N05.0 — Unspecified nephritic syndrome with minor glomerular abnormality
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records must document that the ultrasound was limited to retroperitoneal structures when billing CPT 76770/76775/76776, including images/findings demonstrating limitation to the retroperitoneum.
- If the exam was expanded to include organs outside the retroperitoneum, documentation must reflect the expansion and support billing a full or limited abdominal ultrasound (CPT 76700/76705/76706).
- Claims and documentation should follow the complementary Local Coverage Determination L34577 and any applicable LCD requirements.
- The medical record must include the assessment by the ordering provider as it relates to the patient's complaint for that visit.
Key Coverage Criteria
- Retroperitoneal ultrasound (CPT 76770, 76775, 76776) is covered when the exam is limited solely to retroperitoneal structures.
- A full (complete) or limited abdominal ultrasound (CPT 76700, 76705, 76706) is covered when the exam includes organs or structures outside the retroperitoneum or when primary findings involve non-retroperitoneal structures (e.g., gallbladder, liver, spleen, common bile duct).
- 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.
6 Active Policies
A59101 — Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J06
A60186 — Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J06
L39297 — Off-label Use of Rituximab and Rituximab Biosimilars
J06
L40180 — Off-label Use of Rituximab and Rituximab Biosimilars
J06
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.