According to LCD L25820 only V15.9, V58.11, V58.12 and V66.2 support medical necessity for pegfilgrastim. Notice how it does not list V078!! The language there is super confusing but after stating that it will cover in prophylactic instances, it states further down that â€śV159 should be reported when pegfilgrastim is used to decrease the incidence of infection, as manifested by febrile neutropenia in patience with non-myeloid malignancies receiving myelosuppressive cancer drugs.â€ť So if youâ€™re getting denied when using V078, THATâ€™S why! Even though it SAYS prophylactic, it is very specific as to what to use. (hereâ€™s the link to that http://apps.ngsmedicare.com/SIA/ARTICLE_A48208.htm though you may have to copy/paste) That also means that when the doctor says preventative, prophylactic, etc., you can safely use V159. So, the verbiage we mainly look for in the chart is any language that will support those codes, specifically high risk as in "high risk of toxicity and myelosuppression".
According to the LCD L30306 (found on CMS.gov hereâ€™s the link: http://www.cms.gov/medicare-coverage...AAAAAAA%3d%3d& sorry so long ) coverage guidance gives indications for Neulasta as:
E. Indications for Pegfilgrastim (Neulastaâ„˘): (J2505)
1. To decrease the incidence of infection, as manifested by febrile neutropenia, for patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a significant incidence of febrile neutropenia
2. Prophylactically used to decrease the incidence of infection, for patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a significant incidence of febrile neutropenia
3. Administration may be indicated for patients at high risk for chemotherapy-induced infectious complications. Such risk factors may include the following (V15.9) and should be documented in the patient record:
a. Pre-existing neutropenia due to disease,
b. Extensive prior chemotherapy
c. Previous irradiation to the pelvis or other areas containing large amounts of bone marrow.
d. A history of recurrent febrile neutropenia while receiving earlier chemotherapy of similar or lesser dose-intensity
e. Conditions potentially enhancing the risk of serious infection.
When hx of radiation is documented, I use the V153 code in addition to the V159 to further identify the risk, same with hx of chemo (v8741). And of course when we canâ€™t find the language above in the chart (or to identify the â€śEâ€ť up there since that is left open) we sigh the big sigh and query the doc to get as close to as possible because Neulasta is so tricky. Sorry such a long answer.
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