LCD Reference Article Billing and Coding Article

Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

A55639

Expand All | Collapse All
Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A55639
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
Article Type
Billing and Coding
Original Effective Date
09/16/2017
Revision Effective Date
04/01/2024
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

N/A

Article Guidance

Article Text

The article will address anti-neoplastic agent codes provided for treatment of noncancer diagnoses or to substances such as monoclonal antibody agents, and other biologic response modifiers. The drugs cited are not intended to be a complete list of drugs that may be administered using the chemotherapy administration codes.

Coverage for medication is based on the patient’s condition, the appropriateness of the dose and route of administration, based on the clinical condition, medical necessity and the standard of medical practice regarding the effectiveness of the drug for the diagnosis and condition. 

The listing of the chemotherapy agent and procedure code do not imply coverage. All the procedure codes are subject to Medicare rules and regulations, applicable Local Coverage Determinations (LCDs), and medical necessity. The chemotherapy agents may be subject to CCI (Corrective Coding Initiative) editing and hospital outpatient prospective payment system rules.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(4 Codes)
Group 1 Paragraph

The following drugs will be allowed for other therapy as indicated below.

Group 1 Codes
Code Description
J9190 INJECTION, FLUOROURACIL, 500 MG
J9215 INJECTION, INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU
J9260 INJECTION, METHOTREXATE SODIUM, 50 MG
J9312 INJECTION, RITUXIMAB, 10 MG
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(129 Codes)
Group 1 Paragraph

J9190 Fluorouracil (5FU, Adrucil) 500 mg. 

For the treatment of patients with glaucoma at high risk for filtering surgery failure. 

Group 1 Codes
Code Description
H40.1111 - H40.1114 Primary open-angle glaucoma, right eye, mild stage - Primary open-angle glaucoma, right eye, indeterminate stage
H40.1121 - H40.1124 Primary open-angle glaucoma, left eye, mild stage - Primary open-angle glaucoma, left eye, indeterminate stage
H40.1131 - H40.1134 Primary open-angle glaucoma, bilateral, mild stage - Primary open-angle glaucoma, bilateral, indeterminate stage
H40.1211 - H40.1214 Low-tension glaucoma, right eye, mild stage - Low-tension glaucoma, right eye, indeterminate stage
H40.1221 - H40.1224 Low-tension glaucoma, left eye, mild stage - Low-tension glaucoma, left eye, indeterminate stage
H40.1231 - H40.1234 Low-tension glaucoma, bilateral, mild stage - Low-tension glaucoma, bilateral, indeterminate stage
H40.1311 - H40.1314 Pigmentary glaucoma, right eye, mild stage - Pigmentary glaucoma, right eye, indeterminate stage
H40.1321 - H40.1324 Pigmentary glaucoma, left eye, mild stage - Pigmentary glaucoma, left eye, indeterminate stage
H40.1331 - H40.1334 Pigmentary glaucoma, bilateral, mild stage - Pigmentary glaucoma, bilateral, indeterminate stage
H40.1411 - H40.1414 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage - Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage
H40.1421 - H40.1424 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage - Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage
H40.1431 - H40.1434 Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage - Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage
H40.151 - H40.153 Residual stage of open-angle glaucoma, right eye - Residual stage of open-angle glaucoma, bilateral
H40.211 - H40.213 Acute angle-closure glaucoma, right eye - Acute angle-closure glaucoma, bilateral
H40.2211 - H40.2214 Chronic angle-closure glaucoma, right eye, mild stage - Chronic angle-closure glaucoma, right eye, indeterminate stage
H40.2221 - H40.2224 Chronic angle-closure glaucoma, left eye, mild stage - Chronic angle-closure glaucoma, left eye, indeterminate stage
H40.2231 - H40.2234 Chronic angle-closure glaucoma, bilateral, mild stage - Chronic angle-closure glaucoma, bilateral, indeterminate stage
H40.231 - H40.233 Intermittent angle-closure glaucoma, right eye - Intermittent angle-closure glaucoma, bilateral
H40.241 - H40.243 Residual stage of angle-closure glaucoma, right eye - Residual stage of angle-closure glaucoma, bilateral
H40.31X1 - H40.31X4 Glaucoma secondary to eye trauma, right eye, mild stage - Glaucoma secondary to eye trauma, right eye, indeterminate stage
H40.32X1 - H40.32X4 Glaucoma secondary to eye trauma, left eye, mild stage - Glaucoma secondary to eye trauma, left eye, indeterminate stage
H40.33X1 - H40.33X4 Glaucoma secondary to eye trauma, bilateral, mild stage - Glaucoma secondary to eye trauma, bilateral, indeterminate stage
H40.41X1 - H40.41X4 Glaucoma secondary to eye inflammation, right eye, mild stage - Glaucoma secondary to eye inflammation, right eye, indeterminate stage
H40.42X1 - H40.42X4 Glaucoma secondary to eye inflammation, left eye, mild stage - Glaucoma secondary to eye inflammation, left eye, indeterminate stage
H40.43X1 - H40.43X4 Glaucoma secondary to eye inflammation, bilateral, mild stage - Glaucoma secondary to eye inflammation, bilateral, indeterminate stage
H40.51X1 - H40.51X4 Glaucoma secondary to other eye disorders, right eye, mild stage - Glaucoma secondary to other eye disorders, right eye, indeterminate stage
H40.52X1 - H40.52X4 Glaucoma secondary to other eye disorders, left eye, mild stage - Glaucoma secondary to other eye disorders, left eye, indeterminate stage
H40.53X1 - H40.53X4 Glaucoma secondary to other eye disorders, bilateral, mild stage - Glaucoma secondary to other eye disorders, bilateral, indeterminate stage
H40.61X1 - H40.61X4 Glaucoma secondary to drugs, right eye, mild stage - Glaucoma secondary to drugs, right eye, indeterminate stage
H40.62X1 - H40.62X4 Glaucoma secondary to drugs, left eye, mild stage - Glaucoma secondary to drugs, left eye, indeterminate stage
H40.63X1 - H40.63X4 Glaucoma secondary to drugs, bilateral, mild stage - Glaucoma secondary to drugs, bilateral, indeterminate stage
H40.811 - H40.813 Glaucoma with increased episcleral venous pressure, right eye - Glaucoma with increased episcleral venous pressure, bilateral
H40.821 - H40.823 Hypersecretion glaucoma, right eye - Hypersecretion glaucoma, bilateral
H40.831 - H40.833 Aqueous misdirection, right eye - Aqueous misdirection, bilateral

