LCD and Billing and Coding Article Updates – July 2025
Billing and Coding: Respiratory Pathogen Panel Testing (A58741)
Based on the HCPCS quarterly updates the following updates have been made to the article: PLA Codes 0240U and 0241U have been deleted from Group 1 in the CPT/HCPCS Codes section and from the Group 1 Paragraph in the ICD-10-CM Codes that Support Medical Necessity section. 0563U and 0564U have been added to Group 2 in the CPT/HCPCS Codes section.
Billing and Coding: Ranibizumab and biosimilars, Aflibercept, Aflibercept HD, Brolucizumab-dbll, Faricimab-svoa, PAVBLU™aflibercept-ayyh, AHZANTIVE®aflibercept-abzv. ENZEEVU™aflibercept-mrbb and OPUVIZ™aflibercept-yszy (A52451)
- Based on the HCPCS quarterly update, HCPCS code Q5153 was added to the CPT/HCPCS Code section, effective for services on or after 7/1/2025.
- Effective 7/1/2025, OPUVIZ™ (aflibercept-yszy) should be reported using HCPCS code Q5153.
- OPUVIZ™ (aflibercept-yszy) was added to the "ICD-10-CM Codes that Support Medical Necessity" -Group 2 Paragraph and to the article text.
- ICD-10-CM codes (Diabetic Macular Edema, Diabetic Retinopathy and ICD-10-CM codes H35.3213, H35.3223, H35.3233) were added to the “ICD-10-CM Codes That Support Medical Necessity” section-Group 6 (SUSVIMO), effective 9/1/2024.
- HCPCS codes were added to the ICD-10-CM Group Paragraphs 1-6 for clarity.
Self-Administered Drug Exclusion List: Medical Policy Article (A53021)
Effective 7/1/2025, HCPCS codes Q5098 ustekinumab-srlf , (IMULDOSA™)* biosimilar, 1 mg, Q5099 ustekinumab-stba (SteQeyma)*, biosimilar, 1 mg, and Q5100 ustekinumab-kfce (YESINTEK™)*, biosimilar, 1 mg have been added to the SAD exclusion table.
The previous miscellaneous codes for ustekinumab-stba (SteQeyma)*, C9399, J3490 and J3590 have been end-dated 6/30/2025.
Revised HCPCS code Q9998 descriptor from "INJECTION, USTEKINUMAB-AEKN (SELARSDI), 1 MG" to "Injection, ustekinumab-aekn (selarsdi), biosimilar, 1 mg".
Added Jurisdiction 6 Contract numbers to A53021 to ensure consistency between Jurisdictions 6 and K Self-administered Drug Exclusions.
Posted 7/2/2025