L10.5 — Drug-induced pemphigus
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation should demonstrate the presence of at least one qualifying indication (e.g., records documenting failure of conventional therapy, documentation of contraindication, or evidence of rapidly progressive disease and rationale for short-term IVIg use with conventional therapy).
- Be aware that local contractors may require additional local documentation or definitions (e.g., local coverage determination/criteria), and providers should follow Noridian or applicable LCD requirements.
- 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.
Key Coverage Criteria
- IVIg is covered when the patient has failed conventional therapy for the treated condition.
- IVIg is covered when conventional therapy is contraindicated for the patient.
- IVIg is covered for rapidly progressive disease when a clinical response cannot be achieved quickly enough using conventional agents and IVIg is used only short-term alongside conventional treatment until that therapy takes effect.
- 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.
- Billing and coding for intravenous immunoglobulin (IVIG) should follow the Local Coverage Determination (LCD) L34580 and the billing/coding guidelines in this article as a complement to that LCD.
20 Active Policies
L34771 — Immune Globulins
J05
L37205 — Chemotherapy Drugs and their Adjuncts
J05
A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
J05
A57554 — Billing and Coding: Immune Globulins
J05
L39297 — Off-label Use of Rituximab and Rituximab Biosimilars
Related Codes
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