LCD Reference Article Billing and Coding Article

Billing and Coding: Ibandronate Sodium

A52421

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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General Information

Source Article ID
N/A
Article ID
A52421
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Ibandronate Sodium
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
10/01/2023
Revision Ending Date
N/A
Retirement Date
N/A

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Article Guidance

Article Text

This article contains billing and coding guidelines that complement the Local Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and Off-Label Uses.

The intravenous form of ibandronate was approved by the Food and Drug Administration (FDA) for use every three (3) months.

Specific coding guidelines for this drug:

Ibandronate sodium is available in oral and intravenous forms. National Government Services will consider the intravenous form to be “reasonable and necessary” only for patients for whom biphosphonate therapy including oral ibandronate sodium is medically necessary and who cannot tolerate oral therapy. Documentation must show that the patient cannot tolerate oral biphosphonates or that they are otherwise medically contraindicated.

Coding Information:

  1. When submitting claims for senile osteoporosis or other osteoporosis, ICD-10-CM code K20.80, K20.81, K20.90, K20.91 or Z87.19 should only be added to claims to indicate that the patient has severe esophagitis and cannot take the oral drugs.

  2. When submitting claims for senile osteoporosis or other osteoporosis, ICD-10-CM code T50.995A-T50.995S, Y63.8, Z91.89 or Z92.89 should only be added to claims to indicate that the patient cannot tolerate oral ibandronate sodium.

  3. For management of hypercalcemia of malignancy (E83.52), the rationale for the use of the drug and the related malignancy must be documented in the patient’s medical record.

  4. When submitting claims for patients with osteoporosis as a complication of transplant, the related complication of transplant code as well as T50.995A-T50.995S or Z87.19 is required.

  5. When ibandronate is used to prevent osteoporosis in a postmenopausal woman who is not being treated for osteopenia, the claim should include the -GY modifier which will result in denial of Medicare payment.

Utilization:

Dose and frequency should be in accordance with the FDA label or recognized compendia (for off-label uses). When services are performed in excess of established parameters, they may be subject to review for medical necessity.

FDA and Compendia Review:

American Society of Health-System Pharmacists, Inc. AHFS Drug Information®. Bethesda, MD: 2007.

Clinical Pharmacology Web site. http://www.clinicalpharmacology.com/. Accessed 08/21/2023.

Lexi-Drugs Web site. http://online.lexi.com. Accessed 08/21/2023.

Micromedex DrugDex®. http://www.micromedexsolutions.com/home/dispatch. Accessed 08/21/2023.

National Comprehensive Cancer Network Web site. http://www.nccn.org/index.asp. Accessed 08/21/2023.

U.S. Food and Drug Administration label approved 01/06/2006 accessed on line at http://www.accessdata.fda.gov/scripts/cder/drugsatfda/ on 11/19/2007.

United States Pharmacopoeia (USP), Volume I; Drug Information for the Health Care Professional, 2007.

Response To Comments

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Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(21 Codes)
Group 1 Paragraph

The following are stand-alone diagnosis codes

Group 1 Codes
Code Description
C79.51 Secondary malignant neoplasm of bone
E83.52 Hypercalcemia
M88.0 - M88.812 Osteitis deformans of skull - Osteitis deformans of left shoulder
M88.821 Osteitis deformans of right upper arm
M88.822 Osteitis deformans of left upper arm
M88.831 Osteitis deformans of right forearm
M88.832 Osteitis deformans of left forearm
M88.841 Osteitis deformans of right hand
M88.842 Osteitis deformans of left hand
M88.851 Osteitis deformans of right thigh
M88.852 Osteitis deformans of left thigh
M88.861 Osteitis deformans of right lower leg
M88.862 Osteitis deformans of left lower leg
M88.871 Osteitis deformans of right ankle and foot
M88.872 Osteitis deformans of left ankle and foot
M88.88 Osteitis deformans of other bones
M88.89 Osteitis deformans of multiple sites
M88.9 Osteitis deformans of unspecified bone

Group 2

(207 Codes)
Group 2 Paragraph

Esophagitis or intolerance preventing oral therapy

At least one ICD-10-CM code from Group 2 and Group 3 must be billed.

