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.