Medicare Compliance & Reimbursement

Martha Stewart may be going to prison because she bet against ImClone's new cancer drug Erbitux, but careful coding and documentation can keep physicians out of trouble with billing for this drug.
 
Erbitux is one of two new colorectal cancer drugs that just won Food and Drug Administration approval. The other one, Genetech's Avastin, aims to treat first-line, or previously untreated, colon or rectal cancer. By contrast, Erbitux is designed to treat patients with EGFR-expressing or metastatic colorectal cancer, and particularly ones who are intolerant to irinotecan-based chemotherapy.

Because these are both chemotherapy drugs, physicians should use unlisted code J9999 instead of J3490 to bill for them, says David Davis, medical policy analyst with iHealth Technologies in Atlanta. Also, physicians should supply the name of the drug and the dosage in Box 19 of the paper claim or the comment field of the electronic claim, he adds.

Part B carrier Trailblazer is paying $653 for the 100 mg dose of Avastin, Davis notes.

It's important to have correct ICD-9 diagnosis codes with these drugs, says independent coding consultant Margaret Hickey in New Orleans. With Avastin, Genentech recommends using 153.X (Malignant neoplasm of colon) or 154.X (Malignant neoplasm of rectum, rectosigmoid junction, and anus). Empire Medicare Services says it'll cover Erbitux for 153.0-153.9 and 154.0-154.8.

Erbitux should be administered in combination with Irinotecan or on its own, notes Empire's policy. The first dosage should be 400 mg/m infused over 120 minutes, and the recommended weekly maintenance doses are 250 mg/m infused over 60 minutes, according to Empire. n