Group 2

(4 Codes)
Group 2 Paragraph

J9215 Interferon, Alfa-N3, (human leukocyte derived) (Alferon N) 250,000 IU

Group 2 Codes
Code Description
A63.0 Anogenital (venereal) warts
B07.0 Plantar wart
B07.8 Other viral warts
B07.9 Viral wart, unspecified

Group 3

(299 Codes)
Group 3 Paragraph

J9260 Methotrexate sodium (MTX, Folex) 50 mg
Coverage for indications other than oncologic diseases. 

Group 3 Codes
Code Description
J84.111 - J84.117 Idiopathic interstitial pneumonia, not otherwise specified - Desquamative interstitial pneumonia
J84.170 Interstitial lung disease with progressive fibrotic phenotype in diseases classified elsewhere
J84.178 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere
L12.0 Bullous pemphigoid
L12.8 Other pemphigoid
L40.0 - L40.9 Psoriasis vulgaris - Psoriasis, unspecified
M02.311 - M02.312 Reiter's disease, right shoulder - Reiter's disease, left shoulder
M02.321 - M02.322 Reiter's disease, right elbow - Reiter's disease, left elbow
M02.331 - M02.332 Reiter's disease, right wrist - Reiter's disease, left wrist
M02.341 - M02.342 Reiter's disease, right hand - Reiter's disease, left hand
M02.351 - M02.352 Reiter's disease, right hip - Reiter's disease, left hip
M02.361 - M02.362 Reiter's disease, right knee - Reiter's disease, left knee
M02.371 - M02.372 Reiter's disease, right ankle and foot - Reiter's disease, left ankle and foot
M02.38 Reiter's disease, vertebrae
M02.39 Reiter's disease, multiple sites
M05.211 - M05.212 Rheumatoid vasculitis with rheumatoid arthritis of right shoulder - Rheumatoid vasculitis with rheumatoid arthritis of left shoulder
M05.221 - M05.222 Rheumatoid vasculitis with rheumatoid arthritis of right elbow - Rheumatoid vasculitis with rheumatoid arthritis of left elbow
M05.231 - M05.232 Rheumatoid vasculitis with rheumatoid arthritis of right wrist - Rheumatoid vasculitis with rheumatoid arthritis of left wrist
M05.241 - M05.242 Rheumatoid vasculitis with rheumatoid arthritis of right hand - Rheumatoid vasculitis with rheumatoid arthritis of left hand
M05.251 - M05.252 Rheumatoid vasculitis with rheumatoid arthritis of right hip - Rheumatoid vasculitis with rheumatoid arthritis of left hip
M05.261 - M05.262 Rheumatoid vasculitis with rheumatoid arthritis of right knee - Rheumatoid vasculitis with rheumatoid arthritis of left knee
M05.271 - M05.272 Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot - Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot
M05.29 Rheumatoid vasculitis with rheumatoid arthritis of multiple sites
M05.311 - M05.312 Rheumatoid heart disease with rheumatoid arthritis of right shoulder - Rheumatoid heart disease with rheumatoid arthritis of left shoulder
M05.321 - M05.322 Rheumatoid heart disease with rheumatoid arthritis of right elbow - Rheumatoid heart disease with rheumatoid arthritis of left elbow
M05.331 - M05.332 Rheumatoid heart disease with rheumatoid arthritis of right wrist - Rheumatoid heart disease with rheumatoid arthritis of left wrist
M05.341 - M05.342 Rheumatoid heart disease with rheumatoid arthritis of right hand - Rheumatoid heart disease with rheumatoid arthritis of left hand
M05.351 - M05.352 Rheumatoid heart disease with rheumatoid arthritis of right hip - Rheumatoid heart disease with rheumatoid arthritis of left hip
M05.361 - M05.362 Rheumatoid heart disease with rheumatoid arthritis of right knee - Rheumatoid heart disease with rheumatoid arthritis of left knee
M05.371 - M05.372 Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot - Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot
M05.39 Rheumatoid heart disease with rheumatoid arthritis of multiple sites
M05.411 - M05.412 Rheumatoid myopathy with rheumatoid arthritis of right shoulder - Rheumatoid myopathy with rheumatoid arthritis of left shoulder
M05.421 - M05.422 Rheumatoid myopathy with rheumatoid arthritis of right elbow - Rheumatoid myopathy with rheumatoid arthritis of left elbow
M05.431 - M05.432 Rheumatoid myopathy with rheumatoid arthritis of right wrist - Rheumatoid myopathy with rheumatoid arthritis of left wrist
M05.441 - M05.442 Rheumatoid myopathy with rheumatoid arthritis of right hand - Rheumatoid myopathy with rheumatoid arthritis of left hand
M05.451 - M05.452 Rheumatoid myopathy with rheumatoid arthritis of right hip - Rheumatoid myopathy with rheumatoid arthritis of left hip
M05.461 - M05.462 Rheumatoid myopathy with rheumatoid arthritis of right knee - Rheumatoid myopathy with rheumatoid arthritis of left knee
M05.471 - M05.472 Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot - Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot
M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites
M05.511 - M05.512 Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder - Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder
M05.521 - M05.522 Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow - Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow
M05.531 - M05.532 Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist - Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist
M05.541 - M05.542 Rheumatoid polyneuropathy with rheumatoid arthritis of right hand - Rheumatoid polyneuropathy with rheumatoid arthritis of left hand
M05.551 - M05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of right hip - Rheumatoid polyneuropathy with rheumatoid arthritis of left hip
M05.561 - M05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee - Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
