About this policy
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Intravenous Immunoglobulin (IVIG) L34580. Note: With respect to HCPCS codes J2792 Injection, Rho D immune globulin (human), solvent detergent (WINRho) and J2791 Injection immune globulin (human), (Rhophylac), this article only addresses their use intravenously.
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 |
|---|---|---|
| J1459 | HCPCS | Covered |
| J1552 | HCPCS | Covered |
| J1554 | HCPCS | Covered |
| J1556 | HCPCS | Covered |
| J1557 | HCPCS | Covered |
| J1561 | HCPCS | Covered |
| J1566 | HCPCS | Covered |
| J1568 | HCPCS | Covered |
| J1569 | HCPCS | Covered |
| J1576 | HCPCS | Covered |
| J1599 | HCPCS | Covered |
| J2791 | HCPCS | Covered |
| J2792 | HCPCS | Covered |
| A85.8 | ICD10CM | Covered |
| B08.3 | ICD10CM | Covered |
| B20 | ICD10CM | Covered |
| B25.0 | ICD10CM | Covered |
| B25.1 | ICD10CM | Covered |
| B25.2 | ICD10CM | Covered |
| B25.8 | ICD10CM | Covered |
| B25.9 | ICD10CM | Covered |
| C88.00 | ICD10CM | Covered |
| C90.00 | ICD10CM | Covered |
| C90.02 | ICD10CM | Covered |
| C91.10 | ICD10CM | Covered |
| C91.11 | ICD10CM | Covered |
| C91.12 | ICD10CM | Covered |
| D47.3 | ICD10CM | Covered |
| D55.0 | ICD10CM | Covered |
| D55.1 | ICD10CM | Covered |
| D55.21 | ICD10CM | Covered |
| D55.29 | ICD10CM | Covered |
| D55.3 | ICD10CM | Covered |
| D55.8 | ICD10CM | Covered |
| D55.9 | ICD10CM | Covered |
| D56.0 | ICD10CM | Covered |
| D56.1 | ICD10CM | Covered |
| D56.2 | ICD10CM | Covered |
| D56.3 | ICD10CM | Covered |
| D56.4 | ICD10CM | Covered |
| D56.5 | ICD10CM | Covered |
| D56.8 | ICD10CM | Covered |
| D56.9 | ICD10CM | Covered |
| D57.00 | ICD10CM | Covered |
| D57.01 | ICD10CM | Covered |
| D57.02 | ICD10CM | Covered |
| D57.03 | ICD10CM | Covered |
| D57.04 | ICD10CM | Covered |
| D57.09 | ICD10CM | Covered |
| D57.1 | ICD10CM | Covered |
| D57.20 | ICD10CM | Covered |
| D57.211 | ICD10CM | Covered |
| D57.212 | ICD10CM | Covered |
| D57.213 | ICD10CM | Covered |
| D57.214 | ICD10CM | Covered |
| D57.218 | ICD10CM | Covered |
| D57.219 | ICD10CM | Covered |
| D57.3 | ICD10CM | Covered |
| D57.414 | ICD10CM | Covered |
| D57.434 | ICD10CM | Covered |
| D57.454 | ICD10CM | Covered |
| D57.80 | ICD10CM | Covered |
| D57.811 | ICD10CM | Covered |
| D57.812 | ICD10CM | Covered |
| D57.813 | ICD10CM | Covered |
| D57.814 | ICD10CM | Covered |
| D57.818 | ICD10CM | Covered |
| D57.819 | ICD10CM | Covered |
| D58.0 | ICD10CM | Covered |
| D58.1 | ICD10CM | Covered |
| D58.2 | ICD10CM | Covered |
| D58.8 | ICD10CM | Covered |
| D58.9 | ICD10CM | Covered |
| D59.0 | ICD10CM | Covered |
| D59.11 | ICD10CM | Covered |
| D59.12 | ICD10CM | Covered |
| D59.13 | ICD10CM | Covered |
| D59.9 | ICD10CM | Covered |
| D61.01 | ICD10CM | Covered |
| D61.02 | ICD10CM | Covered |
| D61.810 | ICD10CM | Covered |
| D61.811 | ICD10CM | Covered |
| D61.818 | ICD10CM | Covered |
| D69.0 | ICD10CM | Covered |
| D69.3 | ICD10CM | Covered |
| D69.41 | ICD10CM | Covered |
| D69.42 | ICD10CM | Covered |
| D69.49 | ICD10CM | Covered |
| D80.0 | ICD10CM | Covered |
| D80.1 | ICD10CM | Covered |
| D80.2 | ICD10CM | Covered |
| D80.3 | ICD10CM | Covered |
| D80.4 | ICD10CM | Covered |
| D80.5 | ICD10CM | Covered |
| D80.6 | ICD10CM | Covered |
| D80.7 | ICD10CM | Covered |
| D80.8 | ICD10CM | Covered |
| D80.9 | ICD10CM | Covered |
| D81.0 | ICD10CM | Covered |
| D81.1 | ICD10CM | Covered |
| D81.2 | ICD10CM | Covered |
| D81.4 | ICD10CM | Covered |
| D81.5 | ICD10CM | Covered |
| D81.6 | ICD10CM | Covered |
| D81.7 | ICD10CM | Covered |
| D81.82 | ICD10CM | Covered |
| D81.89 | ICD10CM | Covered |
