Showing posts with label Medicare drug plan. Show all posts
Showing posts with label Medicare drug plan. Show all posts

URIBEL - Drug usage, cost, warning and precautions

URIBEL- methenamine, sodium phosphate, monobasic, monohydrate, phenyls alicylate, methylene blue, and hyoscyamine sulfate capsule

Uribel is a medicine mainly used to cause relief for the pain and discomfort when urinating as well as the frequent urge to urinate. It is also used to help reduce the chance of infection after a medical procedure in the urinary tract. Uribel is mainly made of two components- Methenamine and Salicylate. Patients who have a tendency to have cramps or spasms in their urinary tract are generally prescribed to use this medicine, however, there might be side effects to it so you must use this if only prescribed by a doctor. You are not able to access this medicine without a prescription anyways; just make sure to use as directed. Keep in mind that complications may arise in small children so it is better not to use this medication for children.

Uribel Capsule and Dosage

A Guide To Using Uribel

  Uribel is a rather popular medicine that has been used to cure different kinds of discomfort that can be caused by any irritations or any infections in the urinary tract. It is mostly prescribed to a patient when they are suffering from severe pain, burning or spasms caused by a urinary tract infection.

At the same time it must be noted that Uribel is in no way an antibiotic and this is why it cannot and should not be used to cure a urinary tract infection. It’s main purpose, simply put, is to relieve the patient of the pain that is caused as a result of the infection.

As mentioned earlier, Uribel is made of two major ingredients. The Methenamine is actually a type of antibiotic. There is another variant of this called Methylene blue which is antiseptic in nature. Both of these two are used to help prevent the growth of bacteria in urine and thus it will typically reduce the chance of any infection. Salicylate on the other hand is kind of an Aspirin. It helps to reduce pain and is what helps in giving relief to the user. It also has some additional ingredients like sodium phosphate and benzoic acid which are what helps to make the urine more acidic. What the acidic nature of urine helps with is to make the methenamine work more efficiently. All of these different ingredients work together to give Uribel the helping abilities it has.

The dose and use of Uribel tends to vary from person to person depending on their age, symptoms, nature of ailment etc. Normally this medicine is to be taken orally and with a full glass of water; it is highly advisable not to lie down for at least ten minutes after taking this medication. Some may face stomach aches or pains which is quite typical. If that happens to be the case, then it is recommended to then take Uribel with some food or a meal. The normal frequency when it comes to the dosage of this medicine is four times a day, but it may vary according to the symptoms. The medicine usually takes 1 or 2 days to start the seeing improvement in your condition, so if you do not see any improvement even after 2 to 3 days of use, it is important to with your doctor since Uribel might not be the right medication for you. Also if you face pain or any burning sensation while urinating, consult your doctor immediately as this is a serious reaction that should be taken seriously.

Why is Uribel so effective?

Uribel is considered the go to medicine for relieving the above mentioned discomforts by doctors. This is because where other medicines contain just one ingredient, usually an analgesic meant for pain relief, Uribel is power packed with five ingredients i.e. antiseptic agents to avoid the growth of bacteria in the urinary tract, an antispasmodic that relaxes the muscle tissue of the urinary tract and a pain reliever that reduces the discomfort fromburning sensations and relieves pain.

INDICATIONS AND USAGE

Uribel caps ules indicated for the treatment of symptoms of irritative voiding. Indicated for the relief of local symptoms, such as inflammation, hypermotility, and pain, which accompany lower urinary tract infections. Indicated for the relief of urinary tract symptoms caused by diagnostic procedures.

CONTRAINDICATIONS

Hypersensitivity to any of the ingredients is possible. Risk benefits should be carefully considered when the following medical problems exist: cardiac disease (especially cardiac arrhythmias, congestive heart failure, coronary heart disease, and mitral stenosis); gastrointestinal tract obstructive disease; glaucoma; myasthenia gravis, acute urinary retention may be precipitated in obstructive uropathy (such as bladder neck obstruction due to prostatic hypertrophy).


WARNINGS

Do not exceed recommended dosage. If rapid pulse, dizziness or blurring of vision occurs discontinue use immediately.

When to avoid taking Uribel? 

As with most medicines, there are precautions that need to be taken with the use of Uribel as well. Before your doctor prescribes this medicine to you, you must reveal to him or her whether you have any of the following conditions: -

-Glaucoma
-Heart diseases
-Stomach ailments
-Bladder obstruction
-Intestine ulcers
-Myasthenia gravis
-Enlarged prostate
-If you are breast feeding
-If you are pregnant
-If you are trying to get pregnant
-If you have trouble passing urine


It is not yet established whether the ingredients present in Uribel harm an unborn baby. This is why it is advised that you avoid this medication if you are pregnant and even if you are breast feeding, as the ingredients can be passed on to the nursing baby via breast milk which can be harmful for the little one.

