KRYSTEXXA

An injectable drug called KRYSTEXXA® (pegloticase) is prescribed to adult patients with persistent gout who are not responding to traditional treatment. For proper reimbursement and compliance, accurate billing and coding are necessary. Here are several important rules:
HCPCS Code: J2507: Pegloticase injection, 1 mg.
Example of Billing: Since each unit is equivalent to 1 mg, bill 8 units for an 8 mg dose of KRYSTEXXA.
75987-0080-10: KRYSTEXXA 8 mg/mL single-dose vial is the National Drug Code (NDC).

Codes of Administration: KRYSTEXXA is given intravenously. The administration may be eligible for the following CPT® codes:
96374: Intravenous push, single or initial substance/drug; therapeutic, preventative, or diagnostic injection.
96365: Initial, up to one-hour intravenous infusion for diagnosis, treatment, or prevention.

Diagnosis Codes: The patient's condition should be reflected in the appropriate ICD-10-CM diagnosis codes. The following are typical codes linked to KRYSTEXXA therapy:
M10.00: Unspecified location of idiopathic gout.
Toe idiopathic gout (M10.01).
M10.02: Ankle and foot idiopathic gout.
M10.03: Knee idiopathic gout.
M10.04: Other joint idiopathic gout.
M10.05: Multiple locations of idiopathic gout.
M10.9: Unspecified idiopathic gout.

Additional Billing Considerations: Modifiers: Modifiers like JW (drug quantity discarded/not administered) may be relevant depending on payer restrictions and the particulars of the administration.
Documentation: To prove medical necessity and speed up the processing of claims, keep comprehensive medical records that include the diagnosis, treatment plan, dosage, administration method, and any information on waste.
Pre-Authorization: For biologic treatments like KRYSTEXXA, many insurance companies demand prior authorization. Before starting treatment, make sure that all required approvals have been received.

Consult Horizon Therapeutics' KRYSTEXXA Billing and Coding Guide for complete and current information.
Following these recommendations will help ensure that KRYSTEXXA therapy is accurately billed and reimbursed.