Reimbursement

ACTEMRA Sample Coding

This coding information may assist you as you complete the payer forms for ACTEMRA. These tables are provided for informational purposes only. 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.

You can generate a PDF of these coding tables by selecting either the "Download All" or the "Download Section" button:

  • "Download All" lets you download or print a coding table for all indications
  • "Download Section" lets you download or print a coding table for a specific indication
TYPE CODE DESCRIPTION
Diagnosis: ICD-10-CM M05.60—M05.69 Rheumatoid arthritis with involvement of other organs and systems
M05.70—M05.79 Rheumatoid arthritis with rheumatoid factor without organ or systems involvement
M06.00—M06.09 Rheumatoid arthritis without rheumatoid factor
M06.9 Rheumatoid arthritis, unspecified
M08.20—M08.29 Juvenile rheumatoid arthritis with systemic onset
M08.3 Juvenile rheumatoid polyarthritis (seronegative)
Drug: HCPCS J3262 Injection, tocilizumab, 1 mg
Drug: NDC
Note: Payer requirements regarding use of a 10-digit or 11-digit NDC may vary. Both formats are listed here for your reference.
10-digit 11-digit  
50242-135-01 50242-0135-01 80 mg (4 mL) single-use vial
50242-136-01 50242-0136-01 200 mg (10 mL) single-use vial
50242-137-01 50242-0137-01 400 mg (20 mL) single-use vial
Administration procedures: CPT 96365 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); initial, up to 1 hour
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug

CPT=Current Procedural Terminology.
HCPCS=Healthcare Common Procedure Coding System.
ICD-10-CM=International Classification of Diseases, 10th Revision, Clinical Modification.
NDC=National Drug Code.

TYPE CODE DESCRIPTION
Diagnosis: ICD-10-CM M05.60—M05.69 Rheumatoid arthritis with involvement of other organs and systems
M05.70—M05.79 Rheumatoid arthritis with rheumatoid factor without organ or systems involvement
M06.00—M06.09 Rheumatoid arthritis without rheumatoid factor
M06.9 Rheumatoid arthritis without rheumatoid factor
M08.3
Juvenile rheumatoid polyarthritis (seronegative)
M31.5 Giant cell arteritis with polymyalgia rheumatica
M31.6 Other giant cell arteritis
Drug: HCPCS J3590 Unclassified biologics
J3490 Unclassified drugs

Drug: NDC

Note: Payer requirements regarding use of a 10-digit or 11-digit NDC may vary. Both formats are listed here for your reference.

10-digit 11-digit  
50242-138-01 50242-0138-01 Prefilled syringe providing 162 mg per 0.9 mL
Administration procedures: CPT 96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

CPT=Current Procedural Terminology.
HCPCS=Healthcare Common Procedure Coding System.
ICD-10-CM=International Classification of Diseases, 10th Revision, Clinical Modification.
NDC=National Drug Code.

These codes are not all-inclusive; appropriate codes can vary by patient, setting of care and payer. 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 guarantee concerning reimbursement or coverage for any service or item.

Many payers will not accept unspecified codes. If you use an unspecified code, please check with your payer.

Appeals

If your patient’s health insurance plan has issued a denial, your Immunology Field Reimbursement Manager (IFRM) or Genentech Rheumatology Access Solutions Specialist can provide resources as you prepare an appeal submission, as per your patient’s plan requirements.

If a plan issues a denial:

  1. The denial should be reviewed, along with the health insurance plan’s guidelines to determine what to include in your patient’s appeal submission.
  2. Your IFRM or Genentech Rheumatology Access Solutions Specialist has local payer coverage expertise and can help you determine specific requirements for your patient.

A sample appeal letter, checklist and additional tips are available in Forms and Documents.

Appeals cannot be completed or submitted by Genentech Rheumatology Access Solutions on your behalf.

PAN=Patient Authorization and Notice of Request for Transmission of Health Information to Genentech Access Solutions and Genentech® Access to Care Foundation.

SMN=Statement of Medical Necessity.

Important Safety Information & Indication

Indication

ACTEMRA® (tocilizumab) is indicated for the treatment of:

  • Adult patients with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response to one or more Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
  • Giant cell arteritis (GCA) in adult patients
  • Active polyarticular juvenile idiopathic arthritis in patients 2 years of age and older
  • Active systemic juvenile idiopathic arthritis in patients 2 years of age and older
  • Chimeric antigen receptor (CAR) T cell-induced severe or life-threatening cytokine release syndrome in adults and pediatric patients 2 years of age and older

Important Safety Information

RISK OF SERIOUS INFECTIONS:

Patients treated with ACTEMRA are at increased risk for developing serious infections that may lead to hospitalization or death, including tuberculosis (TB), bacterial, invasive fungal, viral, or other opportunistic infections. If a serious infection develops, interrupt ACTEMRA until the infection is controlled.

Reported infections include:

  • Active tuberculosis, which may present with pulmonary or extrapulmonary disease. Patients should be tested for latent tuberculosis before ACTEMRA use and during therapy. Treatment for latent infection should be initiated prior to ACTEMRA use.
  • Invasive fungal infections, including candidiasis, aspergillosis, and pneumocystis. Patients with invasive fungal infections may present with disseminated, rather than localized, disease.
  • Bacterial, viral and other infections due to opportunistic pathogens.

The risks and benefits of treatment with ACTEMRA should be carefully considered prior to initiating therapy in patients with chronic or recurrent infection.

Patients should be closely monitored for the development of signs and symptoms of infection during and after treatment with ACTEMRA, including the possible development of tuberculosis in patients who tested negative for latent tuberculosis infection prior to initiating therapy.

ACTEMRA is contraindicated in patients with known hypersensitivity to ACTEMRA.

Other serious or potentially life-threatening adverse reactions that have been reported in clinical trials with ACTEMRA include gastrointestinal perforations. Use ACTEMRA with caution in patients who may be at risk for GI perforations.

Laboratory monitoring is recommended due to potential consequences of treatment-related laboratory abnormalities in neutrophils, platelets, lipids, and liver function tests.

ACTEMRA is an immunosuppressant, and treatment with immunosuppressants may result in an increased risk of malignancies.

Hypersensitivity reactions, including anaphylaxis and death, have occurred.

  • If anaphylaxis or other hypersensitivity reaction occurs, stop administration of ACTEMRA immediately and discontinue ACTEMRA permanently.

The impact of treatment with ACTEMRA on demyelinating disorders is not known. Monitor patients for signs and symptoms potentially indicative of demyelinating disorders.

Treatment with ACTEMRA is not recommended in patients with active hepatic disease or hepatic impairment.

Avoid use of live vaccines concurrently with ACTEMRA, as clinical safety has not been established.

Most common adverse reactions included upper respiratory tract infections, nasopharyngitis, headache, hypertension, increased ALT, and injection-site reactions (SC only).

You may report side effects to the FDA at (800) FDA-1088 or http://www.fda.gov/medwatch. You may also report side effects to Genentech at (888) 835-2555.

Please see the full Prescribing Information, including BOXED WARNING, for additional Important Safety Information.