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Clinical Editing Policies Effective December 1, 2022

Audience: All Providers and Facilities

We would like you to be aware of new clinical edits effective for dates of service on or after December 1, 2022. These edits do not impact the retrospective review of claims that currently occur, and apply to physicians, practitioners, laboratories, outpatient facilities and ambulatory surgery centers.

Related policies will be posted on the secure section of our website prior to December 1. You must log in with your username and password to access our policies. The impacted policies are listed in this notice.

The primary resource for clinical editing policies is the Centers for Medicare & Medicaid Services; however, the Health Plan uses several resources, including, but not limited to, the American Medical Association and specialty organizations. These policies support correct coding guidelines.

Please share this information with other appropriate staff at all practice locations.

If you have questions, please contact your Provider Relations representative.

Thank you for your continued participation and for the quality of care and service that you provide to our members.

 

Drugs & Biologicals

We would like you to be aware of new clinical edits regarding drugs and biologicals that will be effective for dates of service December 1, 2022, and after for all lines of business. This change does not impact the retrospective review of claims with dates of service prior to December 1, 2022.

Drug Code(s)

Policy

Provider

Type(s)

Line of Business

All Applicable Drug / Biologicals Codes

Disallow claim lines containing expired national drug code numbers.

ALL

ALL

J9034

Disallow J9034 when billed by any provider other than a specialty of home infusion therapy more than 2 visits every 3 weeks and the diagnosis on the claim is B-cell lymphoma (except indolent non-Hodgkin lymphoma and mantle cell lymphoma), Hodgkin lymphoma (classic), pediatric Hodgkin lymphoma, primary cutaneous lymphoma or T-cell lymphoma.

ALL

ALL

J9034

Disallow J9034 when billed by any provider other than a specialty of home infusion therapy more than 2 visits every 4 weeks and the diagnosis on the claim is chronic lymphocytic leukemia/small lymphocytic lymphoma, mantle cell lymphoma, multiple myeloma, nodular lymphocyte-predominant Hodgkin lymphoma, systemic light chain amyloidosis, or Waldenstrom macroglobulinemia/lymphoplasmacytic lymphoma.

ALL

ALL

Q0138

Disallow Q0138 when billed with a diagnosis of anemia in chronic diseases classified elsewhere or anemia due to antineoplastic chemotherapy and a diagnosis of iron deficiency anemia is not also present on the claim.

ALL

ALL

Q0138

Disallow Q0138 when billed with a diagnosis of adverse effect of antineoplastic and immunosuppressive drugs and both a diagnosis of neoplasm and a diagnosis of anemia due to antineoplastic chemotherapy are not present on the claim.

ALL

ALL

J9228

Disallow J9228 when billed by any provider other than a specialty of home infusion therapy, more than 2 visits every 6 weeks and the diagnosis on the claim is hepatocellular carcinoma, melanoma, microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) metastatic colorectal cancer, microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) advanced or metastatic small bowel adenocarcinoma, renal cell carcinoma, or uveal melanoma.

ALL

ALL

    

Drug Code(s)

Policy

Provider Type(s)

Line of Business

J1756

Disallow J1756 when billed with a diagnosis of anemia in chronic diseases classified elsewhere or anemia due to antineoplastic chemotherapy and a diagnosis of iron deficiency anemia is not also present.

ALL

ALL

J1756

Disallow J1756 when billed more than 5 visits per month by any provider other than a specialty of Home Infusion Therapy and the diagnosis on the claim is cancer-induced iron deficiency anemia or chemotherapy-induced iron deficiency anemia.

ALL

ALL

J9304 or J9305

Disallow J9304 or J9305 when billed and an appropriate laboratory testing for creatinine clearance (80047, 80048, 80050, 80053, 80069, 82565, 82570, 82575) has not been billed for the same date of service or within previous 20 days by any provider.

ALL

ALL

J3240

Disallow J3240 when billed and an FDA approved indication or an approved off-labeled indication is not present on the claim.

ALL

ALL

The following is a list of codes and code definitions:

Drug Code

Code Definition

J9034

Injection, bendamustine HCl (Bendeka), 1 mg

Q0138

Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use)

J9228

Injection, ipilimumab, 1 mg

J1756


Injection, iron sucrose, 1 mg

J9304

Injection, pemetrexed (Pemfexy), 10 mg

J9305

Injection, pemetrexed, NOS, 10 mg

J3240

Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial

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Clinical Editing

 

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