Reimbursement

OCREVUS Sample Coding

This coding information may assist you as you complete the payer forms for OCREVUS. 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.

As of October 2, 2017, OCREVUS has been assigned a unique hospital outpatient HCPCS code (C-code). Please see the table below for more information.

TYPE CODE DESCRIPTION
ICD-10-CM G35 Multiple sclerosis
HCPCS J3590 Unclassified biologics
J3490 Unclassified drugs
J9999 Not otherwise classified, antineoplastic drugs
Hospital Outpatient HCPCS C9494
Injection, ocrelizumab, 1 mg
NDC 10-digit 11-digit  
50242-150-01 50242-0150-01 ocrelizumab, 300 mg vial
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)
96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)

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.

*For payers who do not yet recognize OCREVUS as approved for chemotherapy administration codes 96413 and 96415, other administration codes, such as 96365 and 96366, may be used depending on individual payer policy.1

Reference: 

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. Chapter 12 – Physicians/Nonphysician Practitioners. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Revised April 14, 2017. Accessed September 11, 2017.

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 Neurology Field Reimbursement Manager (NFRM) or OCREVUS 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 NFRM or OCREVUS 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 OCREVUS Access Solutions on your behalf.

Understanding Claims Submission for Office-administered Products Using a Miscellaneous J-code Video

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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.