Esbriet Sample Coding

This coding information may assist you as you complete the payer forms for Esbriet. These tables are provided for informational purposes only. Please visit or other payers’ websites to obtain additional guidance on their processes related to billing and coding for single-use vials and wastage.

Diagnosis: ICD-10-CM J84.112 Idiopathic pulmonary fibrosis
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  
50242-121-01 50242-0121-01 Bottle for a 30-day supply containing 270 capsules and closed with a child-resistant closure
50242-122-05 50242-0122-05 Carton containing 3 bottles, each containing 90 267-mg tablets (270 tablets total), with a child-resistant closure
50242-123-01 50242-0123-01 Carton containing 1 bottle containing 90 801-mg tablets, with a child-resistant closure


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.


If your patient’s health insurance plan has issued a denial, your Pulmonology Field Reimbursement Manager (PFRM) or Esbriet 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 PFRM or Esbriet 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 Esbriet 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.