| D81.9 | ICD10CM | Covered |
| D82.0 | ICD10CM | Covered |
| D82.1 | ICD10CM | Covered |
| D82.2 | ICD10CM | Covered |
| D82.3 | ICD10CM | Covered |
| D82.4 | ICD10CM | Covered |
| D82.8 | ICD10CM | Covered |
| D82.9 | ICD10CM | Covered |
| D83.0 | ICD10CM | Covered |
| D83.1 | ICD10CM | Covered |
| D83.2 | ICD10CM | Covered |
| D83.8 | ICD10CM | Covered |
| D83.9 | ICD10CM | Covered |
| D84.0 | ICD10CM | Covered |
| D84.1 | ICD10CM | Covered |
| D84.9 | ICD10CM | Covered |
| D89.3 | ICD10CM | Covered |
| D89.810 | ICD10CM | Covered |
| D89.811 | ICD10CM | Covered |
| D89.812 | ICD10CM | Covered |
| D89.813 | ICD10CM | Covered |
| D89.82 | ICD10CM | Covered |
| D89.831 | ICD10CM | Covered |
| D89.832 | ICD10CM | Covered |
| D89.833 | ICD10CM | Covered |
| D89.834 | ICD10CM | Covered |
| D89.835 | ICD10CM | Covered |
| D89.839 | ICD10CM | Covered |
| D89.84 | ICD10CM | Covered |
| D89.89 | ICD10CM | Covered |
| D89.9 | ICD10CM | Covered |
| G04.81 | ICD10CM | Covered |
| G11.3 | ICD10CM | Covered |
| G13.0 | ICD10CM | Covered |
| G13.1 | ICD10CM | Covered |
| G25.82 | ICD10CM | Covered |
| G35.A | ICD10CM | Covered |
| G60.3 | ICD10CM | Covered |
| G61.0 | ICD10CM | Covered |
| G61.81 | ICD10CM | Covered |
| G61.82 | ICD10CM | Covered |
| G61.89 | ICD10CM | Covered |
| G62.81 | ICD10CM | Covered |
| G62.89 | ICD10CM | Covered |
| G64 | ICD10CM | Covered |
| G70.00 | ICD10CM | Covered |
| G70.01 | ICD10CM | Covered |
| G70.80 | ICD10CM | Covered |
| G70.81 | ICD10CM | Covered |
| G70.9 | ICD10CM | Covered |
| G72.49 | ICD10CM | Covered |
| G72.81 | ICD10CM | Covered |
| G72.89 | ICD10CM | Covered |
| G73.1 | ICD10CM | Covered |
| G73.3 | ICD10CM | Covered |
| H54.7 | ICD10CM | Covered |
| L10.0 | ICD10CM | Covered |
| L10.1 | ICD10CM | Covered |
| L10.2 | ICD10CM | Covered |
| L10.3 | ICD10CM | Covered |
| L10.4 | ICD10CM | Covered |
| L10.5 | ICD10CM | Covered |
| L10.81 | ICD10CM | Covered |
| L10.89 | ICD10CM | Covered |
| L10.9 | ICD10CM | Covered |
| L12.0 | ICD10CM | Covered |
| L12.1 | ICD10CM | Covered |
| L12.8 | ICD10CM | Covered |
| L12.9 | ICD10CM | Covered |
| L13.8 | ICD10CM | Covered |
| L95.0 | ICD10CM | Covered |
| L95.9 | ICD10CM | Covered |
| M30.3 | ICD10CM | Covered |
| M33.00 | ICD10CM | Covered |
| M33.01 | ICD10CM | Covered |
| M33.02 | ICD10CM | Covered |
| M33.03 | ICD10CM | Covered |
| M33.09 | ICD10CM | Covered |
| M33.10 | ICD10CM | Covered |
| M33.11 | ICD10CM | Covered |
| M33.12 | ICD10CM | Covered |
| M33.13 | ICD10CM | Covered |
| M33.19 | ICD10CM | Covered |
| M33.20 | ICD10CM | Covered |
| M33.21 | ICD10CM | Covered |
| M33.22 | ICD10CM | Covered |
| M33.29 | ICD10CM | Covered |
| M33.90 | ICD10CM | Covered |
| M33.91 | ICD10CM | Covered |
| M33.92 | ICD10CM | Covered |
| M33.93 | ICD10CM | Covered |
| M33.99 | ICD10CM | Covered |
| M36.0 | ICD10CM | Covered |
| M60.80 | ICD10CM | Covered |
| R78.81 | ICD10CM | Covered |
| T86.10 | ICD10CM | Covered |
| T86.11 | ICD10CM | Covered |
| T86.12 | ICD10CM | Covered |
| T86.13 | ICD10CM | Covered |
| T86.19 | ICD10CM | Covered |
| T86.21 | ICD10CM | Covered |
| T86.22 | ICD10CM | Covered |
| T86.23 | ICD10CM | Covered |
| T86.298 | ICD10CM | Covered |
| T86.5 | ICD10CM | Covered |
| Z41.8 | ICD10CM | Covered |
| Z48.21 | ICD10CM | Covered |
| Z48.22 | ICD10CM | Covered |
| Z48.23 | ICD10CM | Covered |
| Z48.24 | ICD10CM | Covered |
| Z48.280 | ICD10CM | Covered |
| Z48.288 | ICD10CM | Covered |
| Z48.290 | ICD10CM | Covered |
| Z48.298 | ICD10CM | Covered |
| Z94.0 | ICD10CM | Covered |
| Z94.1 | ICD10CM | Covered |
| Z94.81 | ICD10CM | Covered |
| Z94.84 | ICD10CM | Covered |