10.14.A. - Lunsumio™ Codes - FY 2024																		
																		
Note:  The applicant provided the following codes and/or MS-DRGs that were used in performing a cost analysis for the Charges section of the new technology add-on payment application.																		
																		
ICD-10-CM codes  used to identify cases to be included in the analysis for all cohorts		ICD-10-CM codes used to select cases to be excluded from the analysis for all cohorts		ICD-10-PCS codes used to select cases to be excluded from the analysis for all cohorts		ICD-10-PCS Codes used to identify chemotherapty administration		ICD-10-CM codes to identify follicular lymphoma grade IIIb 										
C82.00		T86.0		30230G2		3E03302		C82.40										
C82.01		T86.00		30230G3		3E03303		C82.41										
C82.02		T86.03		30230G4		3E03305		C82.42										
C82.03		T86.09		30233G2		3E04302		C82.43										
C82.04		T86.5		30233G3		3E04303		C82.44										
C82.05				30233G4		3E04305		C82.45										
C82.06				30240G2		3E05002		C82.46										
C82.07				30240G3		3E05003		C82.47										
C82.08				30240G4		3E05005		C82.48										
C82.09				30243G2		3E05303		C82.49										
C82.10				30243G3		3E05303												
C82.11				30243G4		3E05305												
C82.12				30230Y2		3E06002												
C82.13				30230Y3		3E06003												
C82.14				30230Y4		3E06005												
C82.15				30233Y2		3E06302												
C82.16				30233Y3		3E06303												
C82.17				30233Y4		3E06305												
C82.18				30240Y2														
C82.19				30240Y3														
C82.20				30240Y4														
C82.21				30243Y2														
C82.22				30243Y3														
C82.23				30243Y4														
C82.24				30230U2														
C82.25				30230U3														
C82.26				30230U4														
C82.27				30233U2														
C82.28				30233U3														
C82.29				30233U4														
C82.30				30240U2														
C82.31				30240U3														
C82.32				30240U4														
C82.33				30243U2														
C82.34				30243U3														
C82.35				30243U4														
C82.36				0BYC0Z0														
C82.37				0BYD0Z0														
C82.38				0BYF0Z0														
C82.39				0BYG0Z0														
C82.40				0BYJ0Z0														
C82.41				30230X2														
C82.42				30230X3														
C82.43				30230X4														
C82.44				30233X2														
C82.45				30233X3														
C82.46				30233X4														
C82.47				30240X2														
C82.48				30240X3														
C82.49				30240X4														
C82.50				30243X2														
C82.51				30243X3														
C82.52				30243X4														
C82.53				XW033C3														
C82.54				XW043C3														
C82.55				3E03302														
C82.56				3E03303														
C82.57				3E03305														
C82.58				3E04302														
C82.59				3E04303														
C82.60				3E04305														
C82.61				3E05002														
C82.62				3E05003														
C82.63				3E05005														
C82.64				3E05303														
C82.65				3E05303														
C82.66				3E05305														
C82.67				3E06002														
C82.68				3E06003														
C82.69				3E06005														
C82.80				3E06302														
C82.81				3E06303														
C82.82				3E06305														
C82.83																		
C82.84																		
C82.85																		
C82.86																		
C82.87																		
C82.88																		
C82.89																		
C82.90																		
C82.91																		
C82.92																		
C82.93																		
C82.94																		
C82.95																		
C82.96																		
C82.97																		
C82.98																		
C82.99																		
