|
24.3.17.12 Immune Globulins
Immune and gamma globulins and the administration of immune and gamma globulins are benefits of the CSHCN Services Program.
Procedure codes 1-J1670, 1-90371, 1-90389, 1-90396, and 1-90291 may be used to submit claims for immune/gamma globulin injections.
The following procedure codes may also be used to submit claims for immune and gamma globulin injections when submitted with an appropriate diagnosis code:
Diagnosis Code Restrictions*
|
Diagnosis Code
|
Description
|
|
042
|
Human immunodeficiency virus (HIV) disease
|
|
20410
|
Lymphoid leukemia, chronic, without mention of remission
|
|
27789
|
Other specified disorders of metabolism
|
|
27900
|
Hypogammaglobulinemia, unspecified
|
|
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
|
Immunodeficiency with predominant T-cell defect, unspecified
|
|
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
|
|
2794
|
Autoimmune disease, not elsewhere classified
|
|
28409
|
Other constitutional aplastic anemia
|
|
28489
|
Other specified aplastic anemias
|
|
28730
|
Primary thrombocytopenia,unspecified
|
|
28731
|
Immune thrombocytopenic purpura
|
|
28732
|
Evans' syndrome
|
|
28733
|
Congenital and hereditary thrombocytopenic purpura
|
|
28739
|
Other primary thrombocytopenia
|
|
3348
|
Other spinocerebellar diseases
|
|
340
|
Multiple sclerosis
|
|
34541
|
Partial epilepsy, 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)
|
|
5855
|
Chronic kidney disease, stage V
|
|
5856
|
End-stage renal disease
|
|
5859
|
Chronic kidney disease, unspecified
|
|
586
|
Renal failure, unspecified
|
|
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 communicable disease; other communicable diseases
|
|
V0260
|
Carrier or suspected carrier of viral hepatitis, unspecified
|
|
V08
|
Asymptomatic human immunodeficiency virus (HIV) infection status
|
|
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
|
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.
The following conditions apply when billing immune globulin procedure codes:
• If any combination of procedure codes 1-90281, 1-90283, 1-J1562, or 1-J1566 are billed together with the same date of service by any provider, only one is considered for reimbursement.
•If any combination of procedure codes 1-90281, 1-90283, 1-J1562, or 1-J1567 are billed together with the same date of service by any provider, only one is considered for reimbursement.
•If procedure codes 1-90389 and 1-J1670 are billed with the same date of service by any provider, only one is considered for reimbursement.
Administration procedure codes 1-90772 and 1-90774 may be billed with the immune globulins listed in this section.
Authorization for immune globulins is not required.
Reimbursement for procedure codes 1-90281, 1-90283, 1-90291, 1-90371, 1-90389, 1-90396, and 1-J1560 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 at the lower of the billed amount or the amount allowed by the Centers for Medicare & Medicaid Services (CMS), when available, or the amount allowed by the Texas Medicaid Program.
|
