Reimbursement

Pulmozyme Sample Coding

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

TYPE CODE DESCRIPTION
Diagnosis: ICD-10-CM E84.0 Cystic fibrosis with pulmonary manifestations
E84.8 Cystic fibrosis with other manifestations
E84.9 Cystic fibrosis, unspecified
Drug: HCPCS J7639 Dornase alfa, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per 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  
50242-100-40 50242-0100-40 30 ampules containing 2.5 mg of dornase alfa in 2.5 mL of solution
Administration procedures: CPT G0333 Pharmacy dispensing fee for initial inhalation drug(s); initial 30-day supply to a beneficiary
Q0513 Pharmacy dispensing fee for inhalation drug(s); per 30 days
Q0514 Pharmacy dispensing fee for inhalation drug(s); per 90 days

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 Pulmozyme 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 Pulmozyme 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 Pulmozyme 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.