Medications Used for Supportive Treatment ONCOLOGY DRUG CODES
The following sections include: • Associated ICD-9-CM codes used for the classification of supportive therapies • Drugs that have been FDA-approved in the prevention of chemotherapy-induced nausea and vomiting and neutropenia. Please note: if a check mark appears in the FDA column it will NOT appear in the Compendia section even if a drug is included in the NCCN (National Comprehensive Cancer Network) Drugs & Biologics Compendium • Drugs included in the NCCN Drugs & Biologics Compendium for off-label use in chemotherapy-induced nausea and vomiting and neutropenia. NCCN is recognized by the Centers for Medicare & Medicaid Services (CMS) as a referencing source • Corresponding HCPCS/CPT codes and code descriptions • Current Code Price (AWP-based pricing) • Most recent ASP plus 6% (Medicare allowable) • Possible CPT Administration Codes for each medication.
787 Symptoms involving digestive system Excludes: constipation (564.00-564.09) pylorospasm (537.81) congenital (750.5) 787.0 Nausea and vomiting Emesis Excludes: hematemesis, not otherwise specified (578.0) vomiting: bilious, following gastrointestinal surgery (564.3) cyclical (536.2) associated with migraine (346.2) psychogenic (306.4) excessive, in pregnancy (643.0-643.9) habit (536.2) of newborn (779.3) psychogenic, not otherwise specified (307.54) 787.01 Nausea with vomiting 787.02 Nausea alone 787.03 Vomiting alone
FDAapproved for prevention of nausea and vomiting
Generic (brand) name
HCPCS code: code description
Aprepitant (Emend) alprazolam (Xanax)
J8501: oral, aprepitant, 5 mg J8499a: oral, prescription drug, nonchemotherapeutic, not otherwise specified J8540: oral, dexamethasone, 0.25 mg J1100: injection, dexamethasone sodium phosphate, 1 mg J1200: injection, diphenhydramine HCl, up to 50 mg J8499a: oral, prescription drug, nonchemotherapeutic, not otherwise specified Q0163: oral, diphenhydramine HCl, 50 mgb J1260: injection, dolasetron mesylate, 10 mg Q0180: oral, dolasetron mesylate, 100 mgc S0174: oral, dolasetron mesylate, 50 mg (for circumstances falling under the Medicare statute, use Q0180) Q0167: oral, dronabinol, 2.5 mgb Q0168: oral, dronabinol, 5 mgb J1453: injection, fosaprepitant, 1 mg
dexamethasone (Decadron) dexamethasone sodium phosphate diphenhydramine (Benadryl) diphenhydramine (Benadryl) diphenhydramine (Benadryl) dolasetron mesylate (Anzemet) dolasetron mesylate (Anzemet) dolasetron mesylate (Anzemet)
dronabinol (Marinol) dronabinol (Marinol) fosaprepitant (Emend)
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Associated ICD-9-CM Codes Used for the Prevention of Chemotherapy-induced Nausea and Vomiting
G REEN H ILL H EALTHCARE C OMMUNICATIONS
NCCN Drugs & Biologics Compendium off-label use for prevention of nausea and vomiting
Current code price (AWPbased pricing), effective 10/1/09
Medicare allowable (ASP + 6%), effective 10/1/09-12/31/09
CPT administration codes
$6.59
$5.52
N/A
NDC level pricing $0.38
N/A
✓
NDC level pricing $0.09
✓
$0.15
$0.08
96372, 96374
✓
$1.13
$0.86
96372, 96374
✓
NDC level pricing $0.05
NDC level pricing $0.02
N/A
✓
$4.68
$4.41
96374
✓
$76.24
$58.40
N/A
✓
$57.52
S0174: not payable by Medicare
N/A
✓
$5.89
$6.80
N/A
✓
$12.26
$13.57
N/A
✓
$1.88
$1.58
✓
✓
✓
N/A
N/A
96374, 96375
September/October 2009
HCPCS code: code description
