ACTEMRA

A monoclonal antibody called ACTEMRA® (tocilizumab) is used to treat a number of inflammatory diseases, such as giant cell arteritis and rheumatoid arthritis. Correct coding and billing are necessary for both compliance and appropriate reimbursement. A guide to help healthcare providers is provided below:
Details of the product:
Routes for Administration:
ACTEMRA is available in single-use vials that contain 80 mg/4 mL, 200 mg/10 mL, or 400 mg/20 mL for intravenous (IV) infusion.
Subcutaneous (SC) Injection: ACTEMRA comes in autoinjectors or prefilled syringes with a 162 mg/0.9 mL dosage.

Details of the Coding:
HCPCS Codes:
IV Infusion:
J3262: 1 mg injection of tocilizumab.
Billing Units: Indicate how many milligrams were given. For instance, enter 400 units for a dose of 400 mg.
SC Injection: J3268: Tocilizumab injection, 1 mg, for subcutaneous administration.
Billing Units: Indicate how many milligrams were given. For instance, enter 162 units for a dose of 162 mg.
ICD-10-CM Codes for diagnosis: Depending on the patient's condition, choose the right code. M05.00–M05.09: Felty's syndrome (rheumatoid arthritis with leukopenia and splenoadenomegaly) is one example.
M05.10–M05.19: Rheumatoid arthritis and rheumatoid lung disease.
M31.6: Arteritis of other large cells.

The CPT codes for IV infusion are:
Chemotherapy administration, via an intravenous infusion approach; single or initial substance/drug; up to 1 hour.
Every extra hour (given individually in addition to the code for the principal procedure) is 96415.
SC Injection: 96372: Subcutaneous or intramuscular injection of a therapeutic, preventative, or diagnostic chemical or medication.

Sample Entries on the CMS-1500 Claim Form:
Enter the correct ICD-10-CM diagnosis code (e.g., M05.00) in locator 21.
Locator 24A: Indicate the service date.
Enter the place of service code (e.g., 11 for office) in locator 24B.
Locator 24D: Indicate the relevant CPT code (96413 or 96372) and the HCPCS code (J3262 or J3268) on a different line.
Locator 24E: Make use of Locator 21's diagnosis code.
Locator 24G: Show how many units were given (400 for a 400 mg dose, for example).

Additional information: NDC Reporting: Properly format the National Drug Code (NDC) and place it in the shaded section of Locator 24D.
JW Modifier: If relevant, report any amount of discarded medication using the JW modifier.
Payer Policies: As each payer may have different needs, confirm specific coding, coverage, and payment policies with them.
See Genentech's ACTEMRA Sample Billing and Coding Guide at actemrahcp.com for more details and resources.
To guarantee correct billing procedures, it is essential to keep abreast of payer-specific policies and any modifications to coding standards.