Similarly, this medicine is not meant for children or infants either. Elderly people who take this medicine might experience side effects like drowsiness, confusion or agitation.


PRECAUTIONS

Cross sensitivity and/or related problem

patients intolerant of belladonna alkaloids or salicylates may be intolerant of this medication also. Delay in gastric emptying could complicate the management of gastric ulcers.

Pregnancy/Reproduction (FDA Pregnancy Category C)

hyoscyamine and methenamine cross the placenta. Studies concerning the effect of hyoscyamine and methenamine on pregnancy and reproduction have not been done in animals or humans. Thus it is not known whether Uribel caps ules cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Uribel caps ules should be given to a pregnant woman only if clearly needed.

Breast feeding

problems in humans have not been documented; however, methenamine and traces of hyoscyamine are excreted in breast milk. Accordingly, Uribel caps ules should be given to a nursing mother with caution and only if clearly needed.

Prolonged use

there have been no studies to establish the safety of prolonged use in humans. No known long-term animal studies have been performed to evaluate carcinogenic potential.

Pediatric
infants and young children are especially susceptible to the toxic effect of the belladonna alkaloids.

Geriatric Use

use with caution in elderly patients as they may respond to usual doses of hyoscyamine with excitement, agitation, drowsiness or confusion.

CPT code J1980 - Injection, hyoscyamine sulfate, up to 0.25 mg - Please double confirm this one


This medicine has a problem when it comes to it’s reaction with caffeine. So it is highly recommended not to ingest any foods or beverages that contain a large amount of caffeine such as tea, coffee or cola. Having these foods and beverages when you are using Uribel would increase the chance of developing negative side effects as well as it will most likely decrease the effectiveness of this medication a great deal.

Dizziness, vomiting and nausea are some of the the main and most common side effects of this medicine. However, depending on the functionality of your body, some of the other side effects can also be observed; these side effects include drowsiness, dry mouth, blurred vision and in some cases constipation. If you have dry mouth, try to have some hard sugarless candy or sugarless chewing gum and make sure to drink enough of water and fluids throughout the day to keep yourself from becoming dehydrated. In some cases, this medicine can turn your stool and urine to a blue-green color, but no need to be worried since this is a totally normal side effect and harmless in nature. This is something that would go away as soon as you stop using this medicine. A few serious side effects include black/tarry stools, abdominal pain, easy bruising or bleeding etc. Contact your doctor immediately if you have any of these more serious side effects. Also, in very rare cases, patients may experience an attack of extremely high blood pressure, but this rarely happens and there are chances only if the patient is already under a lot of different drugs. It is important to be very clear with your doctor about any other medications you may be taking, even if they are over the counter just to make sure there won’t be any negative reactions.

Uribel increases your serotonin levels. This means that if you are already using any medicine that increases serotonin, using Uribel along with it would increase the chance of high amount of serotonin in your body which might result into serotonin syndrome. Serotonin syndrome symptoms include high body temperature, increased reflexes, agitation, dilated pupils, sweating, tremor and diarrhea and they can vary from mild to sever. Like mentioned before, it is always advisable to inform your doctor about all the medicine that you are currently taking so that the doctor can decide whether Uribel would be suitable for you or not. Otherwise, it may lead to unwanted complication and things can get worse.

Serious allergic reactions are very rare among the side effects of Uribel. In rare of the rarest cases, patient may experience severe allergic reaction and he/she should consult the doctor immediately if the symptom persists. Also, it is highly recommended that you ask your doctor about the possible side effects so that you can distinguish between the harmless and harmful side effects and this would reduce any unnecessary unrest among the patient. It is important to be educated about the harmless and harmful side effects of any medication you are taking to make sure you spot any before it is too late.

If you have any kind of allergy to anything, it is advisable to inform your doctor about that as the doctor would be able to determine if any of the substance in the medicine may cause allergic reaction or not. If you have not taken an allergy test, you should get one done immediately since it would not only let you know to which substances are you allergic to, but also decrease the chance of having allergic reaction due to medication. This would minimize a lot of suffering for you and this can even be a life-saver.

Using alcoholic beverages is a strict no while using this medicine, just like with all other prescription medications. Uribel, in some cases, has the ability to cause blurry vision and dizziness; using alcohol would only increase the intensity of this effect and hence it is extremely unsafe to drive, especially you feel any of these symptoms. Do not get involved into any activity that requires you to be on high alert and also do not use any machinery during medication if you feel drowsy. This would greatly impact your normal power and performance to apprehend things and the result may be devastating to yourself and other who may be around you.

It is also advisable for you to inform the doctor of your medical history in detail so that the doctor would be able to decide the dose that is applicable for you, or even if it is appropriate for you to be prescribed this medicine. If you have any liver or kidney problems, doctors may suggest an alternate medicine so that no complication arises. So be informative about your full medical history to your doctor for your own good and don’t keep anything hidden, not even any small thing.

