M02.311 — Reiter's disease, right shoulder
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.
- Providers must follow the Local Coverage Determination (LCD) L35677 for clinical indications, coverage decisions, and documentation requirements for infliximab.
- Claims must include the appropriate CPT code, 1 unit of service (UOS), and the appropriate ICD-10-CM diagnosis code.
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.
- Flow cytometry is covered for examination of body fluids (including peripheral blood and cerebrospinal fluid), bone marrow, and lymphoreticular tissues (lymph nodes, tonsil, spleen).
- Peripheral blood and fine needle aspirate specimens are acceptable for flow cytometry to avoid more invasive diagnostic procedures.
- Coverage decisions are governed by the associated Local Coverage Determination LCD L34215 and its specific coverage criteria.
- No specific clinical indications are provided in this billing and coding article; coverage criteria for amniotic and placental-derived product injections/applications for musculoskeletal non-wound indications are described in Local Coverage Determination L39116.
20 Active Policies
A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
J05
L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
A59434 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
L37205 — Chemotherapy Drugs and their Adjuncts
J05
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