or tissue replaced by transplant, intestines
V4289	Other specified organ or tissue replaced by transplant
V4587	Transplanted organ removal status
V8701	Contact with and (suspected) exposure to arsenic
V8709	Contact with and (suspected) exposure to other hazardous metals
V8711	Contact with and (suspected) exposure to aromatic amines
V8712	Contact with and (suspected) exposure to benzene
V8719	Contact with and (suspected) exposure to other hazardous aromatic compounds

Other diagnoses may be considered on appeal after a review of documentation of medical necessity and of current literature that supports the requested use. Documentation of medical necessity must be submitted to TMHP for review.

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If any combination of the following procedure codes are billed together on the same date of service by any provider, only one may be considered for reimbursement.

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If procedure codes 90389 and J1670 are billed with the same date of service by any provider, only one is considered for reimbursement.

Note: Procedure code J1670 is not restricted to specific diagnosis codes. A valid 3- to 5-digit diagnosis code must be billed on the claim.

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If procedure codes J1571 and 90371 are billed with the same date of service by any provider, only one may be reimbursed.

Administration procedure codes 96369, 96370, 96372, and 96374 may be billed with the immune globulins listed in this section.

Procedure code 96370 must be billed with the same date of service as procedure code 96369.

Reimbursement for the following procedure codes will be based on the lowest AWP, minus 10.5 percent, according to the prices in the current edition of the Red Book, published by Thomson Healthcare, on file with the CSHCN Services Program.

All other procedure codes for immune and gamma globulins may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.