Q5123, Injection, rituximab-arrx, biosimilar, (riabni), 10 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
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.
- The medical record must include the assessment by the ordering provider as it relates to the patient's complaint for that visit.
- Document relevant medical history, results of pertinent tests/procedures, and signed and dated office visit records or operative reports.
- Document previous treatments including medication(s), dosing, frequency, duration of treatment(s), and documentation of response(s).
- If use is due to lack of efficacy, include documentation of prior treatment(s) with dosing, frequency, duration, and response(s).
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 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.
20 Active Policies
A55639, Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
J5
A59101, Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J6
WPS-L37205, Chemotherapy Drugs and their Adjuncts
J8
PALMETTO-JJ-L35026, Rituximab
JJ
NGS-L39297, Off-label Use of Rituximab and Rituximab Biosimilars
JK
NGS-L40180, Off-label Use of Rituximab and Rituximab Biosimilars
JK
PALMETTO-JM-L35026, Rituximab
JM
BCBSMT-RX502.061, Oncology Medications
BCBSMT-RX502.030, Rituximab and Biosimilars for Non-Oncologic Indications
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
BCBSNM-RX502.061, Oncology Medications
BCBSNM-RX502.030, Rituximab and Biosimilars for Non-Oncologic Indications
BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care
BCBSOK-RX502.061, Oncology Medications
BCBSOK-RX502.030, Rituximab and Biosimilars for Non-Oncologic Indications
BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care
UMR-POL-UMR-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage
UMR-POL-UMR-rituxan-rituximab, Rituximab (Riabni, Rituxan, Ruxience, & Truxima)
SUREST-POL-SUREST-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage
SUREST-POL-SUREST-rituxan-rituximab, Rituximab (Riabni, Rituxan, Ruxience, & Truxima)
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.