Local Coverage Article for ICD-9 for Anti-Cancer
Drugs - Irinotecan Hydrochloride (A45258)
Contractor Information
Contractor Name
Pinnacle Business
Solutions, Inc. Arkansas
Article Information
General Information
Article ID Number
A45258
Article Type
Article
Key Article
Yes
Article Title
ICD-9 for Anti-Cancer Drugs Irinotecan Hydrochloride
AMA CPT / ADA CDT Copyright
Statement
CPT only copyright 2002-2011
American Medical Association. All
Rights Reserved. CPT is a
registered trademark of the
American Medical Association.
Applicable FARS/DFARS Apply to
Government Use. Fee schedules,
relative value units, conversion
factors and/or related
components are not assigned by
the AMA, are not part of CPT, and
the AMA is not recommending
their use. The AMA does not
directly or indirectly practice
medicine or dispense medical
services. The AMA assumes no
liability for data contained or not
contained herein. The Code on
Dental Procedures and
Nomenclature (Code) is published
in Current Dental Terminology
(CDT). Copyright © American
Dental Association. All rights
reserved. CDT and CDT-2010 are
trademarks of the American
Dental Association.
Original Article Effective Date
07/15/2007
Article Revision Effective Date
07/01/2012
Article Text
Pinnacle Business Solutions, Inc as a Medicare carrier has determined that the following
anti-cancer drugs may be billed with the specified diagnosis codes only, as of
07/15/2007. Guidelines for coverage of anti-cancer drugs include FDA approval for
specific indications and citation in the USPDI (United States Pharmacopeia Drug
Information) and/or AHFS (American Hospital Formulary Service Drug Information)
providing support for the drug. Text analysis determines the support of a particular use.
Please refer to the Medicare Benefit Manual (Pub.100-02) Chapter 15, Section 50.4.5 for
additional information regarding indications and limitations of coverage and/or medical
necessity as well as documentation requirements.
This is notification that effective July 15, 2007, the following HCPCS codes and
associated ICD-9 codes will be placed on an active audit for verification of appropriate
drug/diagnosis. Claims for anti-cancer drugs billed without a specified allowable
diagnosis will be denied. Approved ICD-9 codes will be updated to reflect changes in
indications and approval as noted by the FDA, AFHS, and/or USPDI.
Coding Information
CPT/HCPCS Codes
J9206
INJECTION, IRINOTECAN, 20 MG
ICD-9 Codes that are Covered
150.0 150.9
151.0 151.9
153.0 153.9
154.0 154.8
157.0 157.3
157.8
157.9
158.8
158.9
MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED
SITE
MALIGNANT NEOPLASM OF CARDIA - MALIGNANT
NEOPLASM OF STOMACH UNSPECIFIED SITE
MALIGNANT NEOPLASM OF HEPATIC FLEXURE MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE
MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM
RECTOSIGMOID JUNCTION AND ANUS
MALIGNANT NEOPLASM OF HEAD OF PANCREAS MALIGNANT NEOPLASM OF PANCREATIC DUCT
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
PANCREAS
MALIGNANT NEOPLASM OF PANCREAS PART
UNSPECIFIED
MALIGNANT NEOPLASM OF SPECIFIED PARTS OF
PERITONEUM
MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED
162.0 162.9
170.0 170.9
174.0 174.9
175.0
175.9
180.0 180.9
183.0 183.9
187.1 187.4
187.8
187.9
191.0 191.9
192.8
197.0
197.6
197.7
198.3
198.5
198.7
200.00 200.88
202.00 -
MALIGNANT NEOPLASM OF TRACHEA - MALIGNANT
NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED
MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE
EXCEPT MANDIBLE - MALIGNANT NEOPLASM OF BONE
AND ARTICULAR CARTILAGE SITE UNSPECIFIED
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF
FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST
(FEMALE) UNSPECIFIED SITE
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF
MALE BREAST
MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED
SITES OF MALE BREAST
MALIGNANT NEOPLASM OF ENDOCERVIX - MALIGNANT
NEOPLASM OF CERVIX UTERI UNSPECIFIED SITE
MALIGNANT NEOPLASM OF OVARY - MALIGNANT
NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE
MALIGNANT NEOPLASM OF PREPUCE - MALIGNANT
NEOPLASM OF PENIS PART UNSPECIFIED
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
MALE GENITAL ORGANS
MALIGNANT NEOPLASM OF MALE GENITAL ORGAN SITE
UNSPECIFIED
MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES
AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN
UNSPECIFIED SITE
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
NERVOUS SYSTEM
SECONDARY MALIGNANT NEOPLASM OF LUNG
SECONDARY MALIGNANT NEOPLASM OF
RETROPERITONEUM AND PERITONEUM
MALIGNANT NEOPLASM OF LIVER SECONDARY
SECONDARY MALIGNANT NEOPLASM OF BRAIN AND
SPINAL CORD
SECONDARY MALIGNANT NEOPLASM OF BONE AND
BONE MARROW
SECONDARY MALIGNANT NEOPLASM OF ADRENAL
GLAND
RETICULOSARCOMA UNSPECIFIED SITE - OTHER
NAMED VARIANTS OF LYMPHOSARCOMA AND
RETICULOSARCOMA INVOLVING LYMPH NODES OF
MULTIPLE SITES
NODULAR LYMPHOMA UNSPECIFIED SITE - OTHER AND
202.98
204.00 204.02
205.00 205.02
209.30
235.2
235.5
UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID
AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES
OF MULTIPLE SITES
ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION - ACUTE LYMPHOID
LEUKEMIA, IN RELAPSE
ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION - ACUTE MYELOID
LEUKEMIA, IN RELAPSE
MALIGNANT POORLY DIFFERENTIATED
NEUROENDOCRINE CARCINOMA, ANY SITE
NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH
INTESTINES AND RECTUM
NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND
UNSPECIFIED DIGESTIVE ORGANS
Other Information
Other Comments
08/10/2008 - This policy was updated by the ICD-9 2008-2009 Annual Update.
