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.

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.

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, checklist and additional tips 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.