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Billing and Coding for Avastin® (bevacizumab)

  •   First- and Second-Line Metastatic Colorectal Cancer
    Type  CodeDescription
    Select Diagnosis: ICD-9-CM* 153.0–153.9 Malignant neoplasm of colon
    154.0 Malignant neoplasm of rectosigmoid junction
    154.1 Malignant neoplasm of rectum
    154.8 Malignant neoplasm of other sites of rectum, rectosigmoid junction, and anus
    Drug: HCPCS J9035 Injection, bevacizumab, 10 mg
    Hospital Outpatient: HCPCS C9257 Injection, bevacizumab, 0.25 mg
    NDC‡§ 10-digit 11-digit  
    50242-060-01 50242-0060-01 100 mg/4 mL single-use vial
    50242-061-01 50242-0061-01 400 mg/16 mL single-use vial
    Select Services, Procedures and Supplies: CPT®|| 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
    96415 Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure)
    96417 Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure)

     

    * International Classification of Diseases, 9th Revision, Clinical Modification.
    Healthcare Common Procedure Coding System.
    National Drug Code.
    § Payer requirements regarding use of a 10-digit or 11-digit NDC may vary. Both formats are listed here for your reference. Avastin Access Solutions provides this information when we perform a benefits investigation (BI) for your patient.
    || Current Procedural Terminology.

     

  •   First-Line Non-Small Cell Lung Cancer
    Type  CodeDESCRIPTION
    Select Diagnosis: ICD-9-CM* 162.2-162.9 Malignant neoplasm of bronchus and lung
    Drug: HCPCS J9035 Injection, bevacizumab, 10 mg
    Hospital Outpatient: HCPCS C9257 Injection, bevacizumab, 0.25 mg
    NDC‡§ 10-digit 11-digit  
    50242-060-01 50242-0060-01 100 mg/4 mL single-use vial
    50242-061-01 50242-0061-01 400 mg/16 mL single-use vial
    Select Services, Procedures and Supplies: CPT®|| 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
    96415 Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure)
    96417 Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure)

     

    * International Classification of Diseases, 9th Revision, Clinical Modification.
    Healthcare Common Procedure Coding System.
    National Drug Code.
    § Payer requirements regarding use of a 10-digit or 11-digit NDC may vary. Both formats are listed here for your reference. Avastin Access Solutions provides this information when we perform a benefits investigation (BI) for your patient.
    || Current Procedural Terminology.

     

  •   Metastatic Renal Cell Carcinoma
    Type  CodeDESCRIPTION
    Select Diagnosis:
    ICD-9-CM*
    189.0 Malignant neoplasm of kidney, except pelvis
    Drug: HCPCS J9035 Injection, bevacizumab, 10 mg
    Hospital Outpatient: HCPCS  C9257 Injection, bevacizumab, 0.25 mg
    NDC‡§ 10-digit 11-digit  
    50242-060-01 50242-0060-01 100 mg/4 mL single-use vial
    50242-061-01 50242-0061-01 400 mg/16 mL single-use vial
    Select Services, Procedures, and Supplies: CPT®|| 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
    96415 Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure)
    96417 Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure)

     

    * International Classification of Diseases, 9th Revision, Clinical Modification.
    Healthcare Common Procedure Coding System.
    National Drug Code.
    § Payer requirements regarding use of a 10-digit or 11-digit NDC may vary. Both formats are listed here for your reference. Avastin Access Solutions provides this information when we perform a benefits investigation (BI) for your patient.
    || Current Procedural Terminology.

