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
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.
- 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
- 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.
18 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
A60186 — Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J06
Related Codes
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