CAM 40106

Transfusion Therapy for Hemolytic Disease of the Fetus and the Newborn

Category:Ob/Gyn/Reproduction   Last Reviewed:March 2020
Department(s):Medical Affairs   Next Review:March 2999
Original Date:March 1996    

Description:
Transfusion therapy for fetal and neonatal diseases can involve either a simple transfusion or an exchange transfusion. In neonates, an exchange transfusion is the method used, while in fetuses, the various intrauterine transfusion therapies may use either a simple transfusion or an exchange transfusion.

In fetuses, one of three types of intrauterine transfusion techniques may be used:

  1. Intraperitoneal intrauterine fetal transfusion
  2. Direct intrauterine transfusion (via umbilical artery/vein) without exchange of donor blood for fetal blood
  3. Intrauterine exchange transfusion (via umbilical artery/vein)

Policy:
Transfusion therapy is considered MEDICALLY NECESSARY in the treatment of the following diseases of the fetus and the newborn:

  • Erythroblastosis fetalis
  • Hydrops fetalis
  • ABO incompatibility
  • Rh incompatibility
  • Hemolytic anemia
  • Hyperbilirubinemia

Coding Section

Codes Number Description
CPT 36430 Transfusion, blood or blood components
  36440 Push transfusion, blood, 2 years or under
  36450 Exchange transfusion, blood, newborn
  36460 Transfusion, intrauterine, fetal
  36510 Catheterization of umbilical vein for diagnosis or therapy, newborn
  36660 Catheterization of umbilical artery, newborn, for diagnosis or therapy
  76941 Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and interpretation
ICD-9 Procedure  38.91 Arterial catheterization
  38.92 Umbilical vein catheterization
  75.2 Intrauterine transfusion
  99.01 Exchange transfusion
  99.03 Other transfusion of whole blood
ICD-9 DIAGNOSIS 773.0-773.3 Hemolytic diseases of fetus and newborn due to isoimmunization. (This code range includes the conditions listed on the policy: erythroblastosis fetalis, hydrops fetalis, ABO incompatibility, Rh incompatibility, hemolytic anemia)
  774.0-774.6

Other perinatal jaundice code range (policy states “severe” hyperbilirubinemia — ICD-9 doesn’t classify to severity, classifies to type)

