CMS Pub. 100-04, ch. 32, § 260.1.1

A - Hospital Outpatient Claims

For hospital outpatient claims, hospitals must bill covered dermal injections for

treatment of facial LDS by having all of the required elements on the claim:

1. A line with HCPCS codes Q2026 or Q2027 with a Line Item Date of service

(LIDOS) on or after March 23, 2010,

NOTE: Q2027 is replaced with Q2028 effective 1/1/14 as per the 2014 HCPCS

update.

2. A line with HCPCS code G0429 with a LIDOS on or after March 23, 2010,

3. If ICD-10-CM is applicable, ICD-10-CM diagnosis codes B20 Human

Immunodeficiency Virus (HIV) disease and E88.1 Lipodystrophy, not elsewhere

classified

The applicable NCD is 250.5 Facial Lipodystrophy.

B - Outpatient Prospective Payment System (OPPS) Hospitals or Ambulatory

Surgical Centers (ASCs):

For line item dates of service on or after March 23, 2010, and until HCPCS codes Q2026

and Q2027 are billable, facial LDS claims shall contain a temporary HCPCS code C9800,

instead of HCPCS G0429 and HCPCS Q2026/Q2027, as shown above.

NOTE: Q2027 is replaced with Q2028 effective 1/1/14 as per the 2014, HCPCS

update.

C - Hospital Inpatient Claims

Hospitals must bill covered dermal injections for treatment of facial LDS by having all of

the required elements on the claim:

C. Discharge date on or after March 23, 2010,

D. If ICD-10-PCS is applicable,

• ICD-10-PCS procedure code 3E00XGC Introduction of Other Therapeutic

Substance into Skin and Mucous Membrances, External Approach, or

E. If ICD-10-CM is applicable on or after 10/01/2015,

• ICD-10-CM diagnosis codes B20 Human Immunodeficiency Virus [HIV]

disease and E88.1 Lipodystrophy not elsewhere classified.

A diagnosis code for a comorbidity of depression may also be required for coverage on an

outpatient and/or inpatient basis as determined by the individual Medicare contractor’s

policy.