D68.311 — Acquired hemophilia
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must be supported by medical record documentation of the patient’s diagnosis/clinical condition and justification that the selected drug, dose, and route of administration are appropriate and medically necessary for the non-oncologic indication.
- Billing must comply with Medicare rules and any applicable LCD prior authorization or documentation requirements; follow any specific forms or prior authorization processes required by the LCD or payer.
- Policy content not provided; unable to determine required documentation, prior authorization, or forms for AICC claims—manual review of the full policy required.
- Clinical records must clearly document the diagnosis, specific foot findings, and the clinical rationale that treatment was medically necessary and that withholding care would be hazardous to the beneficiary.
Key Coverage Criteria
- Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.
- Monoclonal antibody agents and other biologic response modifiers may be administered and billed using chemotherapy administration codes for noncancer indications when the dose, route, and clinical use are appropriate and medically necessary.
- Policy content not provided; unable to determine covered indications for AICC NCD 110.3—manual review of the full policy required.
- Routine foot care is covered only when clinical documentation demonstrates the patient’s condition warrants the provider to render the services and that failure to provide the services would be hazardous to the beneficiary due to underlying medical condition(s), per CMS Pub 100-02, Ch.15, §290.
- Off-label use of rituximab and rituximab biosimilars billed to Medicare should follow the local coverage policy DL38920.
- Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed.
13 Active Policies
A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
J05
L37205 — Chemotherapy Drugs and their Adjuncts
J05
A59101 — Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J06
A60186 — Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J06
Related Codes
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