Reimbursement

This coding information may assist you as you complete payer forms. 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.

ICD-10-CM Tool

ICD-10-CM:


M05.60 Rheumatoid arthritis of unspecified site with involvement of other systems
M05.611 Rheumatoid arthritis of right shoulder with involvement of other organs and systems
M05.612 Rheumatoid arthritis of left shoulder with involvement of other organs and systems
M05.619 Rheumatoid arthritis of unspecified shoulder with involvement of other organs and systems
M05.621 Rheumatoid arthritis of right elbow with involvement of other organs and systems
M05.622 Rheumatoid arthritis of left elbow with involvement of other organs and systems
M05.629 Rheumatoid arthritis of unspecified elbow with involvement of other organs and systems
M05.631 Rheumatoid arthritis of right wrist with involvement of other organs and systems
M05.632 Rheumatoid arthritis of left wrist with involvement of other organs and systems
M05.639 Rheumatoid arthritis of unspecified wrist with involvement of other organs and systems
M05.641 Rheumatoid arthritis of right hand with involvement of other organs and systems
M05.642 Rheumatoid arthritis of left hand with involvement of other organs and systems
M05.649 Rheumatoid arthritis of unspecified hand with involvement of other organs and systems
M05.651 Rheumatoid arthritis of right hip with involvement of other organs and systems
M05.652 Rheumatoid arthritis of left hip with involvement of other organs and systems
M05.659 Rheumatoid arthritis of unspecified hip with involvement of other organs and systems
M05.661 Rheumatoid arthritis of right knee with involvement of other organs and systems
M05.662 Rheumatoid arthritis of left knee with involvement of other organs and systems
M05.669 Rheumatoid arthritis of unspecified knee with involvement of other organs and systems
M05.671 Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems
M05.672 Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems
M05.679 Rheumatoid arthritis of unspecified ankle and foot with involvement of other organs and systems
M05.69 Rheumatoid arthritis of multiple sites with involvement of other organs and systems
M05.70 Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or systems involvement
M05.711 Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement
M05.712 Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement
M05.719 Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or systems involvement
M05.721 Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement
M05.722 Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement
M05.729 Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or systems involvement
M05.731 Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement
M05.732 Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement
M05.739 Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems involvement
M05.741 Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement
M05.742 Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement
M05.749 Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems involvement
M05.751 Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement
M05.752 Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement
M05.759 Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems involvement
M05.761 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement
M05.762 Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement
M05.769 Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement
M05.771 Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement
M05.772 Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement
M05.779 Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement
M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement
M06.00 Rheumatoid arthritis without rheumatoid factor, unspecified site
M06.011 Rheumatoid arthritis without rheumatoid factor, right shoulder
M06.012 Rheumatoid arthritis without rheumatoid factor, left shoulder
M06.019 Rheumatoid arthritis without rheumatoid factor, unspecified shoulder
M06.021 Rheumatoid arthritis without rheumatoid factor, right elbow
M06.022 Rheumatoid arthritis without rheumatoid factor, left elbow
M06.029 Rheumatoid arthritis without rheumatoid factor, unspecified elbow
M06.031 Rheumatoid arthritis without rheumatoid factor, right wrist
M06.032 Rheumatoid arthritis without rheumatoid factor, left wrist
M06.039 Rheumatoid arthritis without rheumatoid factor, unspecified wrist
M06.041 Rheumatoid arthritis without rheumatoid factor, right hand
M06.042 Rheumatoid arthritis without rheumatoid factor, left hand
M06.049 Rheumatoid arthritis without rheumatoid factor, unspecified hand
M06.051 Rheumatoid arthritis without rheumatoid factor, right hip
M06.052 Rheumatoid arthritis without rheumatoid factor, left hip
M06.059 Rheumatoid arthritis without rheumatoid factor, unspecified hip
M06.061 Rheumatoid arthritis without rheumatoid factor, right knee
M06.062 Rheumatoid arthritis without rheumatoid factor, left knee
M06.069 Rheumatoid arthritis without rheumatoid factor, unspecified knee
M06.071 Rheumatoid arthritis without rheumatoid factor, right ankle and foot
M06.072 Rheumatoid arthritis without rheumatoid factor, left ankle and foot
M06.079 Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot
M06.08 Rheumatoid arthritis without rheumatoid factor, vertebrae
M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites
M06.9 Rheumatoid arthritis, unspecified
M08.3 Juvenile rheumatoid polyarthritis (seronegative)
M08.20 Juvenile rheumatoid arthritis with systemic onset, unspecified site
M08.211 Juvenile rheumatoid arthritis with systemic onset, right shoulder
M08.212 Juvenile rheumatoid arthritis with systemic onset, left shoulder
M08.219 Juvenile rheumatoid arthritis with systemic onset, unspecified shoulder
M08.221 Juvenile rheumatoid arthritis with systemic onset, right elbow
M08.222 Juvenile rheumatoid arthritis with systemic onset, left elbow
M08.229 Juvenile rheumatoid arthritis with systemic onset, unspecified elbow
M08.231 Juvenile rheumatoid arthritis with systemic onset, right wrist
M08.232 Juvenile rheumatoid arthritis with systemic onset, left wrist
M08.239 Juvenile rheumatoid arthritis with systemic onset, unspecified wrist
M08.241 Juvenile rheumatoid arthritis with systemic onset, right hand
M08.242 Juvenile rheumatoid arthritis with systemic onset, left hand
M08.249 Juvenile rheumatoid arthritis with systemic onset, unspecified hand
M08.251 Juvenile rheumatoid arthritis with systemic onset, right hip
M08.252 Juvenile rheumatoid arthritis with systemic onset, left hip
M08.259 Juvenile rheumatoid arthritis with systemic onset, unspecified hip
M08.261 Juvenile rheumatoid arthritis with systemic onset, right knee
M08.262 Juvenile rheumatoid arthritis with systemic onset, left knee
M08.269 Juvenile rheumatoid arthritis with systemic onset, unspecified knee
M08.271 Juvenile rheumatoid arthritis with systemic onset, right ankle and foot
M08.272 Juvenile rheumatoid arthritis with systemic onset, left ankle and foot
M08.279 Juvenile rheumatoid arthritis with systemic onset, unspecified ankle and foot
M08.28 Juvenile rheumatoid arthritis with systemic onset, vertebrae
M08.29 Juvenile rheumatoid arthritis with systemic onset, multiple sites
M31.5 Giant cell arteritis with polymyalgia rheumatica
M31.6 Other giant cell arteritis

ACTEMRA® (tocilizumab) ICD-10-CM Coding

These tables are provided for informational purposes only. Many payers will not accept unspecified codes. If you use an unspecified code, please check your payer. Correct coding is the responsibility of the provider.

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.

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.
SJIA=Systemic Juvenile Idiopathic Arthritis.

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
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
96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic

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.

Appeals

If your office has prescribed ACTEMRA® (tocilizumab), but your patient’s insurer has denied coverage, you can appeal that decision. Genentech Rheumatology 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 Genentech Rheumatology 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. Genentech Rheumatology Access Solutions can provide information about this process.