Codes indicating a diagnosis of osteoporosis

Group 2 Codes
Code Description
M80.011A - M80.012S Age-related osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture - Age-related osteoporosis with current pathological fracture, left shoulder, sequela
M80.021A - M80.022S Age-related osteoporosis with current pathological fracture, right humerus, initial encounter for fracture - Age-related osteoporosis with current pathological fracture, left humerus, sequela
M80.031A - M80.032S Age-related osteoporosis with current pathological fracture, right forearm, initial encounter for fracture - Age-related osteoporosis with current pathological fracture, left forearm, sequela
M80.041A - M80.042S Age-related osteoporosis with current pathological fracture, right hand, initial encounter for fracture - Age-related osteoporosis with current pathological fracture, left hand, sequela
M80.051A - M80.052S Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture - Age-related osteoporosis with current pathological fracture, left femur, sequela
M80.061A - M80.062S Age-related osteoporosis with current pathological fracture, right lower leg, initial encounter for fracture - Age-related osteoporosis with current pathological fracture, left lower leg, sequela
M80.071A - M80.072S Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture - Age-related osteoporosis with current pathological fracture, left ankle and foot, sequela
M80.08XA - M80.0B2S Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture - Age-related osteoporosis with current pathological fracture, left pelvis, sequela
M80.811A - M80.812S Other osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture - Other osteoporosis with current pathological fracture, left shoulder, sequela
M80.821A - M80.822S Other osteoporosis with current pathological fracture, right humerus, initial encounter for fracture - Other osteoporosis with current pathological fracture, left humerus, sequela
M80.831A - M80.832S Other osteoporosis with current pathological fracture, right forearm, initial encounter for fracture - Other osteoporosis with current pathological fracture, left forearm, sequela
M80.841A - M80.842S Other osteoporosis with current pathological fracture, right hand, initial encounter for fracture - Other osteoporosis with current pathological fracture, left hand, sequela
M80.851A - M80.852S Other osteoporosis with current pathological fracture, right femur, initial encounter for fracture - Other osteoporosis with current pathological fracture, left femur, sequela
M80.861A - M80.862S Other osteoporosis with current pathological fracture, right lower leg, initial encounter for fracture - Other osteoporosis with current pathological fracture, left lower leg, sequela
M80.871A - M80.872S Other osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture - Other osteoporosis with current pathological fracture, left ankle and foot, sequela
M80.88XA - M80.88XS Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture - Other osteoporosis with current pathological fracture, vertebra(e), sequela
M80.8AXA Other osteoporosis with current pathological fracture, other site, initial encounter for fracture
M80.8AXD Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with routine healing
M80.8AXG Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with delayed healing
M80.8AXK Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with nonunion
M80.8AXP Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with malunion
M80.8AXS Other osteoporosis with current pathological fracture, other site, sequela
M81.0 Age-related osteoporosis without current pathological fracture
M81.6 Localized osteoporosis [Lequesne]
M81.8 Other osteoporosis without current pathological fracture

Group 3

(11 Codes)
Group 3 Paragraph

Codes indicating a diagnosis of severe esophagitis or intolerance to oral ibandronate therapy

Group 3 Codes
Code Description
K20.80 Other esophagitis without bleeding
K20.81 Other esophagitis with bleeding
K20.90 Esophagitis, unspecified without bleeding
K20.91 Esophagitis, unspecified with bleeding
T50.995A - T50.995S Adverse effect of other drugs, medicaments and biological substances, initial encounter - Adverse effect of other drugs, medicaments and biological substances, sequela
Y63.8 Failure in dosage during other surgical and medical care
Z87.19 Personal history of other diseases of the digestive system
Z91.89 Other specified personal risk factors, not elsewhere classified
Z92.89 Personal history of other medical treatment

Group 4

(9 Codes)
Group 4 Paragraph

For management of female patients with postmenopausal osteopenia.

One ICD-10-CM code from Group 4 and one from Group 5 must be billed.

