HCPCS Code J1569

Official Description

Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg

Short Descr	Gammagard liquid injection
Related Drugs	GAMMAGARD Liquid
Coverage	Special coverage instructions apply
Pricing Indicator(s)	51 – Drugs
MPI	A – Not applicable, as HCPCS priced under one methodology
MCM	2049
ASC Payment Group Code	YY – 1/01/2008
BETOS	O1E – Other drugs
TOS Code(s)	1 – Medical care
Added Date	1/1/2008
Status Code	Excluded from Physician Fee Schedule by Regulation
Global Days	XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC)	9 - Not Applicable
Multiple Procedures (51)	9 - Concept does not apply.
Bilateral Surgery (50)	9 - Concept does not apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	9 - Concept does not apply.
Co-Surgeons (62)	9 - Concept does not apply.
Team Surgery (66)	9 - Concept does not apply.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Nonpass-Through Drugs and Nonimplantable Biologicals, Including Therapeutic Radiopharmaceuticals
ASC Payment Indicator	Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate.
MUE	400
MUE	400
IOM	100-02, 15, 50
OTS Orthotic	No
CCS Clinical Classification	240 - Medications (Injections, infusions and other forms)

JZ	Zero drug amount discarded/not administered to any patient
JA	Administered intravenously
KX	Requirements specified in the medical policy have been met
JB	Administered subcutaneously
GA	Waiver of liability statement issued as required by payer policy, individual case
GY	Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
76	Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
GZ	Item or service expected to be denied as not reasonable and necessary
JW	Drug amount discarded/not administered to any patient
KP	First drug of a multiple drug unit dose formulation
Q6	Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
EJ	Subsequent claims for a defined course of therapy, e.g., epo, sodium hyaluronate, infliximab
X2	Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services
KQ	Second or subsequent drug of a multiple drug unit dose formulation
Q1	Routine clinical service provided in a clinical research study that is in an approved clinical research study
GW	Service not related to the hospice patient's terminal condition
JG	Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes
59	Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
EY	No physician or other licensed health care provider order for this item or service
CR	Catastrophe/disaster related
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
JK	One month supply or less of drug or biological
GX	Notice of liability issued, voluntary under payer policy
PD	Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
SS	Home infusion services provided in the infusion suite of the iv therapy provider
XU	Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
53	Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
GV	Attending physician not employed or paid under arrangement by the patient's hospice provider
KZ	New coverage not implemented by managed care
LT	Left side (used to identify procedures performed on the left side of the body)
TB	Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes
UD	Medicaid level of care 13, as defined by each state
XS	Separate structure, a service that is distinct because it was performed on a separate organ/structure