J9312, Injection, rituximab, 10 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
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.
- Signed and dated office visit records and operative reports are required; all services ordered or rendered to Medicare beneficiaries must be signed.
- For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
- The patient's medical record must include the ordering provider's assessment related to the patient's complaint for that visit and relevant medical history.
- Document results of pertinent tests/procedures; for diagnostic tests report the test result if known, otherwise report the symptoms that prompted the test.
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.
- 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).
- Off-label use is allowable when first-line therapy produced an adverse reaction that absolutely contraindicates further use or causes non-transient side effects that impair functional capacity or activities of daily living, with the adverse event documented.
- Off-label use is allowable for refractory disease when documentation includes all first-line treatment(s) with dosing, frequency, duration, and documentation of response(s).
- Off-label use is allowable for disease relapse when documentation includes prior first-line treatment(s) with dosing, frequency, duration, duration of improvement on prior treatment(s), pertinent clinical history, exam findings, test results supporting relapse, and documentation of response to treatment at time of relapse.
20 Active Policies
CGS-L38268, Immune Thrombocytopenia (ITP) Therapy
J15
CGS-L38920, Off-label Use of Rituximab and Rituximab Biosimilars
J15
A55639, Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
J5
A59101, Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J6
WPS-L37205, Chemotherapy Drugs and their Adjuncts
J8
PALMETTO-JJ-L35026, Rituximab
JJ
NGS-L39297, Off-label Use of Rituximab and Rituximab Biosimilars
JK
NGS-L40180, Off-label Use of Rituximab and Rituximab Biosimilars
JK
PALMETTO-JM-L35026, Rituximab
JM
UHC-POL-rituxan-rituximab, Rituximab (Riabni, Rituxan, Ruxience, & Truxima)
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSIL-RX502.030, Rituximab and Biosimilars for Non-Oncologic Indications
BCBSMT-RX502.061, Oncology Medications
BCBSMT-RX502.030, Rituximab and Biosimilars for Non-Oncologic Indications
UHC-POL-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage
A57160, Billing and Coding: Immune Thrombocytopenia (ITP) Therapy
BCBSIL-RX502.061, Oncology Medications
BCBSOK-RX502.061, Oncology Medications
AETNA-CPB-0422, Vitiligo
BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.