     

  •   Glioblastoma With Progressive Disease
    Type  CodeDESCRIPTION
    Select Diagnosis:
    ICD-9-CM*
    191.0–191.9 Malignant neoplasm of brain
    Drug: HCPCS J9035 Injection, bevacizumab, 10 mg
    Hospital Outpatient: HCPCS C9257 Injection, bevacizumab, 0.25 mg
    NDC‡§ 10-digit 11-digit  
    50242-060-01 50242-0060-01 100 mg/4 mL single-use vial
    50242-061-01 50242-0061-01 400 mg/16 mL single-use vial
    Select Services, Procedures and Supplies: CPT®|| 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
    96415 Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure)
    96417 Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure)

     

    * International Classification of Diseases, 9th Revision, Clinical Modification.
    Healthcare Common Procedure Coding System.
    National Drug Code.
    § Payer requirements regarding use of a 10-digit or 11-digit NDC may vary. Both formats are listed here for your reference. Avastin Access Solutions provides this information when we perform a benefits investigation (BI) for your patient.
    || Current Procedural Terminology.

     

 

 

These tables are provided for informational purposes only. Correct coding is the responsibility of the provider submitting the claim for the item or service. Please check with the payer to verify codes and special billing requirements. Genentech does not make any representation or guarantees concerning reimbursement or coverage for any service or item.

 

 

When a physician, hospital or other provider or supplier must discard the remainder of a single-use vial or other single-use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label.

 

 

Regarding billing for unused portions of multi-use vials, please NOTE: Multi-use vials are not subject to payment for discarded amounts of drug or biological.

 

  Please visit CMS.gov or other payers’ websites to obtain additional guidance on their processes related to billing and coding for single-use vials and wastage.
NEXT TOPICAppeals 

Appeals

If your office has prescribed Avastin® (bevacizumab), but your patient’s insurer has denied coverage, you can appeal that decision. Avastin Access Solutions might be able to help you as you resolve the situation. Here is what you can do*:

 

  1. Understand why the request or claim has been denied. This should be in the insurer’s letter of denial or the patient’s Explanation of Benefits (EOB) letter.
  2. Contact Avastin Access Solutions for guidance as you put together an appeal. Use these resources to help you gather the documents and information you need for a successful appeal.
  3. Complete and submit the required forms and documents to the insurer before the appeal deadline. Avastin Access Solutions can provide information about this process.

FAQs

Q: How long does the member or doctor’s office have to file an appeal or grievance?
A: You or your patient may appeal a denial of a benefit or service in writing within a period as short as 15 days or sometimes up to 180 days or more. Check with the insurer to determine its guidelines.

Q: Who is responsible for sending the appeal directly to the patient’s health care plan?
A: The patient or the doctor’s office is responsible for reviewing, approving and sending the appeals package to the insurer.

 

* This description of the appeals process is for informational purposes only. The submission of an appeal is the responsibility of the patient and your office. Avastin Access Solutions makes no representation or guarantee concerning reimbursement or coverage for any service or item. Each health insurer and patient case may require different information. Please review each denial and the health insurer’s guidelines to determine what to include in your patient’s appeal package.

Did you know...

 


 

  • Learn more about the appeals process by downloading our Appeals Tips in Forms and Documents.
  • Make sure you have everything you need for an appeal by downloading an Appeals Checklist in Forms and Documents.

 

Learn More About
Avastin
  • LEARN about treatment with Avastin
  • **Important Information Regarding Counterfeit Drug **
  • LEARN HOW the Genentech BioOncology Co-pay Card can help with the out-of-pocket costs for Avastin
  • Download: new forms for enrollment in GATCF
  • Form Statement of Medical Necessity
  • Form Patient Authorization and Notice of Release of Information

INDICATIONS

Glioblastoma (GBM)
Avastin is indicated for the treatment of glioblastoma as a single agent for adult patients with progressive disease following prior therapy. The effectiveness of Avastin in glioblastoma is based on an improvement in objective response rate. There are no data demonstrating an improvement in disease-related symptoms or increased survival with Avastin.

Metastatic colorectal cancer (MCRC)
Avastin is indicated for the first- or second-line treatment of patients with metastatic carcinoma of the colon or rectum in combination with intravenous 5-fluorouracil–based chemotherapy.

