Documentation

The forms and information available on this page will provide the guidelines necessary for CMS reimbursement for Carnitor^® Injection.

Please note that additional documentation may be necessary to support coverage.

ICD-9-CM Diagnosis Codes for DCD

The following ICD-9-CM diagnosis codes may be relevant for use when submitting Carnitor^® (levocarnitine) Injection claims to your Medicare fiscal intermediary:

DCD and Erythropoietin-resistant Anemia:
End Stage Renal Disease	585.6
Iatrogenic Carnitine Deficiency	277.83
Anemia in Chronic Kidney Disease	285.21

DCD and Intradialytic Hypotension:
End Stage Renal Disease	585.6
Iatrogenic Carnitine Deficiency	277.83
Hypotension of Hemodialysis	458.21

DCD Reimbursement Algorithms

These are conceptual schemes based on the CMS Program Memorandum AB-03-130.

Clinical Monitoring Tools

These comprehensive tools are designed to identify Medicare eligible patients that may qualify for Carnitor^® Injection and track their clinical outcomes.

Sample UB-92 CMS-1450 Claim Form

This sample claim form provides guidance on how to complete the paper UB-92 CMS-1450 Claim Form for CMS Program Memorandum: Levocarnitine for use in the Treatment of Carnitine Deficiency in ESRD Patients.

Health Information Authorization Form

This authorization form is available to authorize the reimbursement hotline to research possible insurance coverage for Carnitor^® Injection.