RITUXAN

A monoclonal antibody called Rituxan® (rituximab) is used to treat a number of illnesses, such as pemphigus vulgaris (PV), rheumatoid arthritis (RA), and some forms of vasculitis. Appropriate reimbursement depends on accurate billing and coding. This is a handbook to help you:
1. HCPCS Code: J9312: 10 mg injection of rituximab. Depending on the dosage given, report the number of units. A dose of 700 mg, for instance, is equivalent to 70 units (700 mg ÷ 10 mg/unit).

2. Drug Administration CPT Codes:
96413: administering chemotherapy, intravenous infusion; single or first substance/drug; up to 1 hour.
96415: For every extra hour of infusion.
Use 96413 for the first hour and 96415 again for the remaining hours, for example, if a Rituxan infusion lasts three hours.
3. Diagnosis Codes: Verify that the ICD-10-CM codes on the claim support the usage of Rituxan and correspond to the patient's medical condition. Typical diagnoses consist of:

Rheumatoid arthritis (RA): Felty's syndrome (M05.00–M05.09).
M05.10–M05.19: Rheumatoid arthritis and rheumatoid lung disease.
Rheumatoid arthritis and rheumatoid vasculitis (M05.20–M05.29).
Rheumatoid arthritis and rheumatoid heart disease (M05.30–M05.39).
Rheumatoid arthritis and rheumatoid myopathy (M05.40–M05.49).
M05.50–M05.59: Rheumatoid arthritis combined with rheumatoid polyneuropathy.
Rheumatoid arthritis involving additional organs and systems (M05.60–M05.69).
M05.70–M05.79: Rheumatoid arthritis without involvement of organs or systems, accompanied with rheumatoid factor.
M05.7A: Rheumatoid arthritis without involvement of organs or systems, with rheumatoid factor in another specific site.
Other rheumatoid arthritis with rheumatoid factor (M05.80–M05.8A).
M05.9: Unspecified rheumatoid arthritis with rheumatoid factor.
Rheumatoid arthritis without rheumatoid factor (M06.00–M06.09).
M06.0A: Rheumatoid arthritis, other specified site, without rheumatoid factor.
Other specified rheumatoid arthritis (M06.80–M06.8A).
M06.9: Unspecified rheumatoid arthritis.
The species Pemphigus vulgaris (PV) is identified in L10.0.

Wegener's granulomatosis without renal involvement is M31.30, which is granulomatosis with polyangiitis (GPA).
M31.31: Renal involvement in Wegener's granulomatosis.
4. National Drug Code (NDC): Payers may have different requirements for using an 11-digit or 10-digit NDC. For reference, both formats are offered:
One-dose vial of 100 mg/10 mL: o10-digit: 50242-051-21 o11-digit: 50242-0051-21
One-dose vial containing 500 mg/50 mL: o10-digit: 50242-053-06 o11-digit: 50242-0053-06
Make sure to confirm with each payer the precise NDC requirements.

5. Adjustments:
JW: Denotes the quantity of medication that was thrown away or not given to any patients.
JZ: Denotes that no medication has been thrown away or given to a patient.
The