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Clinical Policy: Transplant Evaluation - icd 10 for transplant evaluation

Clinical Policy: Transplant Evaluation-icd 10 for transplant evaluation

Clinical Policy: Transplant Evaluation
Reference Number: IL.CP.MP.523 Coding Implications
Last Review Date: 09/20 Revision Log
See Important Reminder at the end of this policy for important regulatory and legal
Transplant Evaluations are requested by facilities in preparation for members to receive an
Actual Transplant.
At the time of the evaluation request, the transplant coordinator or nurse will review with the
requestor the items that will be needed once the facility is ready to request an actual transplant.
If any criteria point is not met, Transplant Coordinator will send to UM RN for further review
I. It is the policy of MeridianHealth affiliated with Centene Corporation? that transplant
evaluation is medically necessary for the following indications:
A. Transplant Coordinators will be able to approve the following members for
transplant evaluations when all of the following are Met:
i. Person receiving the transplant evaluation is an active member with one of
the Meridian Medicaid or Exchange insurance products
ii. Organ to be transplanted is kidney, heart, lung, liver, intestinal/viscera,
pancreas or bone marrow or some combination thereof.
iii. Underlying diagnosis is on the list for the respective transplant policy
iv. Only one transplant evaluation will be approved for each organ/organ
combination requested
B. Specific Diagnoses - Most common diagnosis per organ (This list is not all
inclusive; please check the appropriate policy):
i. Kidney
1. Chronic renal failure nearing dialysis or already on dialysis
ii. Heart
1. Heart failure for kids
2. NYHA class 3 or 4 for adults
iii. Lung
1. Restrictive lung disease
2. Cystic fibrosis
3. Obstructive lung disease
4. COPD/emphysema
5. Primary pulmonary hypertension
iv. Liver
1. Cirrhosis
2. Hepatocellular carcinoma
3. Wilson's disease
4. Hemochromatosis
5. Primary sclerosing cholangitis
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Transplant Evaluation
v. Pancreas
1. Type 1 diabetes
vi. Small Bowel
1. Short gut syndrome or non-functioning bowel with TPN failure
vii. Bone Marrow
1. Sickle cell
2. Leukemia
3. Lymphoma
4. Aplastic anemia
5. Thalassemia major
6. Multiple myeloma
7. Primary immunodeficiency syndromes
Coding Implications
This clinical policy references Current Procedural Terminology (CPT?). CPT? is a registered
trademark of the American Medical Association. All CPT codes and descriptions are copyrighted
2019, American Medical Association. All rights reserved. CPT codes and CPT descriptions are
from the current manuals and those included herein are not intended to be all-inclusive and are
included for informational purposes only. Codes referenced in this clinical policy are for
informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage.
Providers should reference the most up-to-date sources of professional coding guidance prior to
the submission of claims for reimbursement of covered services.
CPT?* Description
ICD-10-CM Diagnosis Codes that Support Coverage Criteria
+ Indicates a code(s) requiring an additional character
ICD-10-CM Code Description
Reviews, Revisions, and Approvals Date Approval
Original approval date 04/19/17
1. Illinois Department of Healthcare and Family Services. Handbook for Practitioners
Rendering Medical Services. Chapter 200: 222.6 Organ Transplant. Issued June 16, 2021
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Transplant Evaluation
Important Reminder
This clinical policy has been developed by appropriately experienced and licensed health care
professionals based on a review and consideration of currently available generally accepted
standards of medical practice; peer-reviewed medical literature; government agency/program
approval status; evidence-based guidelines and positions of leading national health professional
organizations; views of physicians practicing in relevant clinical areas affected by this clinical
policy; and other available clinical information. The Health Plan makes no representations and
accepts no liability with respect to the content of any external information used or relied upon in
developing this clinical policy. This clinical policy is consistent with standards of medical
practice current at the time that this clinical policy was approved. "Health Plan" means a health
plan that has adopted this clinical policy and that is operated or administered, in whole or in part,
by Centene Management Company, LLC, or any of such health plan's affiliates, as applicable.
The purpose of this clinical policy is to provide a guide to medical necessity, which is a
component of the guidelines used to assist in making coverage decisions and administering
benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage
decisions and the administration of benefits are subject to all terms, conditions, exclusions and
limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy,
contract of insurance, etc.), as well as to state and federal requirements and applicable Health
Plan-level administrative policies and procedures.
This clinical policy is effective as of the date determined by the Health Plan. The date of posting
may not be the effective date of this clinical policy. This clinical policy may be subject to
applicable legal and regulatory requirements relating to provider notification. If there is a
discrepancy between the effective date of this clinical policy and any applicable legal or
regulatory requirement, the requirements of law and regulation shall govern. The Health Plan
retains the right to change, amend or withdraw this clinical policy, and additional clinical
policies may be developed and adopted as needed, at any time.
This clinical policy does not constitute medical advice, medical treatment or medical care. It is
not intended to dictate to providers how to practice medicine. Providers are expected to exercise
professional medical judgment in providing the most appropriate care, and are solely responsible
for the medical advice and treatment of members. This clinical policy is not intended to
recommend treatment for members. Members should consult with their treating physician in
connection with diagnosis and treatment decisions.
Providers referred to in this clinical policy are independent contractors who exercise independent
judgment and over whom the Health Plan has no control or right of control. Providers are not
agents or employees of the Health Plan.
This clinical policy is the property of the Health Plan. Unauthorized copying, use, and
distribution of this clinical policy or any information contained herein are strictly prohibited.
Providers, members and their representatives are bound to the terms and conditions expressed
herein through the terms of their contracts. Where no such contract exists, providers, members
and their representatives agree to be bound by such terms and conditions by providing services to
members and/or submitting claims for payment for such services.
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What is the ICD 10 code for pre op? What is the ICD-10 code for pre op? Z01.818 Most pre-op exams will be coded with Z01. 818. The ICD-10 instructions say to use the preprocedural diagnosis code first, and then the reason for the surgery and any additional findings. Evaluations before surgery are reimbursable services. What CPT code do you use for pre op clearance?