Q5115 — Injection, rituximab-abbs, biosimilar, (truxima), 10 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
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.
- Refer to Local Coverage Determination L35026 for clinical coverage criteria, medical necessity requirements, and any required prior authorization; this article complements that LCD with billing/coding guidance.
- Use modifier GZ to indicate that the provider expects Medicare will deny the service as not reasonable and necessary and an ABN has not been signed.
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.
- Off-label use of rituximab and rituximab biosimilars billed to Medicare should follow the local coverage policy DL38920.
- Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed.
- For services that require a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- For diagnostic tests, report the test result if known; if not known, report the symptoms that prompted the test.
20 Active Policies
L37205 — Chemotherapy Drugs and their Adjuncts
J05
A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
J05
L40180 — Off-label Use of Rituximab and Rituximab Biosimilars
J06
A59101 — Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J06
Related Codes
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