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| Reimbursement | Coding Information |
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| TRISENOX® (arsenic trioxide) Injection Reimbursement Reference Guide |
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This coding reference information is intended to be a guide for answering questions regarding TRISENOX® and related services. It is not intended to be a directive, nor does the use of these codes guarantee reimbursement.
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HCPCS
| J9017 |
Arsenic trioxide, 1 mg
Determine if the patient’s payor requires a local code or payor-specific code and use the required or payor-specific code rather than the Level II HCPCS J-Code.
Use the appropriate HCPCS code(s) for other medications that may be administered before, during, or after TRISENOX® administration.
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ICD-9-CM (Diagnosis codes)*
| V58.1 |
Admission or encounter for chemotherapy
This is the code for principal diagnosis; APL is identified with a secondary diagnosis code, 205.00 or 205.01
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| 205.00 |
Myeloid leukemia, acute; promyelocytic leukemia, acute: without mention of remission
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| 205.01 |
Myeloid leukemia, acute; promyelocytic leukemia, acute: in remission
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*Also, code other conditions or co-morbidities
ICD-9-CM (Procedure codes)
| 99.25 |
Injection or infusion of cancer chemotherapeutic substance
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CPT Codes
| 96410† (Effective 1/1/06, use 96413) |
Chemotherapy administration, intravenous; infusion technique, up to 1 hour
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| 96412† (Effective 1/1/06, use 96415) |
Chemotherapy administration, intravenous; infusion technique, each additional hour
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| Effective 1/1/06 |
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| 96413† |
Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
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| 96415† |
Each additional hour, 1 to 8 hours (list separately in addition to code for primary procedure)
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| 96417† |
Each additional sequential infusion (different substance/drug), up to 1 hour (list separately in addition to code for primary procedure)
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†Use only for payor plans that do not use Q0084/Q0085 for chemotherapy infusion (see below)
Medicare Claims
| Q0084 |
Chemotherapy administration by infusion technique only, per visit
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| Q0085 |
Chemotherapy administration by both infusion technique and other technique, per visit
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Revenue Code
| 636 |
Drugs requiring detailed coding
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| 250 |
General pharmacy (non-Medicare payors)
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Expected APC (Medicare)
| 0117 |
Chemotherapy by infusion
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NDC Number
| 63459-600-10 |
TRISENOX® (arsenic trioxide) injection
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| Strength/Size |
10 mg/mL (1 mg/mL) ampule
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| Unit of Sale |
1 carton containing 10 ampules
(10 mg/10 mL ampule)
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TRISENOX® is indicated for induction of remission and consolidation in patients with APL who are refractory to, or have relapsed from, retinoid and anthracycline chemotherapy, and whose APL is characterized by the presence of the t(15;17) translocation or PML/RAR-alpha gene expression.
Please see Prescribing Information and Safety Information, including BOXED WARNING.
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Claim forms have codes that identify three key components of an infusion session:
- Patient diagnosis
- Administration services provided
- Specific drugs adminstered to the patient
The patient's medical record must support the conditions that justify the use of TRISENOX®.
The International Classification of Diseases, Ninth Revision (ICD-9) coding system describes patient conditions. In the context of administering an injectable oncologic, the ICD-9 code identifies the specific indication that the drug is being used to treat.
For TRISENOX® (arsenic trioxide) injection, use the V58.1 ICD-9-CM code as the principal diagnosis. The condition for which chemotherapy is required, APL, will be identified with ICD-9-CM code 205.00 or 205.01 as the secondary diagnosis code.
- V58.1 — Admission or encounter for chemotherapy
- 205.00 — Myeloid leukemia, acute; promyelocytic leukemia, acute: without mention of remission
- 205.01 — Myeloid leukemia, acute; promyelocytic leukemia, acute: in remission
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Also, code other conditions or co-morbidities.
The Centers for Medicare and Medicaid Services (CMS), formerly known as Health Care Financing Administration (HCFA), determine procedure codes. Procedure codes are called Healthcare Common Procedure Coding System (HCPCS), pronounced “hick picks”.
There are three levels of HCPCS codes (Ingenix 2003 HCPCS II Expert, St. Anthony’s/Medicode, 2002):
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LEVEL I
The American Medical Association (AMA) Current Procedural Terminology (CPT) Codes: 5-digit codes that describe procedures provided by physicians.
- 96410 — Chemotherapy administration, intravenous; infusion technique, up to 1 hour (effective 1/1/06, use 96413)
- 96412 — Chemotherapy administration, intravenous; infusion technique, each additional hour (effective 1/1/06, use 96415)
Effective 1/1/2006 (Ingenix 2006 CPT (Current Procedural Terminology) Expert):
- 96413 — Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
- 96415 — Each additional hour, 1 to 8 hours (list separately in addition to code for primary procedure)
- 96417 — Each additional sequential infusion (different substance/drug), up to 1 hour (list separately in addition to code for primary procedure)
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LEVEL II
HCPCS National Codes: Codes, consisting of one alphabetic character (between A and V) followed by 4 numbers, grouped by type of service or supply are required for most medical procedures and supplies by public and private payors.
J-Codes — Drugs administered other than by oral method.
J9017 — arsenic trioxide, 1 mg
Q Codes — For Medicare claims only. These codes are used to identify professional healthcare procedures and services that would otherwise be coded in CPT but for which there are no CPT codes. These are temporary codes.
Q0084 — Chemotherapy administration by infusion technique only, per visit (Medicare)
Q0085 — Chemotherapy by both infusion technique and other technique, per visit (Medicare)
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LEVEL III
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Local Codes: Codes, consisting of one alphabetic character (between W and Z), assigned and maintained by individual state Medicare carriers (codes may not be common to all carriers).
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Note: These codes are not all inclusive. Commercial payors as well as Medicare and Medicaid may choose to create their own temporary codes. This guide is provided for informational purposes only. Correct coding is the responsibility of the provider submitting a claim for the item or service. Please check with the payor to verify codes and special billing requirements. Cephalon does not make any representation or guarantees concerning reimbursement or coverage for any service or item.
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