Coding Guide | TRISENOX®

Injection Reimbursement Reference Guide

In the Physician Office Setting Most third-party payers, including Medicare, state Medicaid plans, managed care organizations, indemnity plans and others, provide coverage for TRISENOX. Claims Submission Physicians submit a CMS-1500 (08-05) claim form or its electronic equivalent for TRISENOX to the appropriate Medicare Administrative Contractor (MAC), Carrier or non-Medicare payer. Physicians report various codes on the claim form to indicate the medical necessity for TRISENOX and its administration in order to receive proper payment from payers. Place of Service Place of Service (POS) 11 indicates the services were provided in an office. POS is reported in Item 24B Place of Service on the CMS-1500 claim form. Diagnosis Code(s) All payers recognize International Classification of Drugs, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes to indicate the medical necessity for TRISENOX. Payers may delay processing, deny, or reject claims without valid diagnoses, requiring the physician to complete and resubmit a corrected claim. The physician must list an appropriate diagnosis code for TRISENOX in Item 21 Diagnosis or Nature of Illness or Injury of the CMS-1500 claim form and then link the diagnosis to Item 24-E Diagnosis Pointer of the corresponding line. TRISENOX is indicated for induction of remission and consolidation in patients with acute promyelocytic leukemia (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/RARalpha gene expression. Please see inside front cover for important safety information and full BOXED WARNING for Trisenox. Please see accompanying Prescribing Information, including BOXED WARNING, on inside back cover. ICD-9-CM Code (Acute Promyelocytic Leukemia) CMS-1500 Location 205.00-205.02 Myeloid leukemia, acute (Acute Promyelocytic Leukemia) Item 21 and 24E ICD-9-CM Code (Encounter for Chemotherapy) CMS-1500 Location V58.11 Encounter for chemotherapy Item 21 and 24E   The primary diagnosis for relapsed/refractory APL is reported with an ICD-9 CM code in the 205.00-205.02 range. Depending on your MAC, Carrier or other payer, ICD-9-CM code V58.11 may be required as a secondary diagnosis code when TRISENOX is administered at the encounter for chemotherapy. TRISENOX Drug Code Healthcare Common Procedure Coding System (HCPCS) Level 2 codes are used to report drugs. TRISENOX is reported with a specific HCPCS J-code, J9017, in Item 24 D Procedures, Services or Supplies CPT/HCPCS of the CMS-1500. HCPCS CMS-1500 Location J9017 Arsenic trioxide, 1 mg Item 24D   HCPCS code J9017 has a specific value of 1mg that represents part of a TRISENOX vial. Providers must report multiple units on the claim form to report an entire vial of TRISENOX. For example, usage of a 10 mg Single Use Vial (SUV) of TRISENOX is reported with 10 units in Item 24G Days or Units. It is important to report on the CMS-1500 all of the drug that was used including amount of TRISENOX administered and discarded since most payers will reimburse for the amount of drug administered and wasted. The medical record documentation should include: Number of single use vials of TRISENOX purchased Amount of drug administered Amount of drug discarded Reason why it was discarded, e.g., partial drug from an SUV was required Some payers require drugs be reported by National Drug Code (NDC) that is specific to manufacturer, dose/strength, and package size. Depending on the payer, the (11-digit) NDC may be reported in either "Comment" field Item 19 Reserved for Local Use or Item 24 D Procedures, Services or Supplies CPT/HCPCS of the CMS-1500. NDC CMS-1500 Location 63459-0600-10 Arsenic trioxide, 10 mg / 10 ml (1 mg / 1 ml) ampule, 10s Item 19 or 24D   TRISENOX Administration Code Healthcare Common Procedure Coding System (HCPCS) Level 1 codes, more commonly known as Current Procedural Terminology (CPT) codes are used to report the administration of TRISENOX. Based on the FDA approved method of administration for TRISENOX, physicians must list an appropriate CPT code for the Intravenous (IV) infusion in Item 24 D Procedures, Services or Supplies of the CMS-1500 claim form. CPT Administration Codes CMS-1500 Location 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug Item 24D 96415 Chemotherapy administration, intravenous infusion technique; each additional hour 96417 Each additional sequential infusion (different substance/drug), up to 1 hour (list separately in addition to code for primary procedure)   Per prescribing information, TRISENOX is administered via IV infusion over 1-2 hours and can be extended to 4 hours if acute vasomotor reactions are observed. Per CPT code guidelines, an IV infusion lasting greater than 15 minutes and up to 90 minutes is reported with one unit (Item 24E) of CPT code 96413 (Item 24D). An IV infusion lasting 91 minutes or longer may be reported with one unit of CPT code 96413 and one (or more units) of 96415. Medical justification for IV infusion times for TRISENOX should be clearly documented in the medical record with start and stop times. TRISENOX Reimbursement Expertise – TRISENOX Reimbursement Expertise is a reimbursement resource for healthcare providers and patients. It provides a support program, and online tools and resources to help make it easier to understand reimbursement information. You can get information on the website www.CephalonOncologyCore.com, or call the Hotline toll-free at 1-888-587-3263. The program provides personalized support with the following: Billing issues Insurance policy benefits Coverage requirements Appeals of coverage denials This guide is provided for informational purposes only and is not intended to be an all inclusive list. You are responsible for the accuracy of any claims, invoices, and related documentation submitted to payers. Please contact the payer and consult source documents to verify codes and billing requirements. Cephalon Oncology does not guarantee success in obtaining insurance payments. In the Hospital Outpatient Department Setting Most third-party payers, including Medicare, state Medicaid plans, managed care organizations, indemnity plans and others, provide coverage for TRISENOX. Claims Submission Hospital Outpatient Department (HOPD) facilities submit a CMS-1450 (also known as Universal Billing form or UB-04) claim form or its electronic equivalent for TRISENOX to the appropriate Medicare Administrative Contractor (MAC), Fiscal Intermediary (FI) or non-Medicare payer. HOPD providers report various codes to indicate the medical necessity for TRISENOX and its administration on the claim form to receive proper payment from payers. Bill Type Hospitals report the type of care provided and the sequence of the claim in a particular episode of care (also referred to as a “frequency” code) with four-digit Type of Bill codes. The first digit is always a leading “zero.” The second digit identifies the type of facility, e.g. Hospital 1. The third digit identifies the bill classification, e.g., Outpatient 3. The fourth digit identifies the frequency code. This code is reported in Field 4 TYPE of BILL on the CMS-1450 claim form. Bill Type CMS-1450 Location 013X Hospital Outpatient Field 4   Diagnosis Code(s) All payers recognize International Classification of Drugs, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes to indicate the medical necessity for TRISENOX. Payers may delay processing, deny, or reject claims without valid diagnoses, requiring the HOPD to complete and resubmit a corrected claim. The HOPD must list an appropriate diagnosis code for TRISENOX in Field 66-67 DX (Diagnosis) of the CMS-1450 claim form. Codes are selected based on the diagnosis documented in the patient’s medical record. TRISENOX is indicated for induction of remission and consolidation in patients with acute promyelocytic leukemia (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/RARalpha gene expression. Please see inside front cover for important safety information and full BOXED WARNING for Trisenox. Please see accompanying Prescribing Information, including BOXED WARNING, on inside back cover. ICD-9-CM Code (Acute Promyelocytic Leukemia) CMS-1500 Location 205.00-205.02 Myeloid leukemia, acute (Acute Promyelocytic Leukemia) Item 21 and 24E ICD-9-CM Code (Encounter for Chemotherapy) CMS-1500 Location V58.11 Encounter for chemotherapy Item 21 and 24E     The primary diagnosis for relapsed/refractory APL is reported with an ICD-9 code in the 205.00-205.02 range. Depending on your MAC, Fiscal