M05.571 - M05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot - Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
M05.611 - M05.612 Rheumatoid arthritis of right shoulder with involvement of other organs and systems - Rheumatoid arthritis of left shoulder with involvement of other organs and systems
M05.621 - M05.622 Rheumatoid arthritis of right elbow with involvement of other organs and systems - Rheumatoid arthritis of left elbow with involvement of other organs and systems
M05.631 - M05.632 Rheumatoid arthritis of right wrist with involvement of other organs and systems - Rheumatoid arthritis of left wrist with involvement of other organs and systems
M05.641 - M05.642 Rheumatoid arthritis of right hand with involvement of other organs and systems - Rheumatoid arthritis of left hand with involvement of other organs and systems
M05.651 - M05.652 Rheumatoid arthritis of right hip with involvement of other organs and systems - Rheumatoid arthritis of left hip with involvement of other organs and systems
M05.661 - M05.662 Rheumatoid arthritis of right knee with involvement of other organs and systems - Rheumatoid arthritis of left knee with involvement of other organs and systems
M05.671 - M05.672 Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems - Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems
M05.69 Rheumatoid arthritis of multiple sites with involvement of other organs and systems
M05.711 - M05.712 Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement
M05.721 - M05.722 Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement
M05.731 - M05.732 Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement
M05.741 - M05.742 Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement
M05.751 - M05.752 Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement
M05.761 - M05.762 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement
M05.771 - M05.772 Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement
M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement
M05.7A Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvement
M05.811 - M05.812 Other rheumatoid arthritis with rheumatoid factor of right shoulder - Other rheumatoid arthritis with rheumatoid factor of left shoulder
M05.821 - M05.822 Other rheumatoid arthritis with rheumatoid factor of right elbow - Other rheumatoid arthritis with rheumatoid factor of left elbow
M05.831 - M05.832 Other rheumatoid arthritis with rheumatoid factor of right wrist - Other rheumatoid arthritis with rheumatoid factor of left wrist
M05.841 - M05.842 Other rheumatoid arthritis with rheumatoid factor of right hand - Other rheumatoid arthritis with rheumatoid factor of left hand
M05.851 - M05.852 Other rheumatoid arthritis with rheumatoid factor of right hip - Other rheumatoid arthritis with rheumatoid factor of left hip
M05.861 - M05.862 Other rheumatoid arthritis with rheumatoid factor of right knee - Other rheumatoid arthritis with rheumatoid factor of left knee
M05.871 - M05.872 Other rheumatoid arthritis with rheumatoid factor of right ankle and foot - Other rheumatoid arthritis with rheumatoid factor of left ankle and foot
M05.89 Other rheumatoid arthritis with rheumatoid factor of multiple sites
M05.8A Other rheumatoid arthritis with rheumatoid factor of other specified site
M06.011 - M06.012 Rheumatoid arthritis without rheumatoid factor, right shoulder - Rheumatoid arthritis without rheumatoid factor, left shoulder
M06.021 - M06.022 Rheumatoid arthritis without rheumatoid factor, right elbow - Rheumatoid arthritis without rheumatoid factor, left elbow
M06.031 - M06.032 Rheumatoid arthritis without rheumatoid factor, right wrist - Rheumatoid arthritis without rheumatoid factor, left wrist
M06.041 - M06.042 Rheumatoid arthritis without rheumatoid factor, right hand - Rheumatoid arthritis without rheumatoid factor, left hand
M06.051 - M06.052 Rheumatoid arthritis without rheumatoid factor, right hip - Rheumatoid arthritis without rheumatoid factor, left hip
M06.061 - M06.062 Rheumatoid arthritis without rheumatoid factor, right knee - Rheumatoid arthritis without rheumatoid factor, left knee
M06.071 - M06.072 Rheumatoid arthritis without rheumatoid factor, right ankle and foot - Rheumatoid arthritis without rheumatoid factor, left ankle and foot
M06.08 Rheumatoid arthritis without rheumatoid factor, vertebrae
M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites
M06.0A Rheumatoid arthritis without rheumatoid factor, other specified site
M06.1 Adult-onset Still's disease
M06.211 - M06.212 Rheumatoid bursitis, right shoulder - Rheumatoid bursitis, left shoulder
M06.221 - M06.222 Rheumatoid bursitis, right elbow - Rheumatoid bursitis, left elbow
M06.231 - M06.232 Rheumatoid bursitis, right wrist - Rheumatoid bursitis, left wrist
M06.241 - M06.242 Rheumatoid bursitis, right hand - Rheumatoid bursitis, left hand
M06.251 - M06.252 Rheumatoid bursitis, right hip - Rheumatoid bursitis, left hip
M06.261 - M06.262 Rheumatoid bursitis, right knee - Rheumatoid bursitis, left knee
M06.271 - M06.272 Rheumatoid bursitis, right ankle and foot - Rheumatoid bursitis, left ankle and foot
M06.28 Rheumatoid bursitis, vertebrae
M06.29 Rheumatoid bursitis, multiple sites
M06.311 - M06.312 Rheumatoid nodule, right shoulder - Rheumatoid nodule, left shoulder
M06.321 - M06.322 Rheumatoid nodule, right elbow - Rheumatoid nodule, left elbow
M06.331 - M06.332 Rheumatoid nodule, right wrist - Rheumatoid nodule, left wrist
