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Billing and Coding for PERJETA® (pertuzumab)

  •   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
    Hospital Outpatient: HCPCS C9292 Injection, pertuzumab, 10 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.

     

 

 

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.

 

 

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 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.

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. PERJETA 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...


 

Make sure you have everything you need for an appeal by downloading an Appeals checklist in the Forms and Documents.

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

PERJETA Indication and Important Safety Information

INDICATION

PERJETA® (pertuzumab) is a HER2/neu receptor antagonist indicated for:

  • Treatment of metastatic breast cancer in combination with Herceptin® (trastuzumab) and docetaxel for the treatment of patients with HER2-positive metastatic breast cancer who have not received prior anti-HER2 therapy or chemotherapy for metastatic disease
  • Use in combination with trastuzumab and docetaxel as neoadjuvant treatment of patients with HER2-positive, locally advanced, inflammatory, or early stage breast cancer (either greater than 2 cm in diameter or node positive) as part of a complete treatment regimen for early breast cancer. This indication is based on demonstration of an improvement in pathological complete response rate. No data are available demonstrating improvement in event-free survival or overall survival

Limitations of Use:

  • The safety of PERJETA as part of a doxorubicin-containing regimen has not been established
  • The safety of PERJETA administered for greater than 6 cycles for early breast cancer has not been established

Important Safety Information

Boxed WARNINGS: Cardiomyopathy and Embryo-Fetal Toxicity

  • PERJETA administration can result in subclinical and clinical cardiac failure. Evaluate left ventricular function in all patients prior to and during treatment with PERJETA. Discontinue PERJETA treatment for a confirmed clinically significant decrease in left ventricular function
  • Exposure to PERJETA can result in embryo-fetal death and birth defects. Studies in animals have resulted in oligohydramnios, delayed renal development, and death. Advise patients of these risks and the need for effective contraception

Additional Important Safety Information

  • PERJETA is contraindicated in patients with known hypersensitivity to pertuzumab or to any of its excipients
  • PERJETA has been associated with infusion and hypersensitivity reactions/anaphylaxis
  • Detection of HER2 protein overexpression is necessary for selection of patients appropriate for PERJETA therapy
  • In the treatment of MBC, the most common adverse reactions (>30%) seen with PERJETA in combination with Herceptin and docetaxel were diarrhea, alopecia, neutropenia, nausea, fatigue, rash, and peripheral neuropathy

Most Common Adverse Reactions in Neoadjuvant Treatment of Breast Cancer:

  • The most common adverse reactions (>30%) with PERJETA in combination with trastuzumab and docetaxel were alopecia, diarrhea, nausea, and neutropenia
  • The most common adverse reactions (>30%) with PERJETA in combination with trastuzumab and docetaxel when given for 3 cycles following 3 cycles of FEC were fatigue, alopecia, diarrhea, nausea, vomiting, and neutropenia
  • The most common adverse reactions (>30%) with PERJETA in combination with docetaxel, carboplatin, and trastuzumab (TCH) were fatigue, alopecia, diarrhea, nausea, vomiting, neutropenia, thrombocytopenia, and anemia

You may report side effects to the FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

You may also report side effects to Genentech at 1-888-835-2555

Please see PERJETA full Prescribing Information including Boxed WARNINGS for additional Important Safety Information.

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