Intermediary or other payer, ICD-9-CM code V58.11 may be required as a secondary diagnosis code when TRISENOX is administered at the encounter for chemotherapy. TRISENOX Drug Code Healthcare Common Procedure Coding System (HCPCS) Level 2 codes are used to report drugs. TRISENOX is reported with a specific HCPCS J-code, J9017, in Field 44 HCPCS/RATE/HIPPS Code of the CMS-1450 claim form. HCPCS CMS-1450 Location J9017 Arsenic trioxide, 1 mg Field 44   HCPCS code J9017 has a specific unit value of 1mg which represents part of a vial of TRISENOX. Providers will need to report multiple units of J9017 to indicate the use of an entire vial of TRISENOX. For example, usage of a 10 mg Single Use Vial (SUV) of TRISENOX is reported with 10 units in Field 46 SERV. UNITS. It is important to report on the CMS-1450 all of the drug that was used including the total amount of TRISENOX administered and discarded since most payers will reimburse for the amount of drug administered and wasted. The medical record documentation should include: Number of single use vials of TRISENOX purchased Amount of drug administered Amount of drug discarded Reason why it was discarded, e.g., partial drug from an SUV was required Some payers require drugs be reported by National Drug Code (NDC) that is specific to manufacturer, dose/strength, and package size. Depending on the payer, the (11-digit) NDC may be reported in either "Comment" field Item 19 Reserved for Local Use or Item 24 D Procedures, Services or Supplies CPT/HCPCS of the CMS-1500. NDC CMS-1500 Location 63459-0600-10 Arsenic trioxide, 10 mg / 10 ml (1 mg / 1 ml) ampule, 10s Item 19 or 24D   TRISENOX Administration Code Healthcare Common Procedure Coding System (HCPCS) Level 1 codes, more commonly known as Current Procedural Terminology (CPT) codes are used to report the administration of TRISENOX. Based on the FDA approved method of administration for TRISENOX, the HOPD must list an appropriate CPT code for the Intravenous (IV) infusion in Field 44 PROCEDURE or SERVICE of the CMS-1450 claim form. CPT Administration Codes CMS-1450 Location 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug Field 44 96415 Chemotherapy administration, intravenous infusion technique; each additional hour 96417 Each additional sequential infusion (different substance/drug), up to 1 hour (list separately in addition to code for primary procedure)   Per prescribing information, TRISENOX is administered via IV infusion over 1-2 hours and can be extended to 4 hours if acute vasomotor reactions are observed. Per CPT code guidelines, an IV infusion lasting greater than 15 minutes and up to 90 minutes is reported with one unit (Field 46) of CPT code 96413 (Field 44). An IV infusion lasting 91 minutes or longer may be reported with one unit of CPT code 96413 and one (or more units) of 96415. Medical justification for IV infusion times for TRISENOX should be clearly documented in the medical record with start and stop times. Although typically reserved for inpatient hospital services, some payers require the administration of TRISENOX be reported with an ICD-9-CM Procedure code in addition to a CPT code. An ICD-9-CM Procedure code is reported in Field 74 PRINCIPAL PROCEDURE or 74a – 74e OTHER PROCEDURE of the CMS-1450 claim form. ICD-9-CM CMS-1450 Location 99.25 Injection or infusion of cancer chemotherapeutic substance Field 74, 74a-74e   Revenue Codes The HOPD is required to indicate a Revenue Code in Field 42 REV. CD. and Revenue Code description in Field 43 DESCRIPTION. Revenue codes identify a specific accommodation (where a service was performed) and/or ancillary charge (the actual service performed).   CPT CMS-1450 Location J9017 | Rev Code: 0636 Drugs Requiring Detailed Coding Field 42,43 96413 | Rev Code: 0636 Drugs Requiring Detailed Coding 96415 | Rev Code: 0335 Chemotherapy Infusion   This guide is provided for informational purposes only and is not intended to be an all inclusive list. You are responsible for the accuracy of any claims, invoices, and related documentation submitted to payers. Please contact the payer and consult source documents to verify codes and billing requirements. Cephalon Oncology does not guarantee success in obtaining insurance payments.   Revision Date: 9/22/2009