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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.74 Therapeutic Apheresis

The following conditions must be met for therapeutic apheresis:
To perform the medical services, including all nonphysician services, and to respond to medical emergencies at all times during client care, direct supervision by a physician is required.
Procedure codes 36511, 36512, 36513, 36514, 36515, and 36516 are limited to the following diagnosis codes:
Procedure codes 36515 and 36516 may be considered for reimbursement when billed for the low density lipoprotein (LDL) apheresis (such as Liposorber LA 15) or the protein A immunoadsorption (such as Prosorba) columns.
The protein A immunoadsorption column is indicated for use in either of the following cases:
Adult clients who have signs and symptoms of moderate to severe rheumatoid arthritis with long‑standing disease who have failed, or are intolerant to, DMARDs.
The LDL apheresis column is indicated for use in clients who have severe familial hypercholesterolemia whose cholesterol levels remain elevated despite a strict diet and ineffective or untolerated maximum drug therapy. Coverage is considered for the following high‑risk population, for whom diet has been ineffective and maximum drug therapy has either been ineffective or not tolerated:
Functional hypercholesterolemia heterozygotes with LDL‑C > 200 mg/dL and documented coronary heart disease.
Baseline LDL‑C levels are to be obtained after the client has had, at a minimum, a six‑month trial on an American Heart Association (AHA) Step II diet or equivalent and maximum tolerated combination drug therapy designed to reduce LDL‑C. Baseline lipid levels are to be obtained during a two‑ to four‑ week period and should be within 10 percent of each other, indicating a stable condition.
Therapeutic apheresis using the LDL apheresis column may be reimbursed for diagnosis code 2720.
Apheresis services represents one 30‑minute time interval of personal physician involvement in the apheresis. Apheresis is limited to three 30‑minute time intervals per procedure. The actual time must be reflected on the claim, or a unit of 1, 2, or 3 must be indicated. If the time (or unit) is not indicated, payment is based on one 30‑minute time interval.
Apheresis is denied for all other diagnosis codes. Other diagnosis codes can be reviewed by the TMHP Medical Director or designee on appeal with documentation of medical necessity.
The following table summarizes the procedure code limitations for therapeutic apheresis. Procedure codes in Column A will be denied when billed with the same date of service by the same provider as procedure codes in Column B.
Laboratory work before and during the apheresis procedure is covered when apheresis is performed in the outpatient setting (POS 5). Laboratory work billed in conjunction with apheresis performed in the inpatient setting (POS 3) is included in the DRG reimbursement and is not paid separately.

Texas Medicaid & Healthcare Partnership
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