ICD-10 Coding for Vascepa Reimbursement
For optimal reimbursement of Vascepa (icosapent ethyl), use ICD-10 code E78.1 (Pure hyperglyceridemia) as the primary diagnosis, with secondary codes for established cardiovascular disease (I25.10 for atherosclerotic heart disease) or diabetes with complications (E11.65 for Type 2 diabetes with hyperglycemia) when applicable. 1
Primary Diagnosis Codes
E78.1 (Pure hyperglyceridemia) is the most direct code for hypertriglyceridemia and should be listed as the primary diagnosis when triglycerides are ≥150 mg/dL, as this aligns with FDA-approved indications for Vascepa 1, 2
E78.5 (Hyperlipidemia, unspecified) can be used as an alternative if mixed dyslipidemia is present, though E78.1 is preferred for insurance authorization 3
Essential Secondary Diagnosis Codes
I25.10 (Atherosclerotic heart disease of native coronary artery without angina pectoris) or more specific ASCVD codes (I25.110-I25.119 for documented coronary artery disease) should be added when the patient has established cardiovascular disease, as Vascepa is FDA-approved specifically for cardiovascular risk reduction in this population 1, 2
E11.65 (Type 2 diabetes mellitus with hyperglycemia) or E11.9 (Type 2 diabetes without complications) must be included when the patient has diabetes, as the REDUCE-IT trial demonstrated 25% cardiovascular risk reduction in diabetic patients with additional risk factors 1, 4
I10 (Essential hypertension), E78.00 (Pure hypercholesterolemia), or Z82.49 (Family history of ischemic heart disease) should be added to document the "≥2 additional cardiovascular risk factors" required by FDA labeling for diabetic patients without established ASCVD 1
Critical Documentation Requirements
Document that triglycerides are ≥150 mg/dL (preferably ≥135 mg/dL based on REDUCE-IT trial criteria) despite statin therapy, as this is the FDA-approved threshold 1, 2
Document that LDL-C is controlled (41-100 mg/dL range) on maximally tolerated statin therapy, as Vascepa is indicated as adjunctive therapy, not monotherapy 1
Include documentation of lifestyle modifications attempted (diet, weight loss, alcohol reduction) before initiating Vascepa, as guidelines recommend optimizing these first 1, 3
Common Pitfalls to Avoid
Do not use E78.2 (Mixed hyperlipidemia) alone without E78.1, as insurance may deny coverage if hypertriglyceridemia is not explicitly documented 3
Do not code for severe hypertriglyceridemia (≥500 mg/dL) when using Vascepa for cardiovascular risk reduction, as this may trigger insurance to suggest fibrates instead—Vascepa's cardiovascular indication is for moderate hypertriglyceridemia (≥150 mg/dL) 1, 2
Avoid using only diabetes codes without cardiovascular disease codes unless you document ≥2 additional cardiovascular risk factors, as insurance may deny coverage for primary prevention without adequate risk stratification 1
Prior Authorization Strategy
Emphasize the cardiovascular outcomes data from REDUCE-IT showing 25% reduction in major adverse cardiovascular events when submitting prior authorization 1, 2
Highlight that Vascepa is the only omega-3 product FDA-approved for cardiovascular risk reduction, distinguishing it from Lovaza and other omega-3 products that lack cardiovascular outcomes data 2, 5
Document that the patient meets specific REDUCE-IT trial criteria: triglycerides ≥150 mg/dL, on statin therapy, with either established ASCVD or diabetes plus ≥2 additional risk factors 1
Note that Vascepa does not increase LDL-C (unlike DHA-containing products like Lovaza), which is particularly important for patients with controlled LDL-C on statin therapy 2, 6