Part B Insider (Multispecialty) Coding Alert

Use J9999 to bill for Avastin and Erbitux,  but document carefully

Martha Stewart may be going to prison because she bet against ImClone's new cancer drug Erbitux, but careful coding and documentation can keep you 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, you should use unlisted code J9999 instead of HCPCS J3490 to bill for them, says David Davis, medical policy analyst with iHealth Technologies in Atlanta. Also, you 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. And you should bill 94610 (up to one hour) and 94612 (one to eight hours) for the chemotherapy administration with these drugs.

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.

To her knowledge, Hickey says, providers haven't been able to get their hands on either drug yet. And it'll probably take some time for both drugs to be listed in all the books governing drug usage and coverage.

If you need help obtaining coverage for Avastin, you can use the Single Point of Contact (SPOC online) Web site set up by the manufacturer at www.spoconline.com/spoconline/avastin/resourceCenter/coding.jsp. You can enroll your patients with the site, look up coding information and find help filling out forms.