L29190-LCD

Automated World Health

Local Coverage Determination (LCD) for Hepatitis C Antibody in the ESRD and non-ESRD Setting (L29190)

Contractor Information

Contractor Name First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29190

LCD Title Hepatitis C Antibody in the ESRD and non-ESRD Setting

Primary Geographic Jurisdiction opens in new window Florida

Contractor's Determination Number 86803

Oversight Region Region IV

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 Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Title XVIII of the Social Security Act, Section 1862 (a)(7)

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A)

CMS Manual System, Pub 100-02, Benefit Policy Manual, Chapter 16, sec 20

Indications and Limitations of Coverage and/or Medical Necessity

Hepatitis C is a blood-bourne virus that can cause significant damage to the liver. The majority of infected individuals remain undiagnosed. Although there is a high prevalence of infection, the hepatitis C virus (HCV) is not an easily transmitted disease. The main route of transmission is by sharing equipment for injecting drug use, mainly via blood contaminated needles and syringes, spoons, filters and water. Chronic infection associated with HCV commonly leads to liver damage. Testing for the hepatitis C antibody is used to confirm the presence of hepatitis C infection.

Indications

Medicare will consider testing for the antibody to hepatitis C to be medically reasonable and necessary when one or more the following conditions have been met:

• Exposure to HCV-infected blood

• The presence of abnormal liver function tests with no apparent cause for abnormality

• Signs and symptoms exhibiting liver damage including fatigue, jaundice, nausea, pain in the abdomen, fever, muscle aches, joint pain swollen legs/feet, loss of appetite, diarrhea and vision loss

• Increased risk factors within the ESRD setting

Limitations

Medicare will not cover HCV testing performed for the purpose of routine screening.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

86803 HEPATITIS C ANTIBODY;

86804 HEPATITIS C ANTIBODY; CONFIRMATORY TEST (EG, IMMUNOBLOT)

ICD-9 Codes that Support Medical Necessity

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the provider must substantiate the medical necessity of the services being billed. In addition, documentation that the service was performed must be included in the patient’s medical record. This information is normally found in the history and physical, office/progress notes, hospital notes, and/or procedure report.

If HCV testing is performed for the indication of abnormal liver function tests with no apparent cause for abnormality, documentation should include copies of the liver function test results.

If HCV testing is performed for the indication of suspected exposure to HCV, the medical records should include the time frame of suspected exposure and the circumstances surrounding the exposure.

If HCV testing is performed for the indication of signs and symptoms of liver damage without apparent cause, the documentation should present a detailed history of symptoms exhibited by the patient.

Appendices

Utilization Guidelines It is expected that testing for hepatitis C will be performed:

In the ESRD setting:

• Upon admission and annually

• When an exposure occurs which might result in seroconversion

• When there is an unexplained new elevation of the transaminases

• If there is an increased risk of exposure identified within the facility

In the non-ESRD setting:

• When an exposure occurs which might result in serconversion

• When there is an unexplained new elevation of the transaminases

Sources of Information and Basis for Decision

Centers for Disease Control and Prevention. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR 2001; 50(No. RR-5):17-24.

Kim, A.I.& Sabb, S. Treatment of hepatitis C. The American Journal of Medicine (2005) 118, 808-815

McInnis-Shaw, V. (2005) What is HCV? Retrieved from http://hepatitis-central.com/?hcv/what March 10, 2006.

Persistently abnormal liver function tests: Marker of occult hepatitis C? (2004) Retrieved from medicalnewstoday.com March 29, 2006.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29190) replaces LCD L23174 as the policy in notice. This document (L29190) is effective on 02/02/2009.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

86804 descriptor was changed in Group 1

Reason for Change