M35.03 — Sjogren syndrome with myopathy
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.
- All documentation must be maintained in the patient's medical record, legible, include patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
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.
- Nerve conduction studies (NCS) without needle EMG (NEMG) are allowed for individuals being evaluated for carpal tunnel syndrome or tarsal tunnel syndrome when one of the following ICD-10-CM codes is reported: G56.01, G56.02, G56.03, G56.11, G56.12, G56.13, G56.21, G56.22, G56.23, G57.51, G57.52, or G57.53.
- NCS without NEMG is allowed for individuals with significant lymphedema in the affected extremity when ICD-10-CM code I89.0 is reported in addition to the primary diagnosis.
- NCS without NEMG is allowed for individuals treated with anticoagulants when ICD-10-CM code Z79.01 or Z79.02 is reported in addition to the primary diagnosis.
- Electrodiagnostic testing (EMG and/or nerve conduction studies) is indicated for evaluation of suspected carpal tunnel syndrome.
20 Active Policies
L34594 — Nerve Conduction Studies and Electromyography
J05
A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
J05
A57478 — Billing and Coding: Nerve Conduction Studies and Electromyography
J05
L37205 — Chemotherapy Drugs and their Adjuncts
J05
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