Neurology & Pain Management Coding Alert

Question: I can’t find a code for the migraine medication Maxalt, aka Rizatriptan Benzoate, as a 10 mg tablet. What HCPCS code should we report for this?

Nevada Subscriber 

Answer:  Your best option might be J8499 (Prescription drug, oral, non chemotherapeutic, NOS). However, know that Medicare and possibly other payers may not cover this oral drug when administered in the physician office. As the Medicare Benefit Policy Manual states, “The Medicare program provides limited benefits for outpatient drugs. The program covers drugs that are furnished ‘incident to’ a physician’s service provided that the drugs are not usually self-administered by the patients who take them. … the term ‘usually’ means more than 50 percent of the time for all Medicare beneficiaries who use the drug. Therefore, if a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage and the contractor may not make any Medicare payment for it.” 

Rizatriptan benzoate is a self-administered oral prescription drug indicated for the acute treatment of migraine with or without aura in adults and in pediatric patients 6 to 17 years of age. Because of this, it falls under Medicare’s self-administered drug non-payment classification.