Children who have the chickenpox or flu should not take this medicine. If they are suffering from any other disease or have received a recent vaccine for any flu, they should also avoid this medicine. Though extremely rare, this medicine may cause Reye’s syndrome in children if not used properly. Also, taking this medicine is also not advisable during pregnancy since it may cause harm to the unborn baby. It is very important to know that this medication mixes in with breast milk, so if you are breast feeding, either you have to stop breast feeding or you have to stop the medication. Please consult your doctor in such scenarios to decide which action to take.

Uribel has been known to have interactions with many substances that include, but is not limited to: atomoxetine, bupropion, buspirone, carbamazepine, cyclobenzaprine, dextromethorphan, maprotiline, methotrexate, mifepristone, potassium capsules/tablets, pramlintide and some other narcotic drugs. Any fatal interaction with any of these substances can cause extreme and serious side effects and this is why it is highly advisable not to take this medication without consulting a doctor first and foremost. This medicine may also interfere with a number of laboratory tests and hence may provide false results. It is recommended that you tell your doctor or laboratory operator that you use this medicine beforehand and they would be able to decide whether it is ok to go ahead with the lab test as well as to determine certain test results to be inaccurate.

As an adult, it is always expected that you take any kind of medicine in the specified amount. Anything more than the specified amount may lead to an overdose and the result of overdose can be fatal at times. If you have skipped any dose by mistake, do take the dose as soon as you remember. But if it is too late, you should skip the dose and continue with the next one. Also, never take two doses at once or too close to each other in order to compensate for the previously missed dose. This would only worsen the situation and would highly increase the chance of an overdose. The symptoms of overdose of Uribel consists of fever, fast heartbeat, severe drowsiness, seizures, unusual excitements or hallucinations. So if you experience any of these overdose symptoms, quickly get in touch with an emergency room or a poison control center.

There are certain cautions you need to follow while storing the medicine. This medicine cannot be kept in your bathroom where you normally keep your all other medicines like aspirins. This must be stored in the normal room temperature, in a dry, moist free area and must not be shared with anyone. Also, never pour this medicine, or any other medicines at that, into drains or flush it down in the toilet. Keep it away from extreme light exposure and also from the reach of children and pets. This may prove extremely harmful to them.

This medicine comes in the typical prescription bottles and normally there are 100 capsules in them. This is not an over the counter medicine and can only be used if prescribed by a doctor. Each capsule of Uribel contains 118 mg of methenamine, 40.8 mg of sodium phosphate monobasic, 36 mg of Phenyl salicylate, 10 mg of methylene blue and 0.12 mg of hyocyamine sulfate. This medication should never be used in treatment of a urinary tract infection. Rather, if you have a bacterial infection, some other antibiotic is normally prescribed for the treatment. It is also very dangerous for children under six years of age since they are more vulnerable and sensitive to the normal side effects. So keep the information stored in your mind that using Uribel for children under six years is a strict no. Also, antacids are known to decrease the functionality of this medicine by reducing the absorption rate in blood. So it is highly recommended to have this medicine at least one hour early before you take antacids.

This medication is likely to make you sweat less and thus it increases the chance of getting a heat stroke. You should avoid any hard work while on this medication and also avoid any activity that may increase the heat of your body. If you live in a hot area, try not to go out frequently and avoid standing under direct sunlight. And if you feel that your body is heating up, quickly look for a shade and take rest to allow your body to cool down. This medicine may also cause side effects like confusion, agitation and constipation among the older adults and the combination of drowsiness and confusion may lead to falling and hence it is also not very suitable for aged people.

Uribel is a widely used drug that is prescribed by doctors to help with a patient’s bladder sensitivity as well as any urinary discomfort. Please keep everything we have gone over in mind when making the decision to take this medication once it is prescribed to you.


Generic drug Brand drug Formulary chapter Effective date

Uro-MP Uribel® 1. Antibiotics & Other Drugs Used for Infection December 22, 2014


BRAND Name GENERIC name PRICING (AWP) INDICATION SIMILAR THERAPIES ON FORMULARY/AWP CODE*


UTA CAPS 120MG   

methenamine/hyo scyamine/meth blue/sod phoscaps

$3.71/tab

For treatment of urinary tract infections

Uribel ($2.71/tab) and Ustell ($2.41/tab)

covered as T3 Exclude – 13 along with existing 120mg UTA and 90 days notice


ICD 10 CODE FOR URINARY TRACT INFECTIONS

O23.30 - Infections of prt urinary tract in pregnancy, unsp trimester

CODE  Z87.440 - Personal history of urinary (tract) infections

O23.31 - Infect of prt urinary tract in pregnancy, first trimester

O23.32 - Infect of prt urinary tract in pregnancy, second trimester

O23.33 - Infect of prt urinary tract in pregnancy, third trimester


. For symptoms of bladder pain, medications such as Pyridium or Uribel can help soothe the bladder. Other medications to help with pain include NSAIDs (Ibuprofen) and Gabapentin. Amitriptyline is a medication that helps with bladder relaxation and pain. Some herbal medications have also been shown to improve symptoms. Cystoprotek has been used for its anti-inflammatory properties and may help the bladder lining to heal. You may find that acidic foods or drinks exacerbate your IC symptoms. Prelief may be recommended to take with meals. Prelief is an over-the-counter acid reducer that can take the acid out of your food and drinks. For chronic prostatitis patients, medications such as Rapaflo or Flomax are used to help relax the muscles of the bladder and prostate making urination easier.