Group 4 Codes
Code Description
M85.80 Other specified disorders of bone density and structure, unspecified site
M85.831 Other specified disorders of bone density and structure, right forearm
M85.832 Other specified disorders of bone density and structure, left forearm
M85.851 Other specified disorders of bone density and structure, right thigh
M85.852 Other specified disorders of bone density and structure, left thigh
M85.88 Other specified disorders of bone density and structure, other site
M85.89 Other specified disorders of bone density and structure, multiple sites
M85.9 Disorder of bone density and structure, unspecified
M89.9 Disorder of bone, unspecified

Group 5

(6 Codes)
Group 5 Paragraph

N/A

Group 5 Codes
Code Description
E28.310 Symptomatic premature menopause
E28.319 Asymptomatic premature menopause
E89.40 Asymptomatic postprocedural ovarian failure
E89.41 Symptomatic postprocedural ovarian failure
N95.1 Menopausal and female climacteric states
Z78.0 Asymptomatic menopausal state
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

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Group 1 Codes

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Additional ICD-10 Information

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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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2023 R7

The ICD-10 code range M88.0 – M88.9 in Group 1 and ICD-10 code range M80.00XA - M80.88XS in Group 2 have been revised to remove all unspecified codes. Unspecified codes M85.839 and M85.859 have been removed from Group 4. Based on the annual ICD-10 code update, the following ICD-10 codes: M80.0B1A, M80.0B1D, M80.0B1G, M80.0B1K, M80.0B1P, M80.0B1S, M80.0B2A, M80.0B2D, M80.0B2G, M80.0B2K, M80.0B2P and M80.0B2S are included in ICD-10 code range M80.08XA - M80.0B2S in Group 2.

10/01/2020 R6

Based on the annual ICD-10 code update, ICD-10 codes M80.0AXA, M80.0AXD, M80.0AXG, M80.0AXK, M80.0AXP and M80.0AXS have been added to code range M80.00XA - M80.88XS and ICD-10 codes M80.8AXA, M80.8AXD, M80.8AXG, M80.8AXK, M80.8AXP and M80.8AXS have been added to Group 2. ICD-10 codes K20.8 and K20.9 have been deleted and replaced by K20.80, K20.81, K20.90 and K20.91 in Coding Information Guideline 1 and Group 3 in the ICD-10 Codes that Support Medical Necessity section.

11/07/2019 R5

This article was converted to the new Billing and Coding Article format and the brand name, Boniva® has been removed. The Article Text section has been revised to remove the indications which can be found on the FDA Web site and in the approved compendia. The “Limitations” has been revised to “Specific coding guidelines for this drug.” The “Sources of Information” has been revised to “FDA and Compendia Review.” Sources of information other than the FDA and compendia have been moved to a PDF file attached to LCD L33394. The Bill type codes have been removed from this article. Guidance on these codes is available in the Bill type code section.

10/01/2015 R4 ICD-10-CM codes M85.80 and M85.89 have been added to the Group 4: Codes. ICD-10 codes E28.319, E89.40 and Z78.0 have been added to the Group 5: Codes.
10/01/2015 R3 Based on provider comment, ICD-10-CM code M85.88 has been added to the Group 4: codes.
10/01/2015 R2 The place of service guidelines for the Part B MAC have been removed. ICD-10-CM codes M88.0-M88.9 have been added to the Group 1: Codes and ICD-10-CM code C79.52 has been removed from the Group 1: Codes in the Covered ICD-10 Codes section. ICD-10-CM codes M80.00XA-M80.88XS have been added to the Group 2: Codes. ICD-10-CM codes T50.995D and T50.995S have been added to the Group 3: Codes. ICD-10-CM codes M85.831-M85.839 and M85.851-M85.859 have been added to the Group 4: codes and M94.9 has been removed. ICD-10-CM codes E28.319, E89.40 and Z78.0 have been removed from the Group 5: Codes. ICD-10-CM codes T50.995D and T50.995S have been added to the "Coding Information" guidelines #2 and #4 and utilization guidelines have been added. The information regarding the treatment of osteopenia in postmenopausal women has been revised.
10/01/2015 R1 Updated to include revisions made since April 2014. ICD-10-CM code Y63.8 has been added to the Group 3 Covered ICD-10 Codes.
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