M06.341 - M06.342 Rheumatoid nodule, right hand - Rheumatoid nodule, left hand
M06.351 - M06.352 Rheumatoid nodule, right hip - Rheumatoid nodule, left hip
M06.361 - M06.362 Rheumatoid nodule, right knee - Rheumatoid nodule, left knee
M06.371 - M06.372 Rheumatoid nodule, right ankle and foot - Rheumatoid nodule, left ankle and foot
M06.38 Rheumatoid nodule, vertebrae
M06.39 Rheumatoid nodule, multiple sites
M06.4 Inflammatory polyarthropathy
M06.811 - M06.812 Other specified rheumatoid arthritis, right shoulder - Other specified rheumatoid arthritis, left shoulder
M06.821 - M06.822 Other specified rheumatoid arthritis, right elbow - Other specified rheumatoid arthritis, left elbow
M06.831 - M06.832 Other specified rheumatoid arthritis, right wrist - Other specified rheumatoid arthritis, left wrist
M06.841 - M06.842 Other specified rheumatoid arthritis, right hand - Other specified rheumatoid arthritis, left hand
M06.851 - M06.852 Other specified rheumatoid arthritis, right hip - Other specified rheumatoid arthritis, left hip
M06.861 - M06.862 Other specified rheumatoid arthritis, right knee - Other specified rheumatoid arthritis, left knee
M06.871 - M06.872 Other specified rheumatoid arthritis, right ankle and foot - Other specified rheumatoid arthritis, left ankle and foot
M06.88 Other specified rheumatoid arthritis, vertebrae
M06.89 Other specified rheumatoid arthritis, multiple sites
M06.8A Other specified rheumatoid arthritis, other specified site
M08.0A Unspecified juvenile rheumatoid arthritis, other specified site
M08.1 Juvenile ankylosing spondylitis
M08.211 - M08.212 Juvenile rheumatoid arthritis with systemic onset, right shoulder - Juvenile rheumatoid arthritis with systemic onset, left shoulder
M08.221 - M08.222 Juvenile rheumatoid arthritis with systemic onset, right elbow - Juvenile rheumatoid arthritis with systemic onset, left elbow
M08.231 - M08.232 Juvenile rheumatoid arthritis with systemic onset, right wrist - Juvenile rheumatoid arthritis with systemic onset, left wrist
M08.241 - M08.242 Juvenile rheumatoid arthritis with systemic onset, right hand - Juvenile rheumatoid arthritis with systemic onset, left hand
M08.251 - M08.252 Juvenile rheumatoid arthritis with systemic onset, right hip - Juvenile rheumatoid arthritis with systemic onset, left hip
M08.261 - M08.262 Juvenile rheumatoid arthritis with systemic onset, right knee - Juvenile rheumatoid arthritis with systemic onset, left knee
M08.271 - M08.272 Juvenile rheumatoid arthritis with systemic onset, right ankle and foot - Juvenile rheumatoid arthritis with systemic onset, left ankle and foot
M08.28 Juvenile rheumatoid arthritis with systemic onset, vertebrae
M08.29 Juvenile rheumatoid arthritis with systemic onset, multiple sites
M08.2A Juvenile rheumatoid arthritis with systemic onset, other specified site
M08.3 Juvenile rheumatoid polyarthritis (seronegative)
M08.4A Pauciarticular juvenile rheumatoid arthritis, other specified site
M08.811 - M08.812 Other juvenile arthritis, right shoulder - Other juvenile arthritis, left shoulder
M08.821 - M08.822 Other juvenile arthritis, right elbow - Other juvenile arthritis, left elbow
M08.831 - M08.832 Other juvenile arthritis, right wrist - Other juvenile arthritis, left wrist
M08.841 - M08.842 Other juvenile arthritis, right hand - Other juvenile arthritis, left hand
M08.851 - M08.852 Other juvenile arthritis, right hip - Other juvenile arthritis, left hip
M08.861 - M08.862 Other juvenile arthritis, right knee - Other juvenile arthritis, left knee
M08.871 - M08.872 Other juvenile arthritis, right ankle and foot - Other juvenile arthritis, left ankle and foot
M08.88 Other juvenile arthritis, other specified site
M08.89 Other juvenile arthritis, multiple sites
M08.9A Juvenile arthritis, unspecified, other specified site
M31.5 - M31.6 Giant cell arteritis with polymyalgia rheumatica - Other giant cell arteritis
M32.0 Drug-induced systemic lupus erythematosus
M32.10 - M32.19 Systemic lupus erythematosus, organ or system involvement unspecified - Other organ or system involvement in systemic lupus erythematosus
M32.8 Other forms of systemic lupus erythematosus
M33.21 - M33.22 Polymyositis with respiratory involvement - Polymyositis with myopathy
M33.29 Polymyositis with other organ involvement
M35.03 Sjogren syndrome with myopathy
M35.04 Sjogren syndrome with tubulo-interstitial nephropathy
M45.0 - M45.8 Ankylosing spondylitis of multiple sites in spine - Ankylosing spondylitis sacral and sacrococcygeal region
M48.8X1 - M48.8X8 Other specified spondylopathies, occipito-atlanto-axial region - Other specified spondylopathies, sacral and sacrococcygeal region
N08 Glomerular disorders in diseases classified elsewhere
O00.00 Abdominal pregnancy without intrauterine pregnancy
O00.01 Abdominal pregnancy with intrauterine pregnancy
O00.101 Right tubal pregnancy without intrauterine pregnancy
O00.102 Left tubal pregnancy without intrauterine pregnancy
O00.111 Right tubal pregnancy with intrauterine pregnancy
O00.112 Left tubal pregnancy with intrauterine pregnancy
O00.201 Right ovarian pregnancy without intrauterine pregnancy
O00.202 Left ovarian pregnancy without intrauterine pregnancy
O00.211 Right ovarian pregnancy with intrauterine pregnancy
O00.212 Left ovarian pregnancy with intrauterine pregnancy
O00.80 Other ectopic pregnancy without intrauterine pregnancy
O00.81 Other ectopic pregnancy with intrauterine pregnancy

