M34.81 — Systemic sclerosis with lung involvement
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.
- Medical record must include most recent blood pressure and demonstrate reasonable control, weight in kilograms, date and results of Hb or HCT prior to ESA administration, and assessment that other causes of anemia are ruled out or managed.
- Every page of the medical record must be legible with patient identification, dates of service, and the legible signature of the responsible physician or non-physician practitioner; submitted records must support the selected ICD-10-CM and CPT/HCPCS codes.
- Non-ESRD claims for J0881, J0885 and Q5106 must include one of modifiers EA (chemo-induced), EB (radio-induced), or EC (non-chemo/radio); all applicable ESA claims must report exactly one route modifier: JA (IV), JB (subcutaneous), or JE (via dialysate).
Key Coverage Criteria
- ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
- ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
- ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.
- Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
- Erythrocyte sedimentation rate (ESR) testing is covered only when reasonable and necessary as defined by Local Coverage Determination L34021.
- ESR performed for rheumatoid arthritis patients to assess the need for medication adjustments should be billed with a diagnosis code that reflects the specific antirheumatic medication the patient is receiving.
20 Active Policies
L34633 — Erythropoiesis Stimulating Agents (ESAs)
J05
L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
A56795 — Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)
J05
A59434 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
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