Local Coverage Article Billing and Coding

Billing and Coding: Chemotherapy

A56141

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Contractor Information

Article Information

General Information

Article ID
A56141
Article Title
Billing and Coding: Chemotherapy
Article Type
Billing and Coding
Original Effective Date
11/01/2018
Revision Effective Date
11/19/2020
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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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Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

CMS Internet-Only Manual, Pub 100-02, Chapter 15, §50.4.1 Approved Use of Drug and §50.4.5 Off Label Use of Anti-Cancer Drugs and Biologicals

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

 

 

Article Guidance

Article Text

The purpose of this article is to provide billing guidance for chemotherapeutic agents, that are usually billed as “incident to” medications under Part B. This article provides the information which must be included in box 19 of the CMS-1500 Claim Form or the electronic equivalent for Part B or in the remarks field (Field Locator 80) of the CMS- 1450 (UB-04) Claim Form or the electronic equivalent for Part A in order to process the claim.

Palmetto GBA expects that providers identify off-label uses by the use of the “KX” modifier appended to the CPT/HCPCS code for the drug. These off-label uses must be supported by clinical research under the conditions identified in this section. Peer-reviewed medical literature may appear in scientific, medical, and pharmaceutical publications in which original manuscripts are published, only after having been critically reviewed for scientific accuracy, validity, and reliability by unbiased, independent experts prior to publication. In-house publications of entities whose business relates to the manufacture, sale, or distribution of pharmaceutical products are excluded from consideration. Abstracts (including meeting abstracts) are excluded from consideration. Such usages will be subject to review at the discretion of Palmetto GBA. For review of medications under these considerations, please submit full articles, not abstracts, for consideration.

The JW modifier is required for wastage in single dose vials; this modifier does not apply to multidose vials.

This article applies only to those medications that have designated “J” codes. For those medications that have not been provided “J” codes use CPT C9399 using the instructions found in the published article A55913 Correct Billing and Coding for Hospital Outpatient Drugs and Biologicals Under the Outpatient Prospective Payment System (OPPS). For those medications that have not been provided “J” codes and are being billed under Part B use the appropriate NOC code (J9999 Not otherwise classified, antineoplastic drugs; J3490 Unclassified drugs; J3590 Unclassified biologics). Administration coding for these drugs is addressed in the Billing and Coding of Drug and Biological Infusions A55297 article.

It is noted that some drugs have approvals for specific forms of the cancers, such as estrogen receptor positivity in breast cancers. If the approved indications require that level of specificity, it is expected that the coded diagnosis will include the additional codes (Z codes on occasion) that improve the specificity to the level shown in the FDA (or other) approval.

Per the manual, Medicare limits coverage to those indications listed in the FDA label as approved, or in the NCCN Guidelines listing as category 2B or higher or in the additional approved compendia listed in the manual per the rating or recommendation level assigned for each of those compendia. As new agents and indications are approved, general coverage guidelines are found in the CMS Internet-Only Manual, Pub 100-02, Chapter 15, §50.4.1 Approved Use of Drug and § 50.4.5 Off Label Use of Anti-Cancer Drugs and Biologicals. Other off-label indications may be approved as noted above with the KX modifier.

Coding Information

CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

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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
11/19/2020 R10

Revisions were made to the Billing and Coding: Chemotherapy A56141 article. Under Article Text verbiage was added related to specific cancers, such as breast cancer, and applicable coding guidelines. Verbiage was removed from the 7th and 8th paragraphs related to ICD-10 codes and the frequency to article updates. Under Coding Information removed all groups, codes, and verbiage. This information was removed due to developing confusion regarding the requirements for coverage for specific drugs when specific diagnoses were listed.

04/30/2020 R9

Under CPT/HCPCS Codes Group 30: Paragraph for #8 Herceptin Hylecta (trastuzumab and hyaluronidase) changed HCPCS code J9355 to J9356. Under CPT/HCPCS Codes Group 30: Codes added HCPCS code J9356. This revision is retroactive effective for dates of service on or after 7/1/19.

04/30/2020 R8

Under ICD-10 Codes that Support Medical Necessity Group 28: Code added C25.0.

11/07/2019 R7

Under CPT/HCPCS Codes Group 27: Codes deleted HCPCS code C0938 and added J9204. This revision is due to 4th quarter CPT®/HCPCS Code update and is effective on 10/1/2019.

Under CPT/HCPCS Codes Group 10: Codes added HCPCS code J9033. This code is effective on 11/1/2018.

10/31/2019 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. Under CMS National Coverage Policy added regulations. Formatting, punctuation and typographical errors were corrected throughout the article.

