Billing and Coding: Chemotherapy Administration - R24

This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: October 19, 2020
Summary of Article Changes: The following updates were made with multiple effective dates.

  1. Added J0896-Reblozyl® to the Group 1 list of drugs and Code list and administration code to the Group 2 Paragraph effective 04/03/2020.
  2. Added J9999 (OPPS: C9399) for sacituzumab govitecan-hziy (Trodelvey™), mitomycin (JelMyto™), tafasitamab-cxix (Monjuvi®, romidepsin, non-lypohilized (romidepsin), isatuximab-irfc (Sarclisa®), pertuzumab, trastuzumab, and hyaluronidase-zzxf (Phesgo™) and brexucabtagene autoleucel (Tecartus™) with effective dates and associated administration codes to Group 3 and 4.
  3. Effective for dates of service on or after 10/01/2019, updated the effective date of service for some drugs that erroneously had 01/01/2020.
  4. Effective 10/21/2019 add the following Ulcerative Colitis diagnosis codes for IV Stelara to the Group 1 ICD-10 Codes That Support Medical Necessity that were missed with the last update.
    1. K51.30       Ulcerative (chronic) rectosigmoiditis without complications
    2. K51.311     Ulcerative (chronic) rectosigmoiditis with rectal bleeding
    3. K51.312     Ulcerative (chronic) rectosigmoiditis with intestinal obstruction
    4. K51.313     Ulcerative (chronic) rectosigmoiditis with fistula
    5. K51.314     Ulcerative (chronic) rectosigmoiditis with abscess
    6. K51.318     Ulcerative (chronic) rectosigmoiditis with other complication
    7. K51.319     Ulcerative (chronic) rectosigmoiditis with unspecified complications
    8. K51.50       Left sided colitis without complications
    9. K51.511     Left sided colitis with rectal bleeding
    10. K51.512     Left sided colitis with intestinal obstruction
    11. K51.513     Left sided colitis with fistula
    12. K51.514     Left sided colitis with abscess
    13. K51.518     Left sided colitis with other complication
    14. K51.519     Left sided colitis with unspecified complications
    15. K51.80       Other ulcerative colitis without complications
    16. K51.811     Other ulcerative colitis with rectal bleeding
    17. K51.812     Other ulcerative colitis with intestinal obstruction
    18. K51.813     Other ulcerative colitis with fistula
    19. K51.814     Other ulcerative colitis with abscess
    20. K51.818     Other ulcerative colitis with other complication
    21. K51.819     Other ulcerative colitis with unspecified complications
  5. Effective 01/01/2020, clarified all chemotherapy approved drugs listed in Group 3 and 4 require a chemotherapy administration code to be billed in Group 3 and clarified J9280 is not to be billed for ophthalmological procedures because the dose associated with this J-code is much higher than what is actually administered into the eye in Group 3.
  6. In the ICD-10 Codes That Support Medical Necessity Paragraph 1, clarified the IV push codes 96374 or 96375 should not be billed for the initial infusion of IV Stelara since the FDA label indicates it needs to be administered over at least one hour.

    Added missed approved drug codes to the Group 4 Codes section.
  7. Effective 07/01/2020, added 96446 for Paclitaxel (J9267), 96450 for topotecan (J9351) and 96542 for Herceptin J9355) as an approved off-label administration codes to Group 5 Paragraph section.
  8. Effective 10/01/2020 add J9304 - pemetrexed (Pemfexy™) 10 mg to Group Codes section and added 9409 & 96411 as the administration codes to Group 5 Paragraph section.
  9. Effective 10/19/2020, added the DX codes required to bill with Reblozyl® (J0896) to Group 2 of the ICD-10 Codes That Support Medical Necessity section.

Visit the Noridian Medicare Coverage Articles webpage to access the Future, articles available in the CMS MCD.

            Last Updated Fri, 11 Sep 2020 13:53:10 +0000