Group 4

(253 Codes)
Group 4 Paragraph

J9312 Rituximab, 10 mg

  • Post Stem cell transplant and Epstein Barr virus Z94.84 and B27.00-B27.09
Z94.84 Stem cells transplant status
B27.00-B27.09 Gammaherpesviral mononucleosis, Mononucleosis due to Epstein-Barr virus

 

  • Acute refractory and relapsed refractory TTP due to immune-mediate ADAMTS-13 deficiency
M31.11 Hematopoietic stem cell transplantation-associated thrombotic microangiopathy [HSCT-TMA]
M31.19 Other thrombotic microangiopathy

 

  • Allergic purpura
D69.0 Allergic vasculitis, Purpura Henoch(-Schönlein)

 

  • Chronic graft-versus-host disease D89.811 and one of the complications of transplant codes below:
D47.Z1 Post-transplant lymphoproliferative disorder (PTLD)
D89.811 Chronic graft-versus-host disease
T86.01-T86.03 Complications of bone marrow transplant: rejection/failure/infection
T86.09 Other complications of bone marrow transplant
T86.11-T86.13 Complications of kidney transplant: rejection/failure/infection
T86.19 Other complication of kidney transplant
T86.21-T86.23 Complications of heart-lung transplant: rejection/failure/infection
T86.290 Cardiac allograft vasculopathy
T86.298 Other complications of heart transplant
T86.41-T86.43 Complications of liver transplant: rejection/failure/infection
T86.49 Other complications of liver transplant
T86.5 Complications of stem cell transplant
T86.810-T86.812 Complications of lung transplant: rejection/failure/infection
T86.818 Other complications of lung transplant
T86.830-T86.832 Complications of bone graft: rejection/failure/infection
T86.838 Other complications of bone graft
T86.850-T86.852 Complications of intestine transplant: rejection/failure/infection
T86.858 Other complications of intestine transplant
T86.890-T86.892 Complications of other transplanted tissue: rejection/failure/infection
T86.898 Other complications of other transplanted tissue

 

