LCD Reference Article Billing and Coding Article

Billing and Coding: Xofigo Billing Instructions

A54559

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A54559
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Xofigo Billing Instructions
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
09/02/2021
Revision Ending Date
N/A
Retirement Date
N/A

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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim

Article Guidance

Article Text

On May15, 2013, the U. S. Food and Drug Administration (FDA) approved radium Ra 223 dichloride (Xofigo® Injection, Bayer HealthCare Pharmaceuticals Inc.) for the treatment of patients with castration-resistant prostate cancer, symptomatic bone metastases and no known visceral metastatic disease. Xofigo® is an alpha-particle emitting radiotherapeutic drug which mimics calcium and forms complexes with hydroxyapatite at areas of increased bone turnover, such as bone metastases.

The recommended dose and schedule for Xofigo® is 55 kBq/kg (1.49 microcuries/kg) administered by slow intravenous injection over 1 minute every 4 weeks for 6 doses. 

Submit:

  • HCPCS code A9606
  • Diagnoses: ICD-10 code C61 - Malignant neoplasm of prostate and C79.51 - Secondary malignant neoplasm of bone OR C79.52 - Secondary malignant neoplasm of bone marrow
  • Narrative field or electronic equivalent state "visceral metastases are absent".

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(3 Codes)
Group 1 Paragraph

Only C61 and either C79.51 or C79.52

Group 1 Codes
Code Description
C61 Malignant neoplasm of prostate
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description

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N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
09/02/2021 R7

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim was added to the CMS National Coverage Policy section. HCPCS code A9606 was moved from the CPT/HCPCS Codes Group 1: Paragraph section and added to the Group 1: Codes section.

10/03/2019 R6

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles.

08/16/2018 R5

Under Article Text added the acronym (FDA) after the word “Administration” in the first paragraph. The verbiage “ICD-10 Code” was added before C61 in the second bullet. Formatting was corrected throughout the Article.

02/26/2018 R4 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. Effective 02/26/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
10/05/2017 R3

Under Article Text third sentence deleted the verbiage “The recommended dose and schedule for Xofigo is 50 kBq/kg (1.35 microcuries/kg) administered by slow intravenous injection over 1 minute every 4 weeks for 6 doses” and added the verbiage “The recommended dose and schedule for Xofigo is 55 kBq/kg (1.49 microcuries/kg) administered by slow intravenous injection over 1 minute every 4 weeks for 6 doses”.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

 

 

10/20/2015 R2 Annual validation performed-no changes made.
10/20/2015 R1 Under Article Text changed diagnoses to read, C61 - Malignant neoplasm of prostate and C79.51 - Secondary malignant neoplasm of bone OR C79.52 - Secondary malignant neoplasm of bone marrow.
N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
08/30/2021 09/02/2021 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Xofigo