Effective for dates of service on and after July 6, 2023, Medicare will pay for Leqembi (lecanemab-irmb) for monoclonal antibodies directed against amyloid for the treatment of Alzheimer’s disease.
This drug is covered under NCD 200.3 - Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD)
Medicare covers the drugs with traditional FDA approval in this class when a prescribing clinician or their staff decides the Medicare coverage criteria is met and also submits information to help answer treatment questions in a qualifying study. You can participate in the CMS National Patient Registry (or another CMS-approved study) to get Medicare payment for treating your patients with Leqembi.
Institutional claims:
For dates of service on or after July 6, 2023, use HCPCS code Leqembi J0174 (Injection, lecanemab-irmb, 1mg).
Type of Bill: 12X, 13X, or 85X
Revenue code: 0636
Condition code: 30
Value code: D4 with the National Clinical Trail (NCT) Number "99999999" or the dedicated NCT Number.
Report one the following modifiers:
Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study), or
Q1 (Routine clinical service provided in a clinical research study that is in an approved clinical research study)
Diagnosis codes:
Z00.6 (noting a registry) AND one of the following dx codes:
G30.0 Alzheimer’s disease w/early onset
G30.1 Alzheimer’s disease w/late onset
G30.8 Other Alzheimer’s disease
G30.9 Alzheimer’s disease, unspecified
G31.84 mild cognitive impairment
For dates of service on or after July 6, 2023, use HCPCS code Leqembi J0174 (Injection, lecanemab-irmb, 1mg).
Report the NCT (8-digit number) "99999999" or the dedicated NCT Number in the narrative description field (Item 19) or the electronic claim in Loop 2300 REF02 (REF01=P4).
To ensure claims are submitted and processed correctly, please review the reporting information with your software vendor.
Report one of the following modifiers:
Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study),
or
Q1 (Routine clinical service provided in a clinical research study that is in an approved clinical research study)
Diagnosis codes:
Z00.6 (noting a registry) AND one of the following dx codes:
G30.0 Alzheimer’s disease w/early onset
G30.1 Alzheimer’s disease w/late onset
G30.8 Other Alzheimer’s disease
G30.9 Alzheimer’s disease, unspecified
G31.84 mild cognitive impairment
The diagnosis code pointer should be used to indicate the primary diagnosis on the claim form.
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