Additional Indications

Group 4 Codes
Code Description
D47.3 Essential (hemorrhagic) thrombocythemia
D59.0 Drug-induced autoimmune hemolytic anemia
D59.10 Autoimmune hemolytic anemia, unspecified
D59.11 Warm autoimmune hemolytic anemia
D59.12 Cold autoimmune hemolytic anemia
D59.13 Mixed type autoimmune hemolytic anemia
D59.19 Other autoimmune hemolytic anemia
D68.311 Acquired hemophilia
D68.32 Hemorrhagic disorder due to extrinsic circulating anticoagulants
D68.4 Acquired coagulation factor deficiency
D69.3 Immune thrombocytopenic purpura
D69.41 - D69.42 Evans syndrome - Congenital and hereditary thrombocytopenia purpura
D69.49 Other primary thrombocytopenia
G35 Multiple sclerosis
G36.0 Neuromyelitis optica [Devic]
G70.00 - G70.01 Myasthenia gravis without (acute) exacerbation - Myasthenia gravis with (acute) exacerbation
I77.6 Arteritis, unspecified
L10.0 - L10.89 Pemphigus vulgaris - Other pemphigus
L12.0 Bullous pemphigoid
L12.1 Cicatricial pemphigoid
L12.8 - L12.9 Other pemphigoid - Pemphigoid, unspecified
M05.011 - M05.012 Felty's syndrome, right shoulder - Felty's syndrome, left shoulder
M05.021 - M05.022 Felty's syndrome, right elbow - Felty's syndrome, left elbow
M05.031 - M05.032 Felty's syndrome, right wrist - Felty's syndrome, left wrist
M05.041 - M05.042 Felty's syndrome, right hand - Felty's syndrome, left hand
M05.051 - M05.052 Felty's syndrome, right hip - Felty's syndrome, left hip
M05.061 - M05.062 Felty's syndrome, right knee - Felty's syndrome, left knee
M05.071 - M05.072 Felty's syndrome, right ankle and foot - Felty's syndrome, left ankle and foot
M05.09 Felty's syndrome, multiple sites
M05.211 - M05.212 Rheumatoid vasculitis with rheumatoid arthritis of right shoulder - Rheumatoid vasculitis with rheumatoid arthritis of left shoulder
M05.221 - M05.222 Rheumatoid vasculitis with rheumatoid arthritis of right elbow - Rheumatoid vasculitis with rheumatoid arthritis of left elbow
M05.231 - M05.232 Rheumatoid vasculitis with rheumatoid arthritis of right wrist - Rheumatoid vasculitis with rheumatoid arthritis of left wrist
M05.241 - M05.242 Rheumatoid vasculitis with rheumatoid arthritis of right hand - Rheumatoid vasculitis with rheumatoid arthritis of left hand
M05.251 - M05.252 Rheumatoid vasculitis with rheumatoid arthritis of right hip - Rheumatoid vasculitis with rheumatoid arthritis of left hip
M05.261 - M05.262 Rheumatoid vasculitis with rheumatoid arthritis of right knee - Rheumatoid vasculitis with rheumatoid arthritis of left knee
M05.271 - M05.272 Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot - Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot
M05.29 Rheumatoid vasculitis with rheumatoid arthritis of multiple sites
M05.311 - M05.312 Rheumatoid heart disease with rheumatoid arthritis of right shoulder - Rheumatoid heart disease with rheumatoid arthritis of left shoulder
M05.321 - M05.322 Rheumatoid heart disease with rheumatoid arthritis of right elbow - Rheumatoid heart disease with rheumatoid arthritis of left elbow
M05.331 - M05.332 Rheumatoid heart disease with rheumatoid arthritis of right wrist - Rheumatoid heart disease with rheumatoid arthritis of left wrist
M05.341 - M05.342 Rheumatoid heart disease with rheumatoid arthritis of right hand - Rheumatoid heart disease with rheumatoid arthritis of left hand
M05.351 - M05.352 Rheumatoid heart disease with rheumatoid arthritis of right hip - Rheumatoid heart disease with rheumatoid arthritis of left hip
M05.361 - M05.362 Rheumatoid heart disease with rheumatoid arthritis of right knee - Rheumatoid heart disease with rheumatoid arthritis of left knee
M05.371 - M05.372 Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot - Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot
M05.39 Rheumatoid heart disease with rheumatoid arthritis of multiple sites
M05.411 - M05.412 Rheumatoid myopathy with rheumatoid arthritis of right shoulder - Rheumatoid myopathy with rheumatoid arthritis of left shoulder
M05.421 - M05.422 Rheumatoid myopathy with rheumatoid arthritis of right elbow - Rheumatoid myopathy with rheumatoid arthritis of left elbow
M05.431 - M05.432 Rheumatoid myopathy with rheumatoid arthritis of right wrist - Rheumatoid myopathy with rheumatoid arthritis of left wrist
M05.441 - M05.442 Rheumatoid myopathy with rheumatoid arthritis of right hand - Rheumatoid myopathy with rheumatoid arthritis of left hand
M05.451 - M05.452 Rheumatoid myopathy with rheumatoid arthritis of right hip - Rheumatoid myopathy with rheumatoid arthritis of left hip
M05.461 - M05.462 Rheumatoid myopathy with rheumatoid arthritis of right knee - Rheumatoid myopathy with rheumatoid arthritis of left knee
M05.471 - M05.472 Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot - Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot
M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites
M05.511 - M05.512 Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder - Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder
M05.521 - M05.522 Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow - Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow
M05.531 - M05.532 Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist - Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist
M05.541 - M05.542 Rheumatoid polyneuropathy with rheumatoid arthritis of right hand - Rheumatoid polyneuropathy with rheumatoid arthritis of left hand
M05.551 - M05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of right hip - Rheumatoid polyneuropathy with rheumatoid arthritis of left hip
M05.561 - M05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee - Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
M05.571 - M05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot - Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
M05.611 - M05.612 Rheumatoid arthritis of right shoulder with involvement of other organs and systems - Rheumatoid arthritis of left shoulder with involvement of other organs and systems
M05.621 - M05.622 Rheumatoid arthritis of right elbow with involvement of other organs and systems - Rheumatoid arthritis of left elbow with involvement of other organs and systems
M05.631 - M05.632 Rheumatoid arthritis of right wrist with involvement of other organs and systems - Rheumatoid arthritis of left wrist with involvement of other organs and systems
M05.641 - M05.642 Rheumatoid arthritis of right hand with involvement of other organs and systems - Rheumatoid arthritis of left hand with involvement of other organs and systems
M05.651 - M05.652 Rheumatoid arthritis of right hip with involvement of other organs and systems - Rheumatoid arthritis of left hip with involvement of other organs and systems
M05.661 - M05.662 Rheumatoid arthritis of right knee with involvement of other organs and systems - Rheumatoid arthritis of left knee with involvement of other organs and systems
M05.671 - M05.672 Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems - Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems
M05.69 Rheumatoid arthritis of multiple sites with involvement of other organs and systems
M05.711 - M05.712 Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement
M05.721 - M05.722 Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement
M05.731 - M05.732 Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement
M05.741 - M05.742 Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement
M05.751 - M05.752 Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement
M05.761 - M05.762 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement
M05.771 - M05.772 Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement - Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement
M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement
M05.7A Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvement
M05.811 - M05.812 Other rheumatoid arthritis with rheumatoid factor of right shoulder - Other rheumatoid arthritis with rheumatoid factor of left shoulder
M05.821 - M05.822 Other rheumatoid arthritis with rheumatoid factor of right elbow - Other rheumatoid arthritis with rheumatoid factor of left elbow
M05.831 - M05.832 Other rheumatoid arthritis with rheumatoid factor of right wrist - Other rheumatoid arthritis with rheumatoid factor of left wrist
M05.841 - M05.842 Other rheumatoid arthritis with rheumatoid factor of right hand - Other rheumatoid arthritis with rheumatoid factor of left hand
M05.851 - M05.852 Other rheumatoid arthritis with rheumatoid factor of right hip - Other rheumatoid arthritis with rheumatoid factor of left hip
M05.861 - M05.862 Other rheumatoid arthritis with rheumatoid factor of right knee - Other rheumatoid arthritis with rheumatoid factor of left knee
M05.871 - M05.872 Other rheumatoid arthritis with rheumatoid factor of right ankle and foot - Other rheumatoid arthritis with rheumatoid factor of left ankle and foot
M05.89 Other rheumatoid arthritis with rheumatoid factor of multiple sites
M05.8A Other rheumatoid arthritis with rheumatoid factor of other specified site
M06.011 - M06.012 Rheumatoid arthritis without rheumatoid factor, right shoulder - Rheumatoid arthritis without rheumatoid factor, left shoulder
M06.021 - M06.022 Rheumatoid arthritis without rheumatoid factor, right elbow - Rheumatoid arthritis without rheumatoid factor, left elbow
M06.031 - M06.032 Rheumatoid arthritis without rheumatoid factor, right wrist - Rheumatoid arthritis without rheumatoid factor, left wrist
M06.041 - M06.042 Rheumatoid arthritis without rheumatoid factor, right hand - Rheumatoid arthritis without rheumatoid factor, left hand
M06.051 - M06.052 Rheumatoid arthritis without rheumatoid factor, right hip - Rheumatoid arthritis without rheumatoid factor, left hip
M06.061 - M06.062 Rheumatoid arthritis without rheumatoid factor, right knee - Rheumatoid arthritis without rheumatoid factor, left knee
M06.071 - M06.072 Rheumatoid arthritis without rheumatoid factor, right ankle and foot - Rheumatoid arthritis without rheumatoid factor, left ankle and foot
M06.08 Rheumatoid arthritis without rheumatoid factor, vertebrae
M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites
M06.0A Rheumatoid arthritis without rheumatoid factor, other specified site
M06.1 Adult-onset Still's disease
M06.211 - M06.212 Rheumatoid bursitis, right shoulder - Rheumatoid bursitis, left shoulder
M06.221 - M06.222 Rheumatoid bursitis, right elbow - Rheumatoid bursitis, left elbow
M06.231 - M06.232 Rheumatoid bursitis, right wrist - Rheumatoid bursitis, left wrist
M06.241 - M06.242 Rheumatoid bursitis, right hand - Rheumatoid bursitis, left hand
M06.251 - M06.252 Rheumatoid bursitis, right hip - Rheumatoid bursitis, left hip
M06.261 - M06.262 Rheumatoid bursitis, right knee - Rheumatoid bursitis, left knee
M06.271 - M06.272 Rheumatoid bursitis, right ankle and foot - Rheumatoid bursitis, left ankle and foot
M06.28 Rheumatoid bursitis, vertebrae
M06.29 Rheumatoid bursitis, multiple sites
M06.311 - M06.312 Rheumatoid nodule, right shoulder - Rheumatoid nodule, left shoulder
M06.321 - M06.322 Rheumatoid nodule, right elbow - Rheumatoid nodule, left elbow
M06.331 - M06.332 Rheumatoid nodule, right wrist - Rheumatoid nodule, left wrist
M06.341 - M06.342 Rheumatoid nodule, right hand - Rheumatoid nodule, left hand
M06.351 - M06.352 Rheumatoid nodule, right hip - Rheumatoid nodule, left hip
M06.361 - M06.362 Rheumatoid nodule, right knee - Rheumatoid nodule, left knee
M06.371 - M06.372 Rheumatoid nodule, right ankle and foot - Rheumatoid nodule, left ankle and foot
M06.38 Rheumatoid nodule, vertebrae
M06.39 Rheumatoid nodule, multiple sites
M06.811 - M06.812 Other specified rheumatoid arthritis, right shoulder - Other specified rheumatoid arthritis, left shoulder
M06.821 - M06.822 Other specified rheumatoid arthritis, right elbow - Other specified rheumatoid arthritis, left elbow
M06.831 - M06.832 Other specified rheumatoid arthritis, right wrist - Other specified rheumatoid arthritis, left wrist
M06.841 - M06.842 Other specified rheumatoid arthritis, right hand - Other specified rheumatoid arthritis, left hand
M06.851 - M06.852 Other specified rheumatoid arthritis, right hip - Other specified rheumatoid arthritis, left hip
M06.861 - M06.862 Other specified rheumatoid arthritis, right knee - Other specified rheumatoid arthritis, left knee
M06.871 - M06.872 Other specified rheumatoid arthritis, right ankle and foot - Other specified rheumatoid arthritis, left ankle and foot
M06.88 Other specified rheumatoid arthritis, vertebrae
M06.89 Other specified rheumatoid arthritis, multiple sites
M06.8A Other specified rheumatoid arthritis, other specified site
M30.0 - M30.2 Polyarteritis nodosa - Juvenile polyarteritis
M30.8 Other conditions related to polyarteritis nodosa
M31.30 - M31.31 Wegener's granulomatosis without renal involvement - Wegener's granulomatosis with renal involvement
M31.7 Microscopic polyangiitis
M33.00 - M33.03 Juvenile dermatomyositis, organ involvement unspecified - Juvenile dermatomyositis without myopathy
M33.09 Juvenile dermatomyositis with other organ involvement
M33.10 - M33.13 Other dermatomyositis, organ involvement unspecified - Other dermatomyositis without myopathy
M33.19 Other dermatomyositis with other organ involvement
M33.20 - M33.22 Polymyositis, organ involvement unspecified - Polymyositis with myopathy
M33.29 Polymyositis with other organ involvement
M35.01 Sjogren syndrome with keratoconjunctivitis
M35.02 Sjogren syndrome with lung involvement
M35.03 Sjogren syndrome with myopathy
M35.05 Sjogren syndrome with inflammatory arthritis
M35.06 Sjogren syndrome with peripheral nervous system involvement
M35.07 Sjogren syndrome with central nervous system involvement
M35.08 Sjogren syndrome with gastrointestinal involvement
M35.0A Sjogren syndrome with glomerular disease
M35.0B Sjogren syndrome with vasculitis
M35.0C Sjogren syndrome with dental involvement
M35.09 Sjogren syndrome with other organ involvement
M36.0 Dermato(poly)myositis in neoplastic disease
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
04/01/2024 R12