Avastin, in combination with fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy, is indicated for the second-line treatment of patients with metastatic colorectal cancer who have progressed on a first-line Avastin-containing regimen.

Limitation of Use: Avastin is not indicated for adjuvant treatment of colon cancer.

Non-squamous non-small cell lung cancer (NSCLC)
Avastin is indicated for the first-line treatment of unresectable, locally advanced, recurrent or metastatic non–squamous non–small cell lung cancer in combination with carboplatin and paclitaxel.

Metastatic renal cell carcinoma (mRCC)
Avastin is indicated for the treatment of metastatic renal cell carcinoma in combination with interferon alfa.

Boxed WARNINGS

  • Gastrointestinal (GI) perforation

    - Serious and sometimes fatal GI perforation occurs at a higher incidence in Avastin-treated patients compared to controls

    - The incidences of GI perforation ranged from 0.3% to 2.4% across clinical studies

    - Discontinue Avastin in patients with GI perforation

  • Surgery and wound healing complications

    - The incidence of wound healing and surgical complications, including serious and fatal complications, is increased in Avastin-treated patients

    - Do not initiate Avastin for at least 28 days after surgery and until the surgical wound is fully healed. The appropriate interval between termination of Avastin and subsequent elective surgery required to reduce the risks of impaired wound healing/wound dehiscence has not been determined

    - Discontinue Avastin at least 28 days prior to elective surgery and in patients with wound healing complications requiring medical intervention

  • Hemorrhage

    - Severe or fatal hemorrhage, including hemoptysis, GI bleeding, hematemesis, central nervous system hemorrhage, epistaxis, and vaginal bleeding, occurred up to 5-fold more frequently in patients receiving Avastin. Across indications, the incidence of grade ≥3 hemorrhagic events among patients receiving Avastin ranged from 1.2% to 4.6%

    - Do not administer Avastin to patients with serious hemorrhage or recent hemoptysis (≥1/2 tsp of red blood)

    - Discontinue Avastin in patients with serious hemorrhage (ie, requiring medical intervention)

Additional serious adverse events

  • Additional serious and sometimes fatal adverse events with increased incidence in the Avastin-treated arm vs control included

    - Non-GI fistula formation (≤0.3%)

    - Arterial thromboembolic events (grade ≥3, 2.6%)

    - Proteinuria (nephrotic syndrome, <1%)

  • Additional serious adverse events with increased incidence in the Avastin-treated arm vs control included

    - Hypertension (grade 3–4, 5%–18%)

    - Reversible posterior leukoencephalopathy syndrome (RPLS) (<0.1%)

  • Infusion reactions with the first dose of Avastin were uncommon (<3%), and severe reactions occurred in 0.2% of patients
  • Inform females of reproductive potential of the risk of ovarian failure prior to starting treatment with Avastin

Most common adverse events

  • Across indications, the most common adverse reactions observed in Avastin patients at a rate >10% and at least twice the control arm rate were
    - Epistaxis - Proteinuria - Lacrimation disorder
    - Headache - Taste alteration - Back pain
    - Hypertension - Dry skin - Exfoliative dermatitis
    - Rhinitis - Rectal hemorrhage  
  • Across all studies, Avastin was discontinued in 8.4% to 21% of patients because of adverse reactions

Pregnancy warning

  • Avastin may impair fertility
  • Based on animal data, Avastin may cause fetal harm
  • Advise patients of the potential risk to the fetus during and following Avastin and the need to continue adequate contraception for at least 6 months following the last dose of Avastin
  • For nursing mothers, discontinue nursing or Avastin, taking into account the importance of Avastin to the mother

You may report side effects to the FDA at (800) FDA-1088 or www.fda.gov/medwatch.

You may also report side effects to Genentech at (888) 835-2555.

Please see accompanying full Prescribing Information, including Boxed WARNINGS, for additional important safety information.

Avastin® and the Access Solutions logo are registered trademarks of Genentech, Inc.