Side effects of Uribel 


The most common side effect of Uribel is the effect of the urine (and in some cases the stool) turning to a blue color. This is completely harmless and it ceases once the medicine is discontinued.  Some other side effects of Uribel are-

-Vomiting
-Shortness of breath
-Blurred vision
-Dry mouth
-Inability to urinate
-Fast heartbeat
-Flushing
-Nausea
-Dizziness
-Drowsiness


You must immediately contact your doctor if any such side effects turn out to be rather severe. The same applies if you end up suffering from swelling, rash or severe itchiness.  Remember, it is important to stick to the dose that has been recommended to you and not over consume the medicine. If you miss a dose then take it as soon as you can, unless it is time for the next dose in which case just forget about the missed one.


As always, please remember that this article is just an informational guide. Please consult with your doctor before you start using Uribel.

Billing and coverage for drug wastage


Can I bill for drug wastage from a multi-dose/multiuse vial or package of drug or biological?


Answer:


Providers may not bill for drug wastage for multi-does/multiuse vials or packages from which an amount is administered to one patient


Even if a provider is unable to store unused doses for later use because the pharmacy incorrectly reconstituted the drug using sterile water instead of bacteriostatic water, a provider may not bill for drug wastage in a multi-dose/multiuse vial or package


Tips for Submitting Accurate Claims:


Each HCPCS code is associated with a specific number of units and type of units may be described by various units of measure

Verify the number and type of units associated with the HCPCS code before calculating the quantity on your claim

Verify calculations with the physician if needed

Submit the number of units (based on the HCPCS code) for the amount actually administered and not the number of units in the entire multi dose/multiuse vial or package


First Coast Service Options Inc. (First Coast) will consider payment for the unused and discarded portion of a single-use drug/biological product after administration of the appropriate (reasonable and necessary) dosage for the patient’s condition. This applies to drugs priced through the Average Sales Price (ASP) drug/biological program. The Centers for Medicare & Medicaid Services (CMS) encourages physicians, hospitals, and other providers to provide injectable drug therapy incident to a physician’s services in a fashion that maximizes efficiency of therapy in a clinically appropriate manner. If a physician, hospital, or other provider must discard the unused portion of a single-use vial or other single-use package after administering a dose/quantity appropriate to the clinical context for a Medicare beneficiary, the program provides payment for the entire portion of drug or biological indicated on the vial or package label.



If less than a complete vial is administered at the time of service, and the unused portion is discarded, drug wastage must be documented in the patient’s medical record with the date, time, and quantity wasted. Upon review, any discrepancy between amount administered to the patient and the billed amount will be denied, unless wastage is clearly documented. The amount billed as “wastage” must not be administered to another patient or billed again to Medicare. All procedures for drug storage, reconstitution and administration should conform to applicable Federal Drug Administration (FDA) guidelines and provider scope of practice.



Note: For billing purposes, First Coast does not require the use of modifier JW. Drug wastage is billed by combining on a single line the wastage and administered dosage amount.

Medicare covered Immunizations CPT code and vaccine CPT code list with valid DX


Immunizations are generally excluded from coverage under Medicare unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as antirabies treatment or tetanus antitoxin or booster vaccine. In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such disease as smallpox, typhoid and polio, is not covered. In cases where a vaccination or inoculation is excluded from coverage, the entire charge will be denied (such as office visits, which were primarily for the purpose of administering a non-covered injection).

The vaccines listed below are eligible for payment. These vaccines may be reimbursed regardless of the setting in which they are furnished. In addition, the administration fee for these vaccines is also eligible for payment. Medicare provides specific coverage for influenza and pneumococcal vaccines for certain populations (see CMS National Coverage Determinations (NCDs) and other documentation); these vaccines are not addressed in this LCD; specific coverage information is available on the CMS and TrailBlazer Web sites.

