38120
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
16.64
Facility
$998.69
Non-Facility
$998.69
Documentation Required
- Signed and dated office visit records and operative reports are required; all services ordered or rendered to Medicare beneficiaries must be signed.
- For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
- The patient's medical record must include the ordering provider's assessment related to the patient's complaint for that visit and relevant medical history.
- Document results of pertinent tests/procedures; for diagnostic tests report the test result if known, otherwise report the symptoms that prompted the test.
Key Coverage Criteria
- Treatment is indicated for Primary Immune Thrombocytopenia (ITP) when there is severe ITP with bleeding symptoms.
- Treatment is indicated for adults with platelet count <= 30 x10^9/L, especially if risk factors for bleeding are present.
- Treatment may be indicated for patients (adult or child) in preparation for procedures or surgery with a risk of bleeding.
- Treatment may be indicated for patients with professional or lifestyle risks for trauma that increase bleeding risk.
- First-line pharmacologic treatment for children and adults is corticosteroids using standard ITP dosing regimens.
- Intravenous immune globulin (IVIg) may be used as first-line therapy when there is a documented need for rapid platelet response, a documented contraindication or intolerance to corticosteroids, or documented lack of response to corticosteroids.
2 Active Policies
A57160 — Billing and Coding: Immune Thrombocytopenia (ITP) Therapy
L38268 — Immune Thrombocytopenia (ITP) Therapy
Related Codes
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