(Medicare Claims Processing Manual)

Contractors  shall require  the following coding in order  to pay for these claims:    Existing Medicare -approved clinical trial coding conventions, as required in Pub. 100- 04, Medicare Claims  Processing Manual, Chapter 32, section 69, and inpatient  billing requirements regarding acquisition of stem cells in  Pub. 100-  04, Medicare Claims Processing Manual,  Chapter 3, section 90.3.1.    ICD-10-PCS codes 30230G2, 30230G3, 30230Y2, 30230Y3, 30233G2, 30233G3, 30233Y2, 30233Y3, 30240G2, 30240G3, 30240Y2, 30240Y3, 30243G2, 30243G3, 30243Y2, and  30243Y3.   ICD-10-CM diagnosis codes C90.00, C90.01, C90.02, C94.40, C94.41, C94.42, D47.1, D47.4, D75.81, D57.00, D57.01, D57.02, D57.03, D57.09, D57.1, D57.20, D57.211, D57.212, D57.213, D57.218, D57.219, D57.40, D57.411, D57.412, D57.413, D57.418, D57.419, D57.42, D57.431, D57.432, D57.433, D57.438, D57.439, D57.44, D57.451, D57.452, D57.453, D57.458, and D57.459, D57.80, D57.811, D57.812, D57.813, D57.818, D57.819, and Z00.6.   If Outpatient Hospital or Professional Claims: HCPCS procedure code  38240    Professional  claims  only:  place  of service codes  19, 21, or  22.  Denials.  Contractors  shall  deny claims  failing  to meet any  of the above criteria.  In addition, contractors shall apply the  following requirements:    Providers shall issue a hospital issued notice of non-  coverage (HINN)  or advance  beneficiary  notice (ABN)  to the beneficiary if the services performed are not provided  in accordance with  CED.    Contractors  shall  deny claims  that do not  meet  the criteria  for coverage  with the  following messages:   CARC 50 -  These are non -covered services because this is not  deemed  a 'medical necessity'  by the payer.   NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service  Payment Information  REF),  if present.   RARC N386 -  This decision was based on a National Coverage  Determination (NCD). An NCD provides a coverage determination  as to whether a particular item or service is covered. A copy of this  policy is available a  http:www.cms.hhs.gov/mcd/search.asp. If you  do not have web access, you may contact the contractor to request a copy of the NCD.   Group Code   Patient  Responsibility  (PR) if HINN/ABN issued, otherwise  Contractual Obligation (CO)   MSN 16.77  This service/item was not covered because it was  not provided as part of a qualifying trial/study. (Este  servicio/artculo no fue cubierto porque no estaba incluido como parte  de un ensayo  clnico/estudio calificado.)   MSN  15.20  The  following policies  [NCD  110.23] were  used when we made this decision. (Las siguientes polticas [NCD  110.23] fueron utilizadas cuando se  tom esta  decisin.)    90.1 - General  (Rev. 486, Issued: 03- 04-05, Effective Date/Implementation Date: N/A)   Allogeneic Stem Cell Transplantation.   Allogeneic stem cell transplantation is a procedure in which a portion of a healthy donors stem cells is obtained and prepared for intravenous infusion to restore normal hematopoietic function in recipients having an inherited or acquired hematopoietic de ficiency or defect.   Expenses incurred by a donor are a covered benefit to the recipient/beneficiary but, except for physician services, are not paid separately. Services to the donor include physician services, hospital care in connection with screening the stem cell, and ordinary follow -up care.   Autologous Stem Cell Transplantation  Autologous stem cell transplantations is a technique for restoring stem cells using the patients own previously stored cells. Autologous stem cell transplants are covered for certain specified diagnoses for services rendered on or after April 28, 1989.  90.2 - HCPCS and Diagnosis Coding  ICD-9-CM Applicable  (Rev.11035, Issued:10 -13-21, Effective:  11-17-21; Implementation:  11-21)  Allogeneic  Stem Cell Transplantation   Effective  for services  performed on or  after August  1, 1978:For the treatment of leukemia or leukemia in remission,  providers shall use appropriate ICD -10 diagnosis codes  noted in section 90 and HCPCS code  38240.  For the treatment of aplastic anemia, providers shall use  appropriate ICD -10 diagnosis codes noted in section 90 and HCPCS  code  38240.   Effective  for services  performed on or  after June 3,  1985:   For the treatment of severe combined immunodeficiency disease,  providers  shall  use appropriate  ICD -10 diagnosis  codes  noted in section 90 and HCPCS code  38240.   For the treatment of Wiskott- Aldrich syndrome, providers  shall use appropriate ICD -10-CM code D82.0 and HCPCS  code  38240.  Autologous Stem Cell Transplantation .--Is covered under the  following circumstances effective for services performed on or  after April 28, 1989:   For the treatment of patients with acute leukemia in remission  who have a high probability of relapse and who have no human leucocyte antigens (HLA) matched, providers shall use  appropriate ICD -10 diagnosis codes noted in section 90 for  lymphoid; myeloid; monocytic; acute erythremia; erythroleukemia;  unspecified  cell type and HCPCS  code  38241.  For the treatment  of resistant  non- Hodgkins  lymphomas  for those  patients presenting with poor prognostic features following an initial response, providers shall use appropriate ICD -10 diagnosis  codes  noted in section 90 and HCPCS code  38241.  For the treatment of recurrent or refractory neuroblastoma,  providers shall use ICD - 10-CM codes Neoplasm by site, malignant,  the appropriate  HCPCS code  and HCPCS code  38241.  For the treatment of advanced Hodgkins disease for patients who  have failed conventional therapy and have no HLA -matched  donor, providers shall use appropriate ICD -10 diagnosis codes  and HCPCS code  38241 Autologous Stem Cell Transplantation .--Is covered under the following circumstances effective for services furnished on or after October 1, 2000:  For the treatment of multiple myeloma (only for beneficiaries who  are less than age 78, have Durie-Salmon stage II or III newly  diagnosed or responsive multiple myeloma, and have adequate cardiac, renal, pulmonary and hepatic functioning), providers shall  use appropriate ICD-10- CM code and HCPCS code  38241.  For the treatment of recurrent or refractory neuroblastoma,  providers shall use appropriate code (see ICD-10-CM neoplasm by site, malignant)  and HCPCS code 38241.  Effective for services performed on or after March 15, 2005,  when recognized clinical risk factors are employed to select  patients  for transplantation, high-dose melphalan  (HDM)  together  with autologous stem cell transplantation (HDM/AuSCT) is  reasonable and necessary for Medicare beneficiaries of any age group for the treatment of primary amyloid light chain (AL) amyloidosis, ICD-10- CM codes E85.4, E85.81, E85.9, and E85.89  who  meet the following  criteria:   Amyloid  deposition in 2 or fewer  organs; and,  Cardiac left ventricular  ejection  fraction  (EF) greater  than  45%.  90.2.1 - HCPCS and Diagnosis Coding for Stem Cell Transplantation - ICD-10-CM Applicable  (Rev.  11035, Issued:10 -13-21, Effective: 11-17-21; Implementation:  11-17-21)  ICD-10 is applicable to services on and after the implementation of ICD-.   For services provided use the appropriate code from  the ICD -10 CM  codes the table  below..  See 90.2 for a list of covered  conditions