Local Coverage Article Billing and Coding

Billing and Coding: Instructions for Lemtrada® (alemtuzumab) When Used in the Treatment of Relapsing Multiple Sclerosis

A55310

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Contractor Information

Article Information

General Information

Article ID
A55310
Article Title
Billing and Coding: Instructions for Lemtrada® (alemtuzumab) When Used in the Treatment of Relapsing Multiple Sclerosis
Article Type
Billing and Coding
Original Effective Date
09/18/2016
Revision Effective Date
10/24/2019
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

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Article Guidance

Article Text

Lemtrada® is indicated in the treatment of patients with relapsing forms of multiple sclerosis. The dosage of Lemtrada® when used for this indication is 12mg/day infused for 5 consecutive days, then 12mg/day infused for 3 consecutive days at one interval, one year from the first course of treatment.

To submit a claim for Lemtrada® in Part B of A (hospital outpatient) on a UB-04 claim form, the following information must appear on the form:

Diagnosis-(Box 66)

ICD-10 G35 Multiple Sclerosis (for claims with date of service (DOS) from 10/01/2015 forward)

HCPCS drug code-(Field 44)
 
J0202 Injection, alemtuzumab 1mg (DOS 01/01/2016 forward)

Narrative (Remarks) in (Field 80) (or electronic equivalent)

National Drug Code (NDC)- 58468-0200-1 or 58468-0200-01 Single use vial 12mg/1.2 ml (10mg/ml)
Name of Drug (trade and generic)
Dose of drug administered
Route of administration

To submit a claim for Lemtrada® in Part B on a CMS-1500 claim form, the following information must appear on the form:

Diagnosis-(Box 21)

ICD-10 G35 Multiple Sclerosis (for claims with DOS from 10/01/2015 forward)

HCPCS drug code- (Box 24D)

J0202 Injection, alemtuzumab 1mg (DOS 01/01/2016 forward)

Narrative- (Box 19) (or electronic equivalent)

NDC- 58468-0200-1 or 58468-0200-01 Single use vial 12mg/1.2 ml (10mg/ml)
Name of Drug (trade and generic)
Dose of drug administered
Route of administration

Note: This drug is supplied in a single use vial that contains 12mg of alemtuzumab. Per Food and Drug Administration (FDA) labeling, the dose of this drug is 12mg per day, therefore claims reflecting administered dosages other than 12mg per DOS or claims reporting wastage or product NDC numbers other than those listed above will be rejected.

Coding Information

CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
J0202 INJECTION, ALEMTUZUMAB, 1 MG

CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

G35

Group 1 Codes

N/A

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

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.

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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.

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Other Coding Information

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/24/2019 R4

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. Under Article Title added a colon after the word “Coding”. Formatting, punctuation and typographical errors were corrected throughout the article.

04/01/2018 R3

Under CPT/HCPCS Group 1: Codes, added HCPCS J0202.

02/26/2018 R2 The Jurisdiction "J" Part A and Part B Contracts for Alabama (10111/10112), Georgia (10211/10212) and Tennessee (10311/10312) are now being serviced by Palmetto GBA. Effective 02/26/18, these 6 contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 6 Part A and B contract numbers) have been completed in this revision.
08/03/2017 R1

Under Article Text second sentence added the word “consecutive” after the number “3”, under Diagnosis-(Box 66) deleted the verbiage “ICD-9 340 Multiple Sclerosis (for claims with DOS from 11/14/2014 to 9/30/2015)”, under HCPCS drug code-(Field 44) deleted the verbiage “C9399 Unclassified drugs or biologics (DOS from 11/14/2014 to 9/30/2015)” and “Q9979 Injection, alemtuzumab 1mg (DOS from 10/01/2015 to 12/31/2015)” under Diagnosis-(Box 21) deleted the verbiage “ICD-9 340 Multiple Sclerosis (for claims with DOS from 11/14/2014 to 9/30/2015)” and under HCPCS drug code-(Box 24D) deleted the verbiage “J3490 Unclassified drugs or J3590 unclassified biologics (DOS from 11/14/2014 to 9/30/2015)” and  “Q9979 Injection, alemtuzumab 1mg (DOS from 10/01/2015 to 12/31/2015)”.

Associated Documents

Related Local Coverage Documents
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Related National Coverage Documents
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Statutory Requirements URLs
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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
10/14/2019 10/24/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Alemtuzumab