About this policy
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Octreotide Acetate for Injectable Suspension (Sandostatin® LAR Depot) L33438. When ICD-10-CM codes T38.895A, T38.895D, T38.895S, T43.215A, T43.215D, T43.215S, T43.225A, T43.225D, T43.225S, T50.995A, T50.995D or T50.995S is submitted for chemotherapy induced diarrhea (CID); the medical record must document the covered chemotherapy agent(s) causing the CID and the previous antidiarrheal treatments that have become ineffective. If ICD-10-CM codes C25.4, C26.0, D13.7, D13.91 and D13.99 are submitted on the claim, the medical record must document that the patient’s diagnosis is VIPoma. If ICD-10-CM code R79.89 is submitted on the claim, the patient’s record must document abnormal findings leading to suspicion of VIPoma. If ICD-10-CM code R94.7 is submitted on the claim, the patient’s record must document an abnormal octreotide scan leading to suspicion of VIPoma.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| J2353 | HCPCS | Covered |
| C25.4 | ICD10CM | Covered |
| C26.0 | ICD10CM | Covered |
| C37 | ICD10CM | Covered |
| C7A.010 | ICD10CM | Covered |
| C7A.011 | ICD10CM | Covered |
| C7A.012 | ICD10CM | Covered |
| C7A.019 | ICD10CM | Covered |
| C7A.020 | ICD10CM | Covered |
| C7A.021 | ICD10CM | Covered |
| C7A.022 | ICD10CM | Covered |
| C7A.023 | ICD10CM | Covered |