Reimbursement

Rituxan Sample Coding

This coding information may assist you as you complete the payer forms for Rituxan. 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 M31.7 Microscopic polyangiitis
M31.30 Wegener’s granulomatosis without renal involvement
M31.31 Wegener’s granulomatosis with renal involvement
Drug: HCPCS J9310 Injection, rituximab, 100 mg
Injection, rituximab, 100 mg J1100 Injection, dexamethasone sodium phosphate, 1 mg
J1200 Injection, diphenhydramine HCL, up to 50 mg
J2920 Injection, methylprednisolone sodium succinate, up to 40 mg
J2930 Injection, methylprednisolone sodium succinate, up to 125 mg
J7030 Infusion, normal saline solution, 1000 cc
J7040 Infusion, normal saline solution, sterile (500 mL = 1 unit)
J7050 Infusion, normal saline solution, 250 cc
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  
50242-051-21 50242-0051-21 100 mg/10 mL single-use vial
50242-053-06 50242-0053-06 500 mg/50 mL 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)
96367 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure) (Report 96367 in conjunction with 96365, 96374, 96409, 96413 if provided as a secondary or subsequent service after a different initial service is administered through the same IV access. Report 96367 only once per sequential infusion of same infusate mix)
96375 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) (Use 96375 in conjunction with 96365, 96374, 96409, 96413) (Report 96375 to identify intravenous push of a new substance/drug if provided as a secondary or subsequent service after a different initial service is administered through the same IV access)

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.

TYPE CODE DESCRIPTION
Diagnosis: ICD-10-CM L10.0
Pemphigus vulgaris
Drug: HCPCS J9310 Injection, rituximab, 100 mg
Injection, rituximab, 100 mg J1100 Injection, dexamethasone sodium phosphate, 1 mg
J1200 Injection, diphenhydramine HCL, up to 50 mg
J2920 Injection, methylprednisolone sodium succinate, up to 40 mg
J2930 Injection, methylprednisolone sodium succinate, up to 125 mg
J7030 Infusion, normal saline solution, 1000 cc
J7040 Infusion, normal saline solution, sterile (500 mL = 1 unit)
J7050 Infusion, normal saline solution, 250 cc
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  
50242-051-21 50242-0051-21 100 mg/10 mL single-use vial
50242-053-06 50242-0053-06 500 mg/50 mL 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)
96367 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure) (Report 96367 in conjunction with 96365, 96374, 96409, 96413 if provided as a secondary or subsequent service after a different initial service is administered through the same IV access. Report 96367 only once per sequential infusion of same infusate mix)
96375 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) (Use 96375 in conjunction with 96365, 96374, 96409, 96413) (Report 96375 to identify intravenous push of a new substance/drug if provided as a secondary or subsequent service after a different initial service is administered through the same IV access)

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 and Biogen do 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 Immunology Field Reimbursement Manager (IFRM) or Genentech 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 IFRM or Genentech 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 are available in Forms and Documents.

Appeals cannot be completed or submitted by Genentech 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.

Important Safety Information & Indication

Indications

  • Rituxan® (rituximab), in combination with methotrexate, is indicated for the treatment of adult patients with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response to one or more TNF antagonist therapies
  • Rituxan® (rituximab), in combination with glucocorticoids, is indicated for the treatment of adult patients with Granulomatosis with Polyangiitis (GPA) (Wegener’s Granulomatosis) and Microscopic Polyangiitis (MPA)
  • Rituxan® (rituximab) is indicated for the treatment of adult patients with moderate to severe pemphigus vulgaris (PV)

BOXED WARNINGS and Additional Important Safety Information

Infusion Reactions: Rituxan administration can result in serious, including fatal infusion reactions. Deaths within 24 hours of Rituxan infusion have occurred. Approximately 80% of fatal infusion reactions occurred in association with the first infusion. Monitor patients closely. Discontinue Rituxan infusion for severe reactions and provide medical treatment for Grade 3 or 4 infusion reactions

Severe Mucocutaneous Reactions: Severe, including fatal, mucocutaneous reactions can occur in patients receiving Rituxan

Hepatitis B Virus (HBV) Reactivation: HBV reactivation can occur in patients treated with Rituxan, in some cases resulting in fulminant hepatitis, hepatic failure, and death. Screen all patients for HBV infection before treatment initiation, and monitor patients during and after treatment with Rituxan. Discontinue Rituxan and concomitant medications in the event of HBV reactivation

Progressive Multifocal Leukoencephalopathy (PML), including fatal PML, can occur in patients receiving Rituxan

Warnings and Precautions

Rituxan administration can also result in additional serious, including fatal, adverse reactions including:

  • Tumor lysis syndrome (TLS): Administer aggressive intravenous hydration, anti-hyperuricemic agents, monitor renal function
  • Infections: Withhold Rituxan and institute appropriate anti-infective therapy. Rituxan is not recommended for use in patients with severe, active infections
  • Cardiovascular adverse reactions: Discontinue infusions in case of serious or life-threatening events
  • Renal toxicity: Discontinue in patients with rising serum creatinine or oliguria
  • Bowel obstruction and perforation: Consider and evaluate for abdominal pain, vomiting, or related symptoms
  • Immunizations: Live virus vaccinations prior to or during Rituxan treatment are not recommended
  • Embryo-Fetal toxicity: Can cause neonatal harm. Advise of potential risk to neonates and use of effective contraception
  • Concomitant Use with Other Biologic Agents and DMARDS other than Methotrexate in RA, GPA and MPA, PV: Patients with RA should be closely observed for signs of infection if biologic agents and/or DMARDs other than methotrexate are used concomitantly. Use of concomitant immunosuppressants other than corticosteroids has not been studied in GPA or MPA or PV patients exhibiting peripheral B-cell depletion following treatment with Rituxan
  • Use in RA Patients Who Have Not Had Prior Inadequate Response to Tumor Necrosis Factor (TNF) Antagonists: The use of Rituxan in patients with RA who have not had prior inadequate response to one or more TNF antagonists is not recommended
  • Retreatment in Patients with Granulomatosis with Polyangiitis (GPA) (Wegener’s Granulomatosis) and Microscopic Polyangiitis (MPA): The safety and efficacy of retreatment with Rituxan have not been established in patients with GPA and MPA

Most Common Adverse Reactions

Rheumatoid Arthritis (RA):

Most common adverse reactions (≥10%) in clinical trials: upper respiratory tract infection, nasopharyngitis, urinary tract infection, and bronchitis. Other important adverse reactions include infusion reactions, serious infections, and cardiovascular events.

Granulomatosis with Polyangiitis (GPA) (Wegener’s Granulomatosis) and Microscopic Polyangiitis (MPA):

Most common adverse reactions (≥15%) in the clinical study were infections, nausea, diarrhea, headache, muscle spasms, anemia, and peripheral edema. Other important adverse reactions include infusion reactions.

Pemphigus Vulgaris (PV):

Most common adverse reactions (≥15%) in the clinical trial were infusion reactions, depression (other important adverse reactions include infections).

Report side effects to the FDA at (800) FDA-1088 or www.fda.gov/medwatch. Report side effects to Genentech at (888) 835-2555.

For additional Important Safety Information, please see the full Prescribing Information, including BOXED WARNINGS and Medication Guide at www.rituxan.com.