Reimbursement

KADCYLA Sample Coding

This coding information may assist you as you complete the payer forms for KADCYLA. 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 C50.011—C50.019, C50.111—C50.119,
C50.211—C50.219, C50.311—C50.319,
C50.411—C50.419, C50.511—C50.519,
C50.611—C50.619, C50.811—C50.819,
C50.911—C50.919
Malignant neoplasm of the female breast
C50.021—C50.029, C50.121—C50.129, C50.221—C50.229, C50.321—C50.329, C50.421—C50.429, C50.521—C50.529, C50.621—C50.629, C50.821—C50.829, C50.921—C50.929 Malignant neoplasm of the male breast
Drug: HCPCS J9354 Injection, ado-trastuzumab emtansine, 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:  
50242-088-01 50242-0088-01 100-mg single-use vial
50242-087-01 50242-0087-01 160-mg single-use vial
Administration procedures: 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)
Hospital Revenue Codes: 0636 Drugs requiring detailed coding
0250 Pharmacy
0260 IV therapy

 

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 BioOncology Field Reimbursement Manager (BFRM) or KADCYLA 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 BFRM or KADCYLA Access Solutions Specialist has local payer coverage expertise and can help you determine specific requirements for your patient.

A sample appeal letter and additional considerations for appeals are available in Forms and Documents.

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

Important Safety Information & Indication

Indications

Metastatic Breast Cancer (MBC)

KADCYLA, as a single agent, is indicated for the treatment of patients with HER2-positive, metastatic breast cancer who previously received trastuzumab and a taxane, separately or in combination. Patients should have either:

  • Received prior therapy for metastatic disease, or
  • Developed disease recurrence during or within six months of completing adjuvant therapy.

Select patients for therapy based on an FDA-approved companion diagnostic for KADCYLA.

Early Breast Cancer (EBC)

KADCYLA, as a single agent, is indicated for the adjuvant treatment of patients with HER2-positive early breast cancer who have residual invasive disease after neoadjuvant taxane and trastuzumab-based treatment.

Select patients for therapy based on an FDA-approved companion diagnostic for KADCYLA.

Important Safety Information

Boxed WARNINGS: HEPATOTOXICITY, CARDIAC TOXICITY, EMBRYO-FETAL TOXICITY

  • Hepatotoxicity: Serious hepatotoxicity has been reported, including liver failure and death in patients treated with KADCYLA. Monitor serum transaminases and bilirubin prior to initiation of KADCYLA treatment and prior to each KADCYLA dose. Reduce dose or discontinue KADCYLA as appropriate in cases of increased serum transaminases or total bilirubin
  • Cardiac Toxicity: KADCYLA administration may lead to reductions in left ventricular ejection fraction (LVEF). Evaluate left ventricular function in all patients prior to and during treatment with KADCYLA. Withhold treatment for clinically significant decrease in left ventricular function
  • Embryo-Fetal Toxicity: Exposure to KADCYLA can result in embryo-fetal death or birth defects. Advise patients of these risks and the need for effective contraception

Additional Important Safety Information:

  • Interstitial lung disease (ILD), including pneumonitis, some leading to acute respiratory distress syndrome or fatality: Permanently discontinue KADCYLA in patients diagnosed with ILD or pneumonitis
  • Infusion-related reactions (IRR), hypersensitivity: KADCYLA treatment should be interrupted in patients with severe IRR and permanently discontinued in the event of a life-threatening IRR
  • Hemorrhage: Fatal cases of hemorrhage occurred in clinical trials among patients with no known identified risk factors, as well as among patients with thrombocytopenia and those receiving anticoagulation and antiplatelet therapy. Use caution with these agents and consider additional monitoring when concomitant use is medically necessary
  • Thrombocytopenia: Monitor platelet counts prior to initiation of KADCYLA and prior to each dose. Institute dose modifications as appropriate
  • Peripheral neuropathy: Temporarily discontinue KADCYLA in patients experiencing Grade 3 or 4 peripheral neuropathy until resolution to ≤ Grade 2
  • Reactions secondary to extravasation: Closely monitor the infusion site for possible subcutaneous infiltration during drug administration
  • In metastatic breast cancer, the most common adverse reactions (≥25%) with KADCYLA were fatigue, nausea, musculoskeletal pain, hemorrhage, thrombocytopenia, headache, increased transaminases, constipation and epistaxis
  • In early breast cancer, the most common adverse reactions seen with KADCYLA in the KATHERINE trial (frequency >25%) were fatigue, nausea, increased transaminases, musculoskeletal pain, hemorrhage, thrombocytopenia, headache, peripheral neuropathy, and arthralgia
  • Advise women not to breastfeed during treatment and for 7 months following the last dose of KADCYLA

You are encouraged to report side effects to Genentech and the FDA. You may contact Genentech by calling 1-888-835-2555. You may contact the FDA by visiting www.fda.gov/medwatch or calling 1-800-FDA-1088.

Please click here for additional Important Safety Information and accompanying full Prescribing Information, including BOXED WARNINGS.