granisetron (Kytril) granisetron (Kytril, Granisol) granisetron (Kytril, Granisol)
J1626: injection, granisetron HCl, 100 μg Q0166: oral, granisetron HCl, 1 mgc S0091: granisetron HCl, 1 mg (for circumstances falling under the Medicare statute, use Q0166) J3490a: unclassified drugs
granisetron (Sancuso) haloperidol (Haldol) haloperidol (Haldol) lorazepam (Ativan) lorazepam (Ativan) metoclopramide (Reglan) metoclopramide (Reglan) nabilone (Cesamet) olanzapine (Zyprexa) ondansetron (Zofran) ondansetron (Zofran) ondansetron (Zofran)
palonosetron (Aloxi) prochlorperazine maleate (Compazine) prochlorperazine maleate (Compazine) prochlorperazine maleate (Compazine) prochlorperazine maleate (Compazine) prochlorperazine maleate (Compazine)
promethazine (Phenergan)
J1630: injection, haloperidol, up to 5 mg J8499a: oral, prescription drug, nonchemotherapeutic, not otherwise specified J2060: injection, lorazepam, 2 mg J8499a: oral, prescription drug, nonchemotherapeutic, not otherwise specified J2765: injection, metoclopramide HCl, up to 10 mg J8499a: oral, prescription drug, nonchemotherapeutic, not otherwise specified J8650: oral, nabilone, 1 mg J8499a: oral, prescription drug, nonchemotherapeutic, not otherwise specified J2405: injection, ondansetron HCl, per 1 mg Q0179: oral, ondansetron HCl, 8 mgb S0181: oral, ondansetron HCl, 4 mg (for circumstances falling under the Medicare statute, use Q0179) J2469: injection, palonosetron HCl, 25 μg J0780: injection, prochlorperazine, up to 10 mg J8499a: oral, prescription drug, nonchemotherapeutic, not otherwise specified Q0164: oral, prochlorperazine maleate, 5 mgb Q0165: oral, prochlorperazine maleate, 10 mgb S0183: oral, prochlorperazine maleate, 5 mg (for circumstances falling under the Medicare statute, use Q0164-Q0165) J2550: injection, promethazine HCl, up to 50 mg
September/October 2009
NCCN Drugs & Biologics Compendium off-label use for prevention of nausea and vomiting
Current code price (AWPbased pricing), effective 10/1/09
Medicare allowable (ASP + 6%), effective 10/1/09-12/31/09
CPT administration codes
✓
$10.61
$2.00
96374
✓
$58.95
$7.08
N/A
✓
$58.95
S0091: not payable by Medicare
N/A
✓
NDC level pricing $7.04
NDC level pricing $1.63
N/A
NDC level pricing $1.01
NDC level pricing $0.80
NDC level pricing $0.37
NDC level pricing $0.35
NDC level pricing $19.20
NDC level pricing None listed
✓
NDC level pricing $0.60
NDC level pricing $0.25
✓
$39.36
$10.42
N/A
✓
$24.20
S0181: not payable by Medicare
N/A
✓
$41.04
$17.52
✓
$3.30
$2.11
✓
✓
NDC level pricing $0.59
NDC level pricing $0.04
N/A
✓
$0.89
$0.05
N/A
✓
$0.59
S0183: not payable by Medicare
N/A
✓
$2.22
$1.60
✓
✓
✓
✓
✓
✓
✓
✓
ONCOLOGY DRUG CODES
DRUG CODES
Generic (brand) name
FDAapproved for prevention of nausea and vomiting
96372 N/A N/A 96365, 96366, 96372, 96374 N/A
96372, 96374 N/A
N/A N/A
96372, 96374
96374 96372, 96374 N/A
96372, 96374
G REEN H ILL H EALTHCARE C OMMUNICATIONS
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ONCOLOGY DRUG CODES
Generic (brand) name
HCPCS code: code description
promethazine (Phenergan)
J8499a: oral, prescription drug, nonchemotherapeutic, not otherwise specified Q0169: oral, promethazine HCl, 12.5 mgb Q0170: oral, promethazine HCl, 25 mgb
promethazine (Phenergan) promethazine (Phenergan)
FDAapproved for prevention of nausea and vomiting
