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.

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
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TYPE CODE DESCRIPTION
ICD-10-CM G35 Multiple sclerosis
Drug: HCPCS J2350
 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.

*The C-code is used primarily in the Medicare hospital outpatient setting. However, some payers accept C9494 instead of unclassified J- or C-codes when billing for OCREVUS. Please check with your payers to verify codes and special billing requirements.

†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 May 31, 2018. Accessed December 3, 2018.

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 Education and Reimbursement Specialist (ERS) or OCREVUS Patient Navigator 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 ERS or OCREVUS Patient Navigator has local payer coverage expertise and can help you determine specific requirements for your patient.

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

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

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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.

Important Safety Information & Indication

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Indications

OCREVUS is indicated for the treatment of adult patients with relapsing or primary progressive forms of multiple sclerosis.

Contraindications

OCREVUS is contraindicated in patients with active hepatitis B virus infection and in patients with a history of life-threatening infusion reaction to OCREVUS.

Warnings and Precautions

Infusion Reactions:

Management recommendations for infusion reactions depend on the type and severity of the reaction. Permanently discontinue OCREVUS if a life-threatening or disabling infusion reaction occurs.

Infections:

Delay OCREVUS administration in patients with an active infection until the infection is resolved. Vaccination with live-attenuated or live vaccines is not recommended during treatment with OCREVUS and after discontinuation, until B-cell repletion.

Malignancies:

An increased risk of malignancy, including breast cancer, may exist with OCREVUS.

Most Common Adverse Reactions

RMS: The most common adverse reactions in RMS trials (incidence ≥10% and >REBIF): upper respiratory tract infections and infusion reactions.

PPMS: The most common adverse reactions (≥10% and >placebo): upper respiratory tract infections, infusion reactions, skin infections, and lower respiratory tract infections.

For additional safety information, please see the full Prescribing Information and Medication Guide.