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Our Services Reimbursement

Billing and Coding for PERJETA® (pertuzumab)

 

 

This table is 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.

 

 

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.

 

  •   Breast Cancer
    Type  CodeDescription
    Select Diagnosis:
    ICD-9-CM*
    174.0 – 174.9 Malignant neoplasm of female breast
    175.0, 175.9 Malignant neoplasm of male breast
    Drug: HCPCS J9306 Injection, pertuzumab, 1 mg
    NDC‡§ 10-digit: 11-digit:  
    50242-145-01 50242-0145-01 420 mg/14 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. PERJETA Access Solutions provides this information when we perform a benefits investigation (BI) for your patient.
    || Current Procedural Terminology.

     

 

NEXT TOPICAppeals 

Appeals

If your office has prescribed PERJETA, but your patient’s insurer has denied coverage, you can appeal that decision. PERJETA 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 PERJETA 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. PERJETA Access Solutions can provide information about this process.
Below are some helpful files for handling common issues in denials. Download will occur automatically on selection.

  

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