G35.C0 — Secondary progressive multiple sclerosis, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low 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.
- Medical records must document the clinical findings supporting the billed foot care service and be available upon request.
- Claims based on systemic-condition diagnosis codes with an asterisk must include the date patient was last seen (DPLS) and the NPI of the M.D. or D.O. actively managing the systemic condition in the medical record and/or claim.
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.
- Foot care services are covered when the beneficiary has a listed systemic condition that justifies coverage per Medicare Benefit Policy Manual Pub.100-02, Ch.15, Section 290.4D.
- For diagnosis codes designated by an asterisk, the patient must be under the active care of an M.D. or D.O., documented as having been seen for the complicating disease within the 6 months prior to service.
- Claims asserting presumptive coverage must include a systemic-condition diagnosis from IOM 100-02 Ch.15 Section 290 Group 1 and a valid billing modifier Q7, Q8, or Q9.
- Mycotic nail debridement is covered when mycotic nails are present in the context of a systemic disease with class findings and the appropriate Q modifier on the claim.
20 Active Policies
A57595 — Billing and Coding: Pelvic Floor Dysfunction: Anorectal Manometry and EMG
J05
A57597 — Billing and Coding: Somatosensory Testing
J05
L37205 — Chemotherapy Drugs and their Adjuncts
J05
L34624 — Somatosensory Testing
J05
A57478 — Billing and Coding: Nerve Conduction Studies and Electromyography
Related Codes
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