D68.4 — Acquired coagulation factor deficiency
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.
- Refer to Local Coverage Determination L35026 for clinical coverage criteria, medical necessity requirements, and any required prior authorization; this article complements that LCD with billing/coding guidance.
- The submitted medical record must support the selected ICD-10-CM code(s), and the submitted CPT/HCPCS code must accurately describe the service performed.
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.
- For tests that currently lack specific CPT codes (functional intracellular analysis and total antioxidant function), bill using CPT 84999 and add a note identifying which test was performed in the Remarks area for Part A claims and the Narrative area for Part B claims.
- Coverage and reasonable/necessary determinations for assays for vitamins and metabolic function are governed by LCD L34914 and claims must meet that LCD's requirements to be covered.
- 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 or rituximab biosimilars is allowable when the patient has documented lack of efficacy of prior treatments, including dosing, frequency, duration, and documentation of response(s).
14 Active Policies
A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
J05
L37205 — Chemotherapy Drugs and their Adjuncts
J05
L40180 — Off-label Use of Rituximab and Rituximab Biosimilars
J06
A59101 — Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J06
Related Codes
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