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 C83.00—C83.09 Small cell B-cell lymphoma
C83.30—C83.39 Diffuse large B-cell lymphoma, lymph nodes of various sites
C82.00—C82.99 Follicular lymphoma, Grades I-IIIb, diffuse follicle center lymphoma, cutaneous follicle center lymphoma, other and unspecified
C83.80—C83.89 Other non-follicular lymphoma, lymph nodes of specific sites
C85.10—C85.19 Unspecified B-cell lymphoma
C85.80—C85.89 Other specified types of non-Hodgkin’s lymphoma
C85.90—C85.99 Non-Hodgkin’s lymphoma, unspecified
Drug: HCPCS J9310 Injection, rituximab, 100 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  
50242-051-21 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)
96417 Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 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. 

TYPE CODE DESCRIPTION
Diagnosis: ICD-10-CM C91.10 Chronic lymphocytic leukemia of B-cell type not having achieved remission
C91.12 Chronic lymphocytic leukemia of B-cell type in relapse
Drug: HCPCS J9310 Injection, rituximab, 100 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  
50242-051-21 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)
96417 Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 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.

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 BioOncology Field Reimbursement Manager (BFRM) or RITUXAN 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 BFRM or RITUXAN 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 RITUXAN 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.