Use the following codes to process the administration:

90471© – Immunization admin (For OPPS hospitals billing for the hepatitis B vaccine administration.) (For Comprehensive Outpatient Rehabilitation Facilities (CORFs) billing the influenza, pneumococcal and Hepatitis B vaccines.)
90472© – Immunization admin, each add (For OPPS hospitals billing for the hepatitis B vaccine administration.)
G0010 – Administration of hepatitis b vaccine (non-OPPS only.)
G0128 – Administration of the vaccines when provided by a registered nurse on 75X TOB (CORF.) (Part A only code)
Hepatitis B (90740, 90743, 90744, 90746, 90747) vaccine – For those who are at high or intermediate risk of contracting hepatitis B.
High-risk groups currently identified include:
    • End-Stage Renal Disease (ESRD) patients.
    • Hemophiliacs who receive Factor VIII or IX concentrates.
    • Clients of institutions for the mentally retarded.
    • People who live in the same household as a hepatitis B virus (HBV) carrier.
    • Homosexual men.
    • Illicit injectable drug abusers.
Intermediate risk groups currently identified include:
    • Staff in institutions for the mentally retarded.
    • Workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work (V05.3).

Exception:
People in the above listed groups would not be considered at high or intermediate risk of contracting hepatitis B if there is laboratory evidence positive for antibodies to hepatitis B. (ESRD patients are routinely tested for hepatitis B antibodies as part of their continuing monitoring and therapy.)
The vaccine may be administered upon the order of a doctor of medicine or osteopathy by home health agencies, SNFs, ESRD facilities, hospital outpatient departments, people recognized under the “incident to” physicians’ services provision of law and doctors of medicine and osteopathy. A charge separate from the ESRD composite rate will be recognized and paid for administration of the vaccine to ESRD patients.
Tetanus (90703, 90714, 90718) – These injections are covered when given for an acute injury to a person who is incompletely immunized.
When a tetanus booster is given to a patient in the absence of an injury, the injection does not meet the coverage criteria for Medicare (even though it may be appropriate preventive treatment).
Rabies (90675) – Rabies is a disease that is carried by animals and transmitted by a bite or scratch.
When administering a rabies vaccine to a human who has had an encounter with an animal that is at high risk for rabies, bill procedure code 90675 and give the appropriate ICD-9-CM code for the exposure.
Limitations
In the absence of injury or direct exposure, preventative immunizations (vaccination or inoculation) against such diseases as small pox, polio, diphtheria, etc., are not covered. These include:
90476©
Adenovirus vaccine, type 4
90698©
Dtap-hib-ip vaccine, im
90477©
Adenovirus vaccine, type 7
90700©
Dtap vaccine, < 7yrs, 1m
90581©
Anthrax vaccine, sc
90701©
Dtp vaccine, < 7yrs, 1m
90585©
Bcg vaccine, precut
90702©
Dt vaccine, im
90586©
Bcg vaccine, intravesical
90704©
Mumps vaccine, sc
90632©
Hep a vaccine, adult im
90705©
Measles vaccine, sc
90633©
Hep a vacc, ped/adol, 2 dose
90706©
Rubella vaccine, sc
90634©
Hep a vacc, ped/adol, 3 dose
90707©
Mmr vaccine, sc
90636©
Hep a/hep b vacc, adult im
90708©
Measles-rubella vaccine, sc
90644©
Hib/men/tt vaccine, im
90710©
Mmrv vaccine, sc
90645©
Hib vaccine, hboc, im
90712©
Oral poliovirus vaccine
90646©
Hib vaccine, prp-d, im
90713©
Poliovirus, ipv, sc/im
90647©
Hib vaccine, prp-omp, im
90715©
Tdap vaccine >7 im
90648©
Hib vaccine, prp-t, im
90716©
Chicken pox vaccine, sc
90649©
hpv vaccine 4 valent, im
90717©
Yellow fever vaccine, sc
90650©
hpv vaccine 2 valent, im
90719©
Diphtheria vaccine, im
Influenza virus vaccine
90720©
Dtp/hib vaccine, im
90660©*
Flu vaccine, nasal
90721©
Dtap/hib vaccine, im
90663©
Flu vacc pandemic h1n1
90723©
Dtap-hep b-ipv vaccine, im
90664©
Flu vacc pandemic intranasal
90725©
Cholera vaccine, injectable
90665©
Lyme disease vaccine, im
90727©
Plague vaccine, im
90666©
Flu vac pandem prsrv free im
90733©
Meningococcal vaccine, sc
90667©
Flu vac pandemic adjuvant im
90734©
Meningococcal vaccine, im
90668©
Flu vac pandemic splt im
90735©
Encephalitis vaccine, sc
90669©*
Pneumococcal vacc, 7 val im
90736©
Zoster vacc, sc
90670©
Pneumococcal vacc, 13 val im
Rabies vaccine, id
90680©
Rotovirus vaccine, 3 dose, oral
90681©
Rotavirus vacc 2 dose oral
90690©
Typhoid vaccine, oral
90691©
Typhoid vaccine, im
90692©
Typhoid vaccine, h-p, sc/id
90693©
Typhoid vaccine, akd, sc
90696©
Dtap-ipv vacc 4-6 yr im
In cases where a vaccination or inoculation is excluded from coverage, the entire charge will be denied (such as office visits, which were primarily for the purpose of administering a non-covered injection).
*Note: Coverage of 90660© (flu vaccine, nasal) is expanded for individuals ages 5 through 49 (previously non-covered). See CMS NCDs related to Flu vaccines for additional details.
*Note: Coverage of 90669© (pneumococcal vacc, 7 val im) is expanded for individuals younger than 5 years (previously non-covered). See CMS Change Request (CR) 5910 for additional details.

