J9190, Injection, fluorouracil, 500 mg
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
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.
- A Standard Written Order (SWO) must be communicated to the supplier before claim submission and a signed Written Order Prior to Delivery (WOPD) must be received before delivery of DMEPOS base items that require WOPD.
- Proof of delivery (POD) documentation must be maintained by the supplier and be made available to the Medicare contractor upon request; claims without appropriate POD will be denied.
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.
- External infusion pumps (HCPCS E0779, E0780, E0781, E0791) are covered for administration of deferoxamine for treatment of chronic iron overload.
- External infusion pumps are covered for administration of anticancer chemotherapy for unresectable primary hepatocellular carcinoma or unresectable colorectal cancer or when the beneficiary refuses surgical excision of the tumor.
- External infusion pumps are covered for administration of morphine for intractable cancer pain.
- Continuous subcutaneous insulin infusion (pump E0784) is covered for diabetes mellitus when the beneficiary meets either criterion A (C-peptide/autoantibody evidence of insulin deficiency) or B (prior successful insulin pump use before Medicare enrollment) and either criterion C (prior multiple daily injection program with documented deficiencies) or D (prior pump use with documented glucose testing).
14 Active Policies
A55639, Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
J5
WPS-L37205, Chemotherapy Drugs and their Adjuncts
J8
AETNA-CPB-0484, Glaucoma Surgery
AETNA-CPB-0389, Hypertrophic Scars and Keloids
CIGNA-0328, Scar Revision
Related Codes
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