08/22/2019 R5

Under Article Title revised the title to remove the word “for”. Under Article Text revised the verbiage to support the purpose of this article. All CPT/HCPCS groups and ICD-10 code groups were re-grouped to correspond with one another. Under CPT/HCPCS Codes Group 10: Codes added HCPCS code J9036. Under CPT/HCPCS Codes Group 20: Paragraph revised the indications for Lutathera® (Lutetium Lu 177 Dotatate). Under Covered ICD-10 Codes Group 28: Codes added ICD-10 code C25.1. Added CPT/HCPCS Codes Group 29: Paragraph and Codes as well as Covered ICD-10 Codes Group 29: Paragraph and Codes for Secondary for Onivyde® (Irinotecan liposome). Added CPT/HCPCS Codes Group 30: Paragraph and Codes to include multiple drugs where no ICD-10 codes have been identified under the Covered ICD-10 Codes section of the article. Indications were revised under CPT/HCPCS Codes Group 30: Paragraph for #5 Keytruda® (Pembrolizumab) J9271 and #11 Tecentriq® (Atezolizumab) J9022. Indications were added under CPT/HCPCS Codes Group 30: Paragraph for #8 Herceptin Hylecta (trastuzumab and hyaluronidase) J9355. Under CPT/HCPCS Codes Group 30: Codes added Q5112, Q5113 and Q5114 for #7 HERCEPTIN® (Trastuzumab) J9355, Q5112, Q5113, Q5114 and J9355 for #8 Herceptin Hylecta (trastuzumab and hyaluronidase) J9355.

This revision becomes effective on 8/22/2019; however, HCPCS codes J9036, J9355, Q5112, Q5113 and Q5114 are effective for dates of service on or after 7/1/19 and were added due to the Q3 CPT/HCPCS Update.

04/18/2019 R4

Under CPT/HCPCS Codes Group 7: Paragraph formatting was corrected to make, “As a first-line, single-agent treatment of metastatic non-small cell lung cancer (NSCLC) in patients with tumors with high PD-L1 expression (tumor proportion score [TPS] ≥50%), as determined by an approved test, and with no EGFR or ALK genomic tumor aberrations” the first bullet point under “Non-small cell lung cancer (metastatic):”

 

03/21/2019 R3

Under CPT/HCPCS Codes Group 11: Paragraph removed “level of” verbiage from the second paragraph.

01/10/2019 R2

Under CPT/HCPCS Codes Group 3: Paragraph-Onivyde® added the third paragraph regarding narrative requirements. This revision becomes effective 01/10/2019.

01/01/2019 R1

Under CPT/HCPCS Codes Group 6: Paragraph- Empliciti® revised the trademark symbol for the drug to be a registered symbol and added the first bullet and sub-bullet. Under CPT/HCPCS Codes Group 7: Paragraph- Keytruda® added the first 3 bullets. Under CPT/HCPCS Codes Group 8: Codes deleted C9492 and J9999 and added HCPCS J9173. Under CPT/HCPCS Codes Group 15: Paragraph- Adcetris® added the first bullet. Under CPT/HCPCS Codes Group 16: Codes- Aliqopa™ deleted C9030 and J9999 and added HCPCS J9057. Under CPT/HCPCS Codes Group 20: Codes- Besponsa® deleted C9028 and added HCPCS J9229. Under CPT/HCPCS Codes Group 30: Codes- Lutathera® deleted C9031 and added HCPCS A9513. Under CPT/HCPCS Codes Group 31: Paragraph- Opdivo® added the last sentence regarding narrative inclusions. Under CPT/HCPCS Codes Group 35: Paragraph- Vyxeos® revised the trademark symbol for the drug to be a registered symbol and under CPT/HCPCS Codes Group 35: deleted C9024 and J9999 and added HCPCS J9153. Under CPT/HCPCS Codes added Group 38: Paragraph and Codes- Velcade® and Group 39: Paragraph and Codes- Poteligeo. Under Covered ICD-10 Codes Group 5: Paragraph- Empliciti® revised the trademark symbol for the drug to be a registered symbol. Under Covered ICD-10 Codes Group 8: Paragraph- Adcetris® added ICD-10 codes C84.60- C84.69. Under Covered ICD-10 Codes Group 12: Paragraph-Bendeka® added ICD-10 codes C82.00- C82.99, C83.10-C83.19, and C88.4. Under Covered ICD-10 Codes added Group 28- Velcade® and Group 29- Poteligeo ICD-10 Codes. This revision is due to the Annual CPT/HCPCS Code Update.

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
11/12/2020 11/19/2020 - N/A Currently in Effect You are here
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Keywords

  • Chemotherapy