NCCN Drugs & Biologics Compendium off-label use for prevention of nausea and vomiting
Current code price (AWPbased pricing), effective 10/1/09
Medicare allowable (ASP + 6%), effective 10/1/09-12/31/09
CPT administration codes
✓
NDC level pricing $0.49
NDC level pricing $0.43
N/A
✓
$0.51
$0.15
N/A
✓
N/A
Associated ICD-9-CM Codes Used for the Prevention of Chemotherapy-induced Neutropenia 288 Diseases of white blood cells Excludes: leukemia (204.0-208.9) 288.03 Drug-induced neutropenia Use additional E code to identify drug E933 Primary systemic agents E933.1 Antineoplastic and immunosuppressive drugs Examples: azathioprine busulfan chlorambucil cyclophosphamide cytarabine fluorouracil mechlorethamine hcl mercaptopurine thiotepa Excludes: antineoplastic antibiotics (E930.7) E930.7 Antineoplastic antibiotics Actinomycins Examples: bleomycin dactinomycin daunorubicin mitomycin Excludes: other antineoplastic drugs (E933.1)
Generic (brand) name
HCPCS code: code description
filgrastim (Neupogen) filgrastim (Neupogen) pegfilgrastim (Neulasta) sargramostim (Leukine)
J1440: injection, filgrastim (G-CSF), 300 g J1441: injection, filgrastim (G-CSF), 480 g J2505: injection, pegfilgrastim, 6 mg J2820: injection, sargramostim (GM-CSF), 50 μg
FDAapproved for neutropenia
NCCN Drugs & Biologics Compendium off-label use for neutropenia
Current code price (AWPbased pricing), effective 10/1/09
Medicare allowable (ASP + 6%), effective 10/1/09-12/31/09
CPT administration codes
✓
$267.24
$212.55
✓
$425.58
$330.68
✓
$3762.00
$2264.81
96365, 96366, 96369, 96370, 96372, 96374 96365, 96366, 96369, 96370, 96372, 96374 96372
✓
$39.60
$23.75
96365, 96366, 96372
a
When billing a nonclassified medication using a CMS 1500 claim form you must include both the HCPCS code (ie, J3490 for Sancuso) in Column 24D and the drug name, strength, and National Drug Code (NDC) in Box 19 in order to ensure appropriate reimbursement. b FDA-approved prescription antiemetic, for use as a complete therapeutic substitute for an intravenous antiemetic at time of chemotherapy treatment, not to exceed a 48-hour dosage regimen. c
FDA-approved prescription antiemetic, for use as a complete therapeutic substitute for an intravenous antiemetic at time of chemotherapy treatment, not to exceed a 24-hour dosage regimen. References • HCPCS Level II Expert, 2009 • CPT 2009; 2008 • ICD-9-CM for Professionals Volumes 1 & 2; 2009 • The Drug Reimbursement Coding and Pricing Guide, Vol 6, No 4; RJ Health Systems International LLC; 4th Quarter 2009 • FDA-approved indication (from products’ prescribing information) • NCCN • National Cancer Institute • www.ReimbursementCodes.com powered by RJ Health Systems International, LLC, Wethersfield, Connecticut • CMSMedicare allowable 4th Quarter 2009 (effective dates 10/1/09-12/31/09). Prices listed herein are effective as of October 1, 2009. ASP indicates average sales price; AWP, average wholesale price; CMS, Centers for Medicare & Medicaid Services; CPT, Current Procedural Terminology; FDA, US Food and Drug Administration; G-CSF, granulocyte-colony stimulating factor; GM-CSF, granulocyte macrophage-colony stimulating factor; HCPCS, Healthcare Common Procedure Coding System; NCCN, National Comprehensive Cancer Network.
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G REEN H ILL H EALTHCARE C OMMUNICATIONS
September/October 2009