Posted 04/25/2024 Under Coding Information CPT/HCPCS Codes Gorup 1 Codes deleted J9070 and J2950. Changed description to J2960. Under ICD 10 Codes that Support Medical Necessity deleted Group 1 Paragraph J9070 Cyclophosphamide (Cytocan) 100 mg information and all Group 1 Codes. Updated numbering of all remaining Group Paragraphs and Group Codes. These changes are due to the 2024 Q2 CPT/HCPCS Codes Updates and are effective 04/01/2024.

11/30/2023 R11

Posted 11/30/2023 Review completed 10/26/2023 with no change in coverage.

10/01/2023 R10

Posted 09/28/2023 Under ICD-10 Codes that Support Medical Necessity Group 1 Codes added ICD 10 codes N04.20, N04.21, N04.22, and N04.29. These were added due to 2024 Annual ICD-10-CM Code Updates and are effective 10/01/2023.

11/25/2021 R9

11/25/2021 Under Article Text- removed “chemotherapy administration agent codes which apply to parenteral administration of”. Under Group 5 Paragraph J9312 Rituximab, 10 mg removed “In addition to the tables listed below, please see NCCN compendium for the additional disease indications and ICD-10 codes that are covered for Rituximab.” Review completed 10/22/2021.

10/01/2021 R8

09/30/2021 ICD-10 CM Code annual update. Group 4 description change to M35.04, added M35.03. Under Group 5 Acute refractory and relapsed refractory TTP due to immune-mediate ADAMTS-13 deficiency deleted M31.1, added M31.11 and M31.19, Under Additional Indications Group 5 Codes added M35.01, M35.02, M35.03, M36.05, M35.06, M35.07, M35.08, M35.09, M35.0A, M35.0B, and M35.0C.

10/01/2020 R7

10/01/2020 ICD-10 CM Code annual update. Group 1 Deleted D59.1, added D59.10, D59.11, D59.12, D59.13, D59.19, M05.7A, M05.8A, M06.0A, M06.8A, M08.0A, M08.2A, M08.4A, M08.9A, N00.A, N01.A, N02.A, N03.A, N04.A, N05.A, N06.A, and N07.A. Group 4 added J84.170, J84.178, M05.7A, M05.8A, M06.0A, M06.8A, M08.0A, M08.2A, M08.4A, and M08.9A. Group 5 Deleted D59.1, added D59.10, D59.11, D59.12, D59.13, D59.19, M05.7A, M05.8A, M06.0A, and M06.8A.

11/28/2019 R6

Corrected URL for link to "CMS Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, Section 50, Drugs and Biologicals" under Rules and Regulations s).

11/28/2019 R5

11/28/2019 Associated A55640: Not Otherwise Classified Chemotherapy Agents (NOC) retired effective 11/28/2019 and link removed. Content has been moved to the new template. Review completed 11/01/2019.

01/01/2019 R4

01/01/2019 Annual CPT/HCPCS update. Group 1 Codes: removed J9310 and added J9312. Group 5 Paragraph: removed J9310 and added J9312.

10/01/2018 R3

10/01/2018: ICD-10 CM Code updates: Group 6: O00.212 description change. Article updated/reformatted to support Article Guidance on Non-Oncological Conditions: Removed from Group 1 Code Table: A9606, J9151, J9165, J9270, and Q2017. These medications were removed as they are applicable to oncologic conditions and do not support the article guidance for non-oncological conditions. This article is related to LCD L37205 Chemotherapy Drugs and their Adjuncts. Please refer to the LCD for coverage for chemotherapy agents. Removed Group 1 Paragraph and associated information: A9606 and associated Group 1 Codes. Removed Group 3 Paragraph and associated information: J9151, J9165, J9270, and Q2017 and associated Group 3 Codes: Ranges C00.0 – C96.0, C96.21 – D46.9, D47.09 – D49.9, and E34.0 – E34.9. Group Paragraphs and Group Codes corrected for numerical order.

08/01/2018 R2

08/01/2018: Annual reviewed completed 06/29/2018. No change in coverage.

10/01/2017 R1

10/01/2017 ICD-10 CM Code updates: Group 3: Delete C96.2, D47.0; Add: C96.21, C96.22, C96.29, D47.09.  Group 6 Codes: Range of O00.00-O00.81 table reformatted due to deleted codes: O00.10, O00.11, O00.20, O00.21; Add: O00.101, O00.102, O00.111, O00.112, O00.201, O00.202, O00.211, O00.212. Group 7 Description change: M33.00, M33.01, M33.02, M33.09, M33.10, M33.11, M33.12, M33.19; Add: M33.03, M33.13.

 

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L37205 - Chemotherapy Drugs and their Adjuncts
Related National Coverage Documents
N/A
SAD Process URL 1
N/A
SAD Process URL 2
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/Pub100_20pdf.pdf
Description: PUB.100-20 One time Notification (OTN); Change Request (CR) 3818, 3631, 3028)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Description: Publications 100-04 Medicare Claims Processing Manual, Chapter 12 Section 30.5 Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions
N/A
CMS Manual Explanations URLs
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
Description: CMS Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, Section 50, Drugs and Biologicals
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Description: CMS 100-04 Medicare Claims Processing Manual, Ch. 12, Physician/Nonphysician Practitioners, Sec. 30.5, Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c14.pdf
Description: CMS 100-04 Medicare Claims Processing Manual, Chapter 14, Ambulatory Surgical Centers, Section 10, General
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf
Description: CMS 100-04 Medicare Claims Processing Manual, Chapter17, Drugs and Biologicals, Section 90.2, Drugs, Biologicals, and Radiopharmaceuticals
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
04/16/2024 04/01/2024 - N/A Currently in Effect You are here
11/20/2023 11/30/2023 - 03/31/2024 Superseded View
09/19/2023 10/01/2023 - 11/29/2023 Superseded View
11/16/2021 11/25/2021 - 09/30/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Chemotherapy
  • Non-Oncologic conditions