11/09/2008 - The description for CPT/HCPCS code J9206 was changed in group 1
05/01/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003,
FI and Carrier Pinnacle Business Solutions, Inc. (Carrier 00524, FI 00021) were
removed from this Article as the claims processing for the state of Rhode Island was
transitioned to MAC - Part A OR B, NHIC.
Revision History Explanation
05/31/2007 - Revised to allow effective 07/15/2007.
11/08/2007 - Updated to include covered ICD-9 Diagnosis code 183.0 effective
7/15/2007.
02/25/2008 - PBSI article retired effective 02/29/08 for New Mexico and Oklahoma
(00521 & 00522) due to the transition of workload to J4 MAC contractor (Trailblazer
Health Enterprises, LLC).
05/19/2008 - Added covered ICD-9 Codes 150.0-150.9, 151.0-151.9, 200.00-200.88,
202.00-202.98, 204.00-204.01 and 205.00-205.01 per January 2008 update.
05/28/2008 - PBSI article retired effective 05/31/08 for Missouri (00523) due to the
transition of workload to J5 MAC contractor (Wisconsin Physicians Service).
06/09/2008 - Per January 2008, added covered ICD-9 code range 191.0-191.9.
06/26/2008 - Per NCCN update, expanded covered ICD-9 code 183.0 to range of codes
183.0-183.9 effective 06/05/2008.
07/18/2008 - Effective retroactively to 07/15/2007, updated covered ICD-9 Codes to
include 174.0-174.9, 175.0 and 175.9.
08/10/2008 - This policy was updated by the ICD-9 2008-2009 Annual Update.
10/15/2008 - Effective 10/01/2008, extend covered ICD-9 code ranges from 204.00204.01 to 204.00-204.02; from 205.00-205.01 to 205.00-205.02.
11/09/2008 - The description for CPT/HCPCS code J9206 was changed in group 1
05/01/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003,
FI and Carrier Pinnacle Business Solutions, Inc. (Carrier 00524, FI 00021) were
removed from this Article as the claims processing for the state of Rhode Island was
transitioned to MAC - Part A OR B, NHIC.
11/17/2009 - Amended Article Text to reference National Coverage Determination (NCD)
Pub. 100-02 in place of Local Coverage Determination (LCD) AC-01-024 which has
been retired.
01/20/2010 - Per January 2010 update, added covered ICD-9 codes 158.8, 197.0, 197.7
and 235.5 effective 01/01/2010.
03/12/2010 - Per March 2010 update, added covered ICD-9 code 235.2 effective
03/01/2010.
04/22/2010 - Per April 2010 update, added covered ICD-9 Code range 170.0-170.9 and
ICD-9 Codes 197.6 and 209.30 effective 04/01/2010.
05/14/2010 - Per May 2010 update, added covered ICD-9 Codes 198.3, 198.5 and 198.7
effective 05/01/2010.
06/15/2010 - Per June 2010 update, added covered ICD-9 Code 192.8 effective
06/01/2010.
3/18/2011 - Per March update, add covered ICD-9 codes 157.0-157.3, 157.8 and 157.9
effective 03/01/2011.
12/20/2011 - Per December 2011 update, added covered ICD-9 Code 158.9 effective
12/01/2011.
07/17/2012 - Per July 2012 update, added covered ICD-9 Codes 187.1-187.4, 187.8 and
187.9 effective 07/01/2012.
All Versions
Updated on 07/17/2012 with effective dates 07/01/2012 - N/A
Updated on 01/24/2012 with effective dates 12/01/2011 - N/A
Updated on 03/18/2011 with effective dates 03/01/2011 - N/A
Updated on 06/15/2010 with effective dates 06/01/2010 - N/A
Some older versions have been archived. Please visit MCD Archive Site to retrieve
them.
Read the Article Disclaimer