Z51.12 — Encounter for antineoplastic immunotherapy
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Providers must maintain patient weight in kilograms, ESA units administered per kilogram, and medical justification for any ESA doses exceeding usual doses.
- The medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
- For all patients receiving ESAs the medical record must document hemoglobin (Hgb) or hematocrit (Hct) and evidence of adequate iron stores.
- Dialysis patient records must include dialysis schedule and Hgb/Hct immediately prior to the billing period; home dialysis patients additionally must have a care plan, evidence of home monitoring (including records of ESA supplied and doses administered), patient instructions, and patient selection protocol.
Key Coverage Criteria
- Administration of erythropoiesis stimulating agents (ESAs) billed with HCPCS J0881, J0882, J0885, J0886, Q4081, Q5105, or Q5106 for patients with anemia related to ESRD, chronic kidney disease (CKD), chemotherapy, radiation, or myelodysplastic syndrome (MDS), when the use meets the coverage criteria in the applicable LCD.
- Use of ESAs for chemotherapy-induced, radiation-induced, or non-chemo/non-radiation anemia should be identified on non-ESRD claims by reporting modifier EA (chemo-induced), EB (radio-induced), or EC (non-chemo/radio).
- ESA administration may qualify as a Home Health service only when the beneficiary is receiving the ESA for a covered indication specified in the LCD.
- For services that require a referring or ordering physician, the claim must report the referring/ordering physician's name and NPI.
- Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed; otherwise the claim will be returned as incomplete under SSA Section 1833(e).
- For diagnostic tests, the claim should report the test result if known, otherwise report the symptoms that prompted the test.
20 Active Policies
A56743 — Billing and Coding: Cardiovascular Nuclear Medicine
J06
L33560 — Cardiovascular Nuclear Medicine
J06
L34007 — Immune Globulin
J09
A57778 — Billing and Coding: Immune Globulin
J09
A56786 — Billing and Coding: Immune Globulin
Related Codes
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