LCD : Steroid Injections (L1664)

LCD for Steroid Injections (L1664)

Contractor Information

Contractor Name

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number

00390

Contractor Type

LCD Information

LCD ID Number

L1664

LCD Title

Steroid Injections

Contractor's Determination Number

1664

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Primary Geographic Jurisdiction

New Jersey
Tennessee

Secondary Geographic Jurisdiction

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming

Oversight Region

Region IV

Original Determination Effective Date

For services performed on or after 12/27/1996

Original Determination Ending Date

Revision Effective Date

For services performed on or after 07/27/2005

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

Intermuscular steroid injections for treatment of specific symptoms, illnesses, or injury, when oral therapy is not feasible.(not for intravenous use)

Medicare will only provide coverage for IM steroid injections that are medically necessary based on specific symptoms, illnesses or injuries. Medical necessity includes:

1. Specific symptomatology requiring immediate relief of the medical condition (i.e. shortness of breath, inspiration or expiratory wheezing, skin condition causing extreme itching, severe joint discomfort, unrelieved by NSAID or oral steroid, which requires a joint injection)

2. Contraindicatives are present which may make treatment of choice intramuscular injections (i.e. stomach upset producing nausea and/or vomiting, history of gastric conditions).

Coverage Topic

Prescription Drugs

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.

13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
14x	Non-Patient Laboratory Specimens
21x	SNF-inpatient, Part A
22x	SNF-inpatient or home health visits (Part B only)
23x	SNF-outpatient (HHA-A also)
71x	Clinic-rural health
72x	Clinic-hospital based or independent renal dialysis facility
75x	Clinic-CORF

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.