HCPCS No code  
ICD-10-CM (effective 10/01/15) P550  Rh isoimmunization of newborn
  P551  ABO isoimmunization of newborn
  P558  Other hemolytic diseases of newborn
  P559  Hemolytic disease of newborn, unspecified
  P560  Hydrops fetalis due to isoimmunization
  P570  Kernicterus due to isoimmunization
  P588  Neonatal jaundice due to other specified excessive hemolysis
  P580  Neonatal jaundice due to bruising
  P582  Neonatal jaundice due to infection
  P583  Neonatal jaundice due to polycythemia
  P5841  Neonatal jaundice due to drugs or toxins transmitted from mother
  P585  Neonatal jaundice due to swallowed maternal blood
  P590 Neonatal jaundice associated with preterm delivery
  P598  Neonatal jaundice from other specified causes
  P593  Neonatal jaundice from breast milk inhibitor
  P591  Inspissated bile syndrome
  P5929 Neonatal jaundice from other hepatocellular damage
  P599  Neonatal jaundice, unspecified
ICD-10-PCS (effective 10/01/15)  03HY03Z Insertion of Infusion Device into Upper Artery, Open Approach
  03HY33Z  Insertion of Infusion Device into Upper Artery, Percutaneous Approach
  03HY43Z  Insertion of Infusion Device into Upper Artery, Percutaneous Endoscopic Approach
  04HY03Z  Insertion of Infusion Device into Lower Artery, Open Approach
  04HY33Z  Insertion of Infusion Device into Lower Artery, Percutaneous Approach
  04HY43Z  Insertion of Infusion Device into Lower Artery, Percutaneous Endoscopic Approach
  06H033T  Insertion of Infusion Device, Via Umbilical Vein, into Inferior Vena Cava, Percutaneous Approach
  30273H1  Transfusion of Nonautologous Whole Blood into Products of Conception, Circulatory, Percutaneous Approach
  30273J1  Transfusion of Nonautologous Serum Albumin into Products of Conception, Circulatory, Percutaneous Approach
  30273K1  Transfusion of Nonautologous Frozen Plasma into Products of Conception, Circulatory, Percutaneous Approach
  30273L1  Transfusion of Nonautologous Fresh Plasma into Products of Conception, Circulatory, Percutaneous Approach
  30273M1  Transfusion of Nonautologous Plasma Cryoprecipitate into Products of Conception, Circulatory, Percutaneous Approach
  30273N1  Transfusion of Nonautologous Red Blood Cells into Products of Conception, Circulatory, Percutaneous Approach
  30273P1  Transfusion of Nonautologous Frozen Red Cells into Products of Conception, Circulatory, Percutaneous Approach
  30273Q1  Transfusion of Nonautologous White Cells into Products of Conception, Circulatory, Percutaneous Approach
  30273R1  Transfusion of Nonautologous Platelets into Products of Conception, Circulatory, Percutaneous Approach
  30273S1  Transfusion of Nonautologous Globulin into Products of Conception, Circulatory, Percutaneous Approach
  30273T1  Transfusion of Nonautologous Fibrinogen into Products of Conception, Circulatory, Percutaneous Approach
  30273V1  Transfusion of Nonautologous Antihemophilic Factors into Products of Conception, Circulatory, Percutaneous Approach
  30273W1  Transfusion of Nonautologous Factor IX into Products of Conception, Circulatory, Percutaneous Approach
  30277H1  Transfusion of Nonautologous Whole Blood into Products of Conception, Circulatory, Via Natural or Artificial Opening
  30277J1  Transfusion of Nonautologous Serum Albumin into Products of Conception, Circulatory, Via Natural or Artificial Opening
  30277K1  Transfusion of Nonautologous Frozen Plasma into Products of Conception, Circulatory, Via Natural or Artificial Opening
  30277L1  Transfusion of Nonautologous Fresh Plasma into Products of Conception, Circulatory, Via Natural or Artificial Opening
  30277M1  Transfusion of Nonautologous Plasma Cryoprecipitate into Products of Conception, Circulatory, Via Natural or Artificial Opening
  30277N1  Transfusion of Nonautologous Red Blood Cells into Products of Conception, Circulatory, Via Natural or Artificial Opening
  30277P1  Transfusion of Nonautologous Frozen Red Cells into Products of Conception, Circulatory, Via Natural or Artificial Opening
  30277Q1 Transfusion of Nonautologous White Cells into Products of Conception, Circulatory, Via Natural or Artificial Opening
  30277R1  Transfusion of Nonautologous Platelets into Products of Conception, Circulatory, Via Natural or Artificial Opening
  30277S1  Transfusion of Nonautologous Globulin into Products of Conception, Circulatory, Via Natural or Artificial Opening
  30277T1  Transfusion of Nonautologous Fibrinogen into Products of Conception, Circulatory, Via Natural or Artificial Opening
  30277V1  Transfusion of Nonautologous Antihemophilic Factors into Products of Conception, Circulatory, Via Natural or Artificial Opening
  30277W1  Transfusion of Nonautologous Factor IX into Products of Conception, Circulatory, Via Natural or Artificial Opening
  30233H1  Transfusion of Nonautologous Whole Blood into Peripheral Vein, Percutaneous Approach
  30243H1  Transfusion of Nonautologous Whole Blood into Central Vein, Percutaneous Approach
  30253H1  Transfusion of Nonautologous Whole Blood into Peripheral Artery, Percutaneous Approach
  30263H1  Transfusion of Nonautologous Whole Blood into Central Artery, Percutaneous Approach
Type of Service OB/GYN  
Place of Service Inpatient/Outpatient  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

03/02/2020 

Annual review. No change to policy intent. 

03/04/2019 

Annual review. No change to policy intent. 

03/19/2018 

Annual review. No change to policy intent. 

03/02/2017 

Annual review, no change to policy intent. 

03/07/2016 

Annual review. No change to policy intent. 

09/23/2015 

Added ICD-10 coding to policy. 

03/05/2015 

Annual review. No change to policy intent. Added coding.

03/4/2014

Annual review. No changes made.


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