COVERAGE AND CORRECT CODING OF HYQVIA®


Joint DME MAC Publication

In September of 2014, HyQvia was approved by the FDA for subcutaneous administration for the treatment of primary immune deficiency disease. The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have evaluated HyQvia and determined that it is not eligible for inclusion in the Durable Medical Equipment (DME) External Infusion Pump Policy.

Claims for HyQvia will be denied as discussed in a joint DME MAC publication that was posted on June 24, 2011, titled “Drugs Used With External Infusion Pumps - Coverage and Billing Reminders.”

  1. Billing for an infusion drug alone (no pump being used). There is no statutory infusion drug benefit to allow coverage. All infusion drugs and any associated supplies will be denied as statutorily non-covered.
  2. Billing for a pump with an infusion drug not listed in the LCD. Because the drug is not listed in the LCD, all items (the pump, drug, and any associated supplies) will be denied as not reasonable and necessary.

Please refer to the entire Bulletin article and External Infusion Pump policy for complete details.

Claims for HyQvia should be submitted using the DME miscellaneous code J7799.  Suppliers are reminded that when submitting claims for items coded J7799, the supplier must include the following information:

  • Manufacturer name
  • Model name or number
  • Pricing information
  • Explanation of medical necessity

This information must be entered in the narrative field of an electronic claim (NTE 2300 or NTE 2400 of an electronic claim) or Item 19 of a paper claim.
For questions about correct coding, contact the PDAC Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form.

 

Published by Noridian as the PDAC, December 2014.  Republished by Palmetto GBA as the PDAC, February 2019.  Please note that links in this document were accurate at the time of original publication and may change over time and are no longer active.



Last Updated: 12/29/2014