Does E79.0 require prior authorization?

No, E79.0 does not require prior authorization (high confidence). Covered without prior authorization.

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`E79.0`, Hyperuricemia without signs of inflammatory arthritis and tophaceous disease

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

When billing J7999-KD, enter the name and total dose (mg or mcg) of each drug in Box 19 of the CMS-1500 or the appropriate electronic comment loop; if Box 19 cannot accommodate all information, attach the details to the paper claim.
If a portion of a single-dose vial is not used, submit the HCPCS code for the drug on a separate claim line and append modifier JW to indicate discarded/unused portion.
Separate payment may be made for pump refilling and/or adjustments; submit these services using the appropriate drug refill or maintenance CPT/HCPCS code that accurately describes the service rendered.

Compounded drugs are priced by the A/B MAC contractor by multiplying the contractor's price per mcg or mg by the total number of mcg or mg of each drug used; a pharmacy compounding fee may be allowed in addition to the calculated drug amount.

Use the listed CPT/HCPCS codes when billing for opioid drugs or procedures related to implantable pumps for chronic intractable pain: J7999-KD, E0782, E0783, E0785, E0786, J2274 (example), J2278-KD, 62327, 62350, 62351, 62355, 62361, 62362, 62365, 62367, 62368, 62369, 62370, 95990, 95991.

Key Coverage Criteria

Compounded medications for use in implantable infusion pumps may be covered by Medicare when their use meets all other criteria for services provided incident to a physician's service.
True off-the-shelf (non‑compounded) drugs used without compounding and administered via DME may be billed using the drug-specific HCPCS code and are reimbursed under CMS ASP methodology.
If Prialt® is implanted as a single agent in the pump, bill using HCPCS code J2278-KD.
Compounded single-agent or combination drug formulations used in implanted infusion pumps must be billed using HCPCS code J7999-KD for reimbursement.
No specific clinical indications are listed in this article; follow the Local Coverage Determination (LCD) L39400 for indications for magnesium testing or services.
Serum iron testing is consideredmedically necessaryfor any of the following indications:

5 Active Policies

ANTHEM-CG-LAB-21, Serum Iron Testing

ANTHEM-CG-LAB-25, Outpatient Glycated Hemoglobin and Protein Testing

A56695, Billing and Coding: Implantable Infusion Pump

A57189, Billing and Coding: Serum Magnesium

A59186, Billing and Coding: Magnesium

`E79.0`, Hyperuricemia without signs of inflammatory arthritis and tophaceous disease

Prior Authorization

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

E79.0, Hyperuricemia without signs of inflammatory arthritis and tophaceous disease

Prior Authorization

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

`E79.0`, Hyperuricemia without signs of inflammatory arthritis and tophaceous disease