0636	Drugs requiring specific identification-detailed coding (eff 3/92)

CPT/HCPCS Codes

J1100

INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG

ICD-9 Codes that Support Medical Necessity

053.20	HERPES ZOSTER DERMATITIS OF EYELID
124	TRICHINOSIS
135	SARCOIDOSIS
200.00 - 208.91*	RETICULOSARCOMA UNSPECIFIED SITE - UNSPECIFIED LEUKEMIA IN REMISSION
245.0	ACUTE THYROIDITIS
255.2	ADRENOGENITAL DISORDERS
275.42	HYPERCALCEMIA
283.0 - 283.9	AUTOIMMUNE HEMOLYTIC ANEMIAS - ACQUIRED HEMOLYTIC ANEMIA UNSPECIFIED
284.01 - 284.89	CONSTITUTIONAL RED BLOOD CELL APLASIA - OTHER SPECIFIED APLASTIC ANEMIAS
287.4	SECONDARY THROMBOCYTOPENIA
351.0 - 351.9	BELL'S PALSY - FACIAL NERVE DISORDER UNSPECIFIED
360.11	SYMPATHETIC UVEITIS
363.10 - 363.15	DISSEMINATED CHORIORETINITIS UNSPECIFIED - DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY
363.20	CHORIORETINITIS UNSPECIFIED
364.00 - 364.9*	ACUTE AND SUBACUTE IRIDOCYCLITIS UNSPECIFIED - UNSPECIFIED DISORDER OF IRIS AND CILIARY BODY
370.00 - 370.9	CORNEAL ULCER UNSPECIFIED - UNSPECIFIED KERATITIS
372.05 - 372.14	ACUTE ATOPIC CONJUNCTIVITIS - OTHER CHRONIC ALLERGIC CONJUNCTIVITIS
377.30	OPTIC NEURITIS UNSPECIFIED
380.00	PERICHONDRITIS OF PINNA UNSPECIFIED
380.14	MALIGNANT OTITIS EXTERNA
386.00 - 386.03	MENIERE'S DISEASE UNSPECIFIED - ACTIVE MENIERE'S DISEASE VESTIBULAR
386.30 - 386.35	LABYRINTHITIS UNSPECIFIED - VIRAL LABYRINTHITIS
388.2	SUDDEN HEARING LOSS UNSPECIFIED
461.0 - 461.9	ACUTE MAXILLARY SINUSITIS - ACUTE SINUSITIS UNSPECIFIED
462	ACUTE PHARYNGITIS
463	ACUTE TONSILLITIS
464.11	ACUTE TRACHEITIS WITH OBSTRUCTION
464.21	ACUTE LARYNGOTRACHEITIS WITH OBSTRUCTION
464.30 - 464.31	ACUTE EPIGLOTTITIS WITHOUT OBSTRUCTION - ACUTE EPIGLOTTITIS WITH OBSTRUCTION
465.9	ACUTE UPPER RESPIRATORY INFECTIONS OF UNSPECIFIED SITE
466.0	ACUTE BRONCHITIS
471.0 - 471.9	POLYP OF NASAL CAVITY - UNSPECIFIED NASAL POLYP
472.0	CHRONIC RHINITIS
474.11	HYPERTROPHY OF TONSILS ALONE
477.9	ALLERGIC RHINITIS CAUSE UNSPECIFIED
478.0	HYPERTROPHY OF NASAL TURBINATES
478.25	EDEMA OF PHARYNX OR NASOPHARYNX
478.6	EDEMA OF LARYNX
493.01	EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS
493.11	INTRINSIC ASTHMA WITH STATUS ASTHMATICUS
493.21	CHRONIC OBSTRUCTIVE ASTHMA WITH STATUS ASTHMATICUS
493.91	ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS
690.10 - 690.12	SEBORRHEIC DERMATITIS UNSPECIFIED - SEBORRHEIC INFANTILE DERMATITIS
691.8	OTHER ATOPIC DERMATITIS AND RELATED CONDITIONS
692.0 - 692.79	CONTACT DERMATITIS AND OTHER ECZEMA DUE TO DETERGENTS - OTHER DERMATITIS DUE TO SOLAR RADIATION
692.81 - 692.9	DERMATITIS DUE TO COSMETICS - CONTACT DERMATITIS AND OTHER ECZEMA UNSPECIFIED CAUSE
693.0 - 693.9	DERMATITIS DUE TO DRUGS AND MEDICINES TAKEN INTERNALLY - DERMATITIS DUE TO UNSPECIFIED SUBSTANCE TAKEN INTERNALLY
694.0 - 694.5	DERMATITIS HERPETIFORMIS - PEMPHIGOID
694.60 - 694.61	BENIGN MUCOUS MEMBRANE PEMPHIGOID WITHOUT OCULAR INVOLVEMENT - BENIGN MUCOUS MEMBRANE PEMPHIGOID WITH OCULAR INVOLVEMENT
694.8	OTHER SPECIFIED BULLOUS DERMATOSES
694.9	UNSPECIFIED BULLOUS DERMATOSES
695.1	ERYTHEMA MULTIFORME
695.4	LUPUS ERYTHEMATOSUS
695.81 - 695.89	RITTER'S DISEASE - OTHER SPECIFIED ERYTHEMATOUS CONDITIONS
696.0	PSORIATIC ARTHROPATHY
696.1	OTHER PSORIASIS AND SIMILAR DISORDERS
697.0	LICHEN PLANUS
698.3	LICHENIFICATION AND LICHEN SIMPLEX CHRONICUS
701.4	KELOID SCAR
704.01	ALOPECIA AREATA
708.8	OTHER SPECIFIED URTICARIA
709.3	DEGENERATIVE SKIN DISORDERS
710.0	SYSTEMIC LUPUS ERYTHEMATOSUS
714.0 - 714.33	RHEUMATOID ARTHRITIS - MONOARTICULAR JUVENILE RHEUMATOID ARTHRITIS
715.00	OSTEOARTHROSIS GENERALIZED INVOLVING UNSPECIFIED SITE
716.10	TRAUMATIC ARTHROPATHY SITE UNSPECIFIED
716.98	UNSPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES
719.00 - 719.99	EFFUSION OF JOINT SITE UNSPECIFIED - UNSPECIFIED JOINT DISORDER OF MULTIPLE SITES
720.0	ANKYLOSING SPONDYLITIS
726.0 - 726.91	ADHESIVE CAPSULITIS OF SHOULDER - EXOSTOSIS OF UNSPECIFIED SITE
727.00 - 727.09	SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED - OTHER SYNOVITIS AND TENOSYNOVITIS
727.42	GANGLION OF TENDON SHEATH
787.01	NAUSEA WITH VOMITING
787.02	NAUSEA ALONE
787.03	VOMITING ALONE
791.0	PROTEINURIA
995.20 - 995.3	UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE - ALLERGY UNSPECIFIED NOT ELSEWHERE CLASSIFIED
999.5	OTHER SERUM REACTION NOT ELSEWHERE CLASSIFIED
999.8	OTHER TRANSFUSION REACTION NOT ELSEWHERE CLASSIFIED
V58.11	ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY
V58.12	ENCOUNTER FOR IMMUNOTHERAPY FOR NEOPLASTIC CONDITION
* latest code update

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

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

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentation Requirements

Medical documentation for all intramuscular steroid injections, which are covered by Medicare, is expected to indicate the medical necessity within the patients medical records, should a review become necessary. Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted when requested. If documentation is requested, submit:

M.D. orders/progress notes
Drug administration record
Itemization of charges

Appendices

Utilization Guidelines

Sources of Information and Basis for Decision

Carrier Policy

Medical texts

PDR physicains’ desk reference-2003

Advisory Committee Meeting Notes

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period

11/27/1996

Revision History Number

1664a

Revision History Explanation

10/01/2004 Annual ICD-9 Code Update: Inserted 692.84 in ICD-9 Codes that Support Medical Necessity.

07/24/2002 Formatted

11/8/2000 updated ICD-9 codes to be compatible with ICD-9 Code book 2001, & HCPCS code book

01/29/2005 - CPT/HCPCS code J1095 was deleted from group 1

This LCD was converted from an LMRP on 7/26/2005

09/04/2005 - This policy was updated by the ICD-9 2005-2006 Annual Update.

7/2/2006 - The description for Bill code 14 was changed

09/04/2006 - This policy was updated by the ICD-9 2006-2007 Annual Update.

09/03/2007 - This policy was updated by the ICD-9 2007-2008 Annual Update.

09/28/2007 - Frequently Asked Questions restored to Appendices.

2/18/2008 - The description for Bill code 21 was changed

04/03/2008 - Frequently Asked Questions removed from Appendices as link could not be restored