Actemra

Blog post description.

9/21/20232 min read

ACTEMRA® (tocilizumab) is a monoclonal antibody used to treat various inflammatory conditions, including rheumatoid arthritis and giant cell arteritis. Accurate billing and coding are essential for proper reimbursement and compliance. Below is a guide to assist healthcare providers:

Intravenous (IV) Infusion: ACTEMRA is supplied in single-use vials containing 80 mg/4 mL, 200 mg/10 mL, or 400 mg/20 mL.

Subcutaneous (SC) Injection: ACTEMRA is available in prefilled syringes or autoinjectors containing 162 mg/0.9 mL.

Coding Details:

HCPCS Codes:

IV Infusion:

  • J3262: Injection, tocilizumab, 1 mg.

  • Billing Units: Report the number of milligrams administered. For example, for a 400 mg dose, enter 400 units.

o SC Injection:

  • J3268: Injection, tocilizumab, for subcutaneous use, 1 mg.

  • Billing Units: Report the number of milligrams administered. For example, for a 162 mg dose, enter 162 units.

· ICD-10-CM Diagnosis Codes: Select the appropriate code based on the patient's condition. Examples include:

  • M05.00–M05.09: Felty’s syndrome (rheumatoid arthritis with splenoadenomegaly and leukopenia).

  • M05.10–M05.19: Rheumatoid lung disease with rheumatoid arthritis.

  • M31.6: Other giant cell arteritis.

· CPT Codes:

IV Infusion:

  • 96413: Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug.

  • 96415: Each additional hour (list separately in addition to code for primary procedure).

o SC Injection:

  • 96372: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.

Sample CMS-1500 Claim Form Entries:

· Locator 21: Enter the appropriate ICD-10-CM diagnosis code (e.g., M05.00).

· Locator 24A: Specify the date of service.

· Locator 24B: Enter the place of service code (e.g., 11 for office).

· Locator 24D: List the appropriate HCPCS code (J3262 or J3268) and, on a separate line, the applicable CPT code (96413 or 96372).

· Locator 24E: Reference the diagnosis code from Locator 21.

· Locator 24G: Indicate the number of units administered (e.g., 400 for a 400 mg dose).

· NDC Reporting: Include the National Drug Code (NDC) in the shaded area of Locator 24D, formatted appropriately.

· JW Modifier: Use the JW modifier to report any discarded drug amount, if applicable.

· Payer Policies: Verify specific coding, coverage, and payment policies with individual payers, as they may have unique requirements.

It's crucial to stay updated with payer-specific guidelines and any changes in coding standards to ensure accurate billing practices.