Billing For a Single Administration 

Providers should bill the appropriate Procedure  immunization administration code(s) 90465, 90467, 90471, or 90473 (Immunization administration…first injection/first administration/one vaccine) when administering one immunization. The next line on the claim form must contain the specific Procedure  code for the vaccine, with $0.00 in the “billed charges” column (see pg. 102 for an
example). 


• Do not report Procedure  codes 90465 and 90467 on the same date of service 

• Do not report Procedure  codes 90471 and 90473 on the same date of service

2007 Louisiana Medicaid Professional Services Provider Training 98

Billing for Multiple Administrations

When administering more than one immunization, providers should bill as described above for a single administration. The appropriate procedure code(s) 90466, 90468, 90472, and 90474 (Immunization administration…each additional injection/administration/vaccine) should then be listed with the appropriate number of units for the additional vaccines placed in the “units” column. The specific vaccines should then be listed on subsequent lines. The number of specific vaccines listed after Procedure  administration codes should match the number of units listed in the units column. Examples of this scenario are on pages 103 through 107.

• Use Procedure  codes 90466 and/or 90468 with 90465 OR 90467 to report more than one vaccine administered. Do NOT use 90466 and/or 90468 with 90471 or 90473.

• Use Procedure  codes 90472 and/or 90474 with 90471 OR 90473 to report more than one vaccine administered. Do NOT use 90472 and/or 90474 with 90465 or 90467. 

Hard Copy Claim Filing for Greater Than Four Administrations


When billing hard copy claims for more than four immunizations and the six-line claim form limit is exceeded, providers should bill on two CMS-1500 claim forms. The first claim should follow the instructions above for billing the single administration. A second CMS-1500 claim form should be used to bill the remaining immunizations as described above for billing multiple administrations. An example is shown on pages 104 and 105.

Drug Wastage
Medicare provides payment for the discarded drug/biological remaining in a single-use drug product after administering what is reasonable and necessary for the patient’s condition. If the physician has made good faith efforts to minimize the unused portion of the drug/biological in how patients are scheduled and how he ordered, accepted, stored, used the drug, and made good faith efforts to minimize the unused portion of the drug in how it is supplied, then the program will cover the amount of drug discarded along with the amount administered Documentation requirements are given below. Coding and billing instructions can be referenced in the attached article. Refer to national policy:Medicare Claims Processing Manual – Pub. 100-04, Chapter 17, Section 40.
Note: The JW modifier is not used on claims for drugs or biologicals provided under the Competitive Acquisition Program (CAP). Reference to national policy: Medicare Claims Processing Manual, Pub. 100-04, Chapter 17, Section 100.2.9.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.
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.
12X, 13X, 22X, 23X, 71X, 72X, 73X, 75X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X is effective for dates of service on or after April 1, 2010.
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.
Note: TrailBlazer has identified Bill Type and Revenue Codes applicable for use with CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
0550, 0559, 0636, 0771
CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
90675©
Rabies vaccine, im
90703©
Tetanus vaccine, im
90714©
Td vaccine no prsrv >/= 7 im
90718©
Td vaccine > 7, im
90740©
Hep b vacc, ill pat 3 dose im
90743©
Hep b vacc, adol, 2 dose, im
90744©
Hep b vaccine, ped/adol, im
90746©
Hep b vaccine, adult, im
90747©
Hep b vaccine, ill pat, im
G0010
Administration of hepatitis b vaccine
G0128
Administration of the vaccines when provided by a registered nurse on 75X TOB (CORF)(Part A only)
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as preventive services.
Medicare is establishing the following limited coverage for hepatitis B (CPT/HCPCS codes 90740, 90743, 90744, 90746, 90747 and G0010):
Covered for:
286.0–286.1
Coagulation defects
302.0
Ego-dystonic sexual orientation
304.00–304.03
Opioid type dependence
304.10–304.13
Sedative, hypnotic or anxiolytic dependence
304.20–304.23
Cocaine dependence
304.30–304.33
Cannabis dependence
304.40–304.43
Amphetamine and other psychostimulant dependence
304.50–304.53
Hallucinogen dependence
304.60–304.63
Other specified drug dependence
304.70–304.73
Combinations of opioid type drug with any other
304.80–304.83
Combinations of drug dependence excluding opioid type drug
304.90–304.93
Unspecified drug dependence
305.90–305.93
Nondependent abuse of drugs
318.1–318.2
Other specified mental retardation
319
Unspecified mental retardation
585.1–585.6
Chronic kidney disease (CKD)
585.9
Chronic kidney disease, unspecified
758.0
Down’s syndrome
V05.3
Need for viral hepatitis prophylactic vaccination and inoculation against single disease
Medicare is establishing the following limited coverage for tetanus (CPT/HCPCS codes 90703, 90714 and 90718):
Covered for:
870.0–870.4
Open wound of ocular adnexa
870.8–870.9
Open wound of ocular adnexa
871.0–871.7
Open wound of eyeball
871.9
Unspecified open wound of eyeball
872.00–872.02
Open wound, external ear without mention of complication
872.10–872.12
Open wound, external ear, complicated
872.61–872.64
Open wound, other specified parts of ear, without mention of complication
872.69
Open wound, other and multiple sites of ear, without mention of complication
872.71–872.74
Open wound, other specified parts of ear, complicated
872.79
Open wound, other and multiple sites of ear, complicated
872.8–872.9
Open wound of ear
873.0–873.1
Other open wound of head
873.20–873.22
Open wound of nose, without mention of complication
873.29
Open wound of multiple sites of nose, without mention of complication
873.30–873.33
Open wound of nose, complicated
873.39
Open wound of multiple sites of nose, complicated
873.40–873.44
Open wound of face, without mention of complication
873.49
Open wound of other and multiple sites of face, without mention of complication
873.50–873.54
Open wound of face, complicated
873.59
Open wound of other and multiple sites of face, complicated
873.60–873.65
Open wound of internal structures of mouth, without mention of complication
873.69
Open wound of other and multiple sites of internal structures of mouth, without mention of complication
873.70–873.75
Open wound of internal structures of mouth, complicated
873.79
Open wound of other and multiple sites of internal structures of mouth, complicated
873.8–873.9
Other open wound of head
874.00–874.02
Open wound of larynx and trachea, without mention of complication
874.10–874.12
Open wound of larynx and trachea, complicated
874.2–874.5
Open wound of neck
874.8–874.9
Open wound of neck
875.0–875.1
Open wound of chest (wall)
876.0–876.1
Open wound of back
877.0–877.1
Open wound of buttock
878.0–878.9
Open wound of genital organs (external), including traumatic amputation
879.0–879.9
Open wound of other and unspecified sites, except limbs
880.00–880.03
Open wound of shoulder and upper arm, without mention of complication
880.09
Open wound of multiple sites of shoulder and upper arm, without mention of complication
880.10–880.13
Open wound of shoulder and upper arm, complicated
880.19
Open wound of multiple sites of shoulder and upper arm, complicated
880.20–880.23
Open wound of shoulder and upper arm, with tendon involvement
880.29
Open wound of multiple sites of shoulder and upper arm, with tendon involvement
881.00–881.02
Open wound of elbow, forearm and wrist, without mention of complication
881.10–881.12
Open wound of elbow, forearm and wrist, complicated
881.20–881.22
Open wound of elbow, forearm and wrist, with tendon involvement
882.0–882.2
Open wound of hand except finger(s) alone
883.0–883.2
Open wound of finger(s)
884.0–884.2
Multiple and unspecified open wound of upper limb
885.0–885.1
Traumatic amputation of thumb (complete) (partial)
886.0–886.1
Traumatic amputation of other finger(s) (complete) (partial)
887.0–887.7
Traumatic amputation of arm and hand (complete) (partial)
890.0–890.2
Open wound of hip and thigh
891.0–891.2
Open wound of knee, leg (except thigh) and ankle
892.0–892.2
Open wound of foot except toe(s) alone
893.0–893.2
Open wound of toe(s)
894.0–894.2
Multiple and unspecified open wound of lower limb
895.0–895.1
Traumatic amputation of toe(s) (complete) (partial)
896.0–896.3
Traumatic amputation of foot (complete) (partial)
897.0–897.7
Traumatic amputation of leg(s) (complete) (partial)
910.6–910.9
Superficial injury of face, neck, and scalp except eye
911.6–911.9
Superficial injury of trunk
912.6–912.9
Superficial injury of shoulder and upper arm
913.6–913.9
Superficial injury of elbow, forearm, and wrist
914.6–914.9
Superficial injury of hand(s) except finger(s) alone
915.6–915.9
Superficial injury of finger(s)
916.6–916.9
Superficial injury of hip, thigh, leg, and ankle
917.6–917.9
Superficial injury of foot and toes
918.9
Other and unspecified superficial injuries of eye
919.6–919.9
Superficial injury of other, multiple, and unspecified site
959.01
Head injury, unspecified
959.09
Injury of face and neck
959.11–959.14
Injury, trunk
959.19
Injury, other sites of trunk
959.2–959.9
Injury, other and unspecified
Medicare is establishing the following limited coverage for rabies (CPT/HCPCS code 90675):
Covered for:
872.00–872.02
Open wound, external ear without mention of complication
872.10–872.12
Open wound, external ear, complicated
872.79
Open wound of ear, other and multiple sites, complicated
872.8–872.9
Open wound of ear, part unspecified
873.0–873.1
Open wound of scalp
873.20
Open wound of nose, unspecified site, without mention of complication
873.29
Open wound of nose, multiple sites, without mention of complication
873.30
Open wound of nose, unspecified site, complicated
873.39
Open wound of nose, multiple sites, complicated
873.40–873.44
Open wound of face, without mention of complication
873.49
Open wound of other and multiple sites of face, without mention of complication
873.50–873.54
Open wound of face, complicated
873.59
Open wound of other and multiple sites of face, complicated
873.60
Open wound of mouth, unspecified site, without mention of complication
873.69
Open wound of other and multiple sites of mouth, without mention of complication
873.70
Open wound of mouth, unspecified site, complicated
873.79
Open wound of other and multiple sites of mouth, complicated
873.8–873.9
Other and unspecified open wound of head
874.8–874.9
Open wound of neck, other and unspecified parts
875.0–875.1
Open wound of chest (wall)
876.0–876.1
Open wound of back
877.0–877.1
Open wound of buttocks
878.0–878.9
Open wound of genital organs (external), including traumatic amputation
879.0–879.9
Open wound of other and unspecified sites, except limbs
880.00–880.03
Open wound of shoulder and upper arm, without mention of complication
880.09
Open wound of multiple sites of shoulder and upper arm, without mention of complication
880.10–880.13
Open wound of shoulder and upper arm, complicated
880.19
Open wound of multiple sites of shoulder and upper arm, complicated
880.20–880.23
Open wound of shoulder and upper arm, with tendon involvement
880.29
Open wound of multiple sites of shoulder and upper arm, with tendon involvement
881.00–881.02
Open wound of elbow, forearm and wrist, without mention of complication
881.10–881.12
Open wound of elbow, forearm and wrist, complicated
881.20–881.22
Open wound of elbow, forearm and wrist, with tendon involvement
882.0–882.2
Open wound of hand except finger(s) alone
883.0–883.2
Open wound of finger(s)
884.0–884.2
Multiple and unspecified open wound of upper limb
885.0–885.1
Traumatic amputation of thumb (complete) (partial)
886.0–886.1
Traumatic amputation of other finger(s) (complete) (partial)
887.0–887.7
Traumatic amputation of arm and hand (complete) (partial)
890.0–890.2
Open wound of hip and thigh
891.0–891.2
Open wound of knee, leg (except thigh) and ankle
892.0–892.2
Open wound of foot except toe(s) alone
893.0–893.2
Open wound of toe(s)
894.0–894.2
Multiple and unspecified open wound of lower limb
895.0–895.1
Traumatic amputation of toe(s) (complete) (partial)
896.0–896.3
Traumatic amputation of foot (complete) (partial)
897.0–897.7
Traumatic amputation of leg(s) (complete) (partial)
910.8–910.9
Other and unspecified superficial injury of face, neck and scalp
911.8–911.9
Other and unspecified superficial injury of trunk
912.8–912.9
Other and unspecified superficial injury of shoulder and upper arm
913.8–913.9
Other and unspecified superficial injury of elbow, forearm, and wrist
914.8–914.9
Other and unspecified superficial injury of hand(s) except finger(s) alone
915.8–915.9
Other and unspecified superficial injury of finger(s)
916.8–916.9
Other and unspecified superficial injury of hip, thigh, leg, and ankle
917.8–917.9
Other and unspecified superficial injury of foot and toes
919.8–919.9
Other and unspecified superficial injury of other, multiple, and unspecified site
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Claims for hepatitis B vaccinations must include the identification number of the referring physician.
Drug Wastage Documentation Requirements
Any amount wasted must be clearly documented in the medical record, regardless of whether the JW modifier will be used in billing for the drug/biological, with:
  • Date and time.
  • Amount of medication wasted.
  • Reason for the wastage.
Appendices
N/A
Utilization Guidelines
In accordance with CMS ruling 95-1(V), utilization of the service(s) should be consistent with locally acceptable standards of practice.
Compliance with the provisions in this LCD may be monitored and addressed through postpayment data analysis and subsequent medical review audits.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.
Sources of Information and Basis for Decision
J4 (CO, NM, OK, TX) MAC Consolidation
TrailBlazer adopted, unchanged, the TrailBlazer LCD, “Immunizations”, for the Jurisdiction 4 (J4) MAC transition.
Full disclosure of the sources of information is found with original contractor LCD.

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