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Hemophilia Clotting Factors


Hemophilia is a hereditary blood disease characterized by greatly prolonged coagulation time. The blood fails to clot and abnormal bleeding occurs. It is a sex-linked hereditary trait transmitted by normal heterozygous females who carry the recessive gene. It occurs almost exclusively in males. For purposes of Medicare coverage, hemophilia encompasses Factor VIII deficiency (classic hemophilia, hemophilia A), Factor IX deficiency (hemophilia B, Christmas disease, plasma thromboplastin component), and von Willebrand’s disease. Approximately 80% of those with hemophilia have type A.

Coding Guidelines:

The following are examples of the appropriate HCPCS code to use for the products administered:

1. Factor VIIa (anti-inhibitor)

Novo7- (Coagulation Factor Recombinant) J7189
For the treatment of bleeding episodes in Hemophilia A or B patients with inhibitors to Factor VIII or Factor IX

2. Factor VIII

Hemofil M - J7190
Koate H.P. - J7190
Monocolate - J7190
Humate P - J7190 or J7186 or J7187
Profilate HP- J7190
AHF M - J7190
Alphanate - J7190
Antihemophilic Factor (Porcine) Hyate:C - J7191
Recombinate (Recombinant) - J7192
Kogenate - J7192
Bioclate - J7192
Helixate - J7192
Xyntha – J7185

3. Factor VIII inhibitors

Autoplex T (anti-inhibitor) - J7198
Feiba VH (anti-inhibitor) - J7198

4. Factor IX

Konyne (Heat Treated) - J7194
Profilnine Heat-Treated - J7194
Proplex - J7194
Hemonyne - J7194
Bebulin VH - J7194
Benefix (recombinant) - J7195
AlphaNine (Human, affinity purified) - J7193
Mononine (Human, Monoclonal, purified) - J7193

5. von Willebrand factor complex (human Wilate, 1 I.U) - J7183

6. Factor XIII Injection Factor XIII (antihemophilic factor, human) 1 I.U.

Corifact J7180

ICD-9 Codes that Support Medical Necessity

286.0    CONGENITAL FACTOR VIII DISORDER
286.1    CONGENITAL FACTOR IX DISORDER
286.2    CONGENITAL FACTOR XI DEFICIENCY
286.3    CONGENITAL DEFICIENCY OF OTHER CLOTTING FACTORS
286.4    VON WILLEBRAND'S DISEASE
286.52    ACQUIRED HEMOPHILIA
286.53    ANTIPHOSPHOLIPID ANTIBODY WITH HEMORRHAGIC DISORDER
286.59    OTHER HEMORRHAGIC DISORDER DUE TO INTRINSIC CIRCULATING ANTICOAGULANTS, ANTIBODIES, OR INHIBITORS
286.7    ACQUIRED COAGULATION FACTOR DEFICIENCY

Calculating the number units to submit for hemophilia clotting factor claims:

To calculate the number units to submit for hemophilia clotting factor claims, please use the following steps:

Divide the number of international units (IU) given by 100
Round the submitted units to the nearest whole number

Fractions from .50 to .99 = 1 additional billing unit
Fraction from .01 to .49 = no additional billing unit

Example:

Patient receives 1,232 IU of Factor VIII
Divide 1,232 by 100 (1232/100 = 12.32)
Round to the nearest whole number = 12
Submit 12 as the number of units

Please note:

1. Providers must indicate the total dosage per number of Units or in micrograms (not the number of vials used) in item 19 of the Centers for Medicare & Medicaid Services (CMS) 1500 form, or in the narrative record if filing electronically. List the units of service as one in item 24G of the 1500 form.

2. When using the NOC code J7199, Hemophilia clotting factor, not otherwise classified, indicate the name of the drug, the total dosage, and the method of administration on item 19 of the CMS 1500 form, and in the narrative record if filing electronically. List the units of service (not vials) as one in item 24G of the 1500 form. If filing electronically, the total units should be placed in the NSF Format, Record FAO-18.0, ANSI 837 format Segment SV1-05 (3032) or Segment SV1-04 (3051).

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