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.
Metastatic Breast Cancer
|Diagnosis: ICD-10-CM||C50.011—C50.019, C50.111—C50.119, |
|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.
|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|
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.
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:
- The denial should be reviewed, along with the health insurance plan’s guidelines to determine what to include in your patient’s appeal submission.
- 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, checklist and additional tips are available in Forms and Documents.
Appeals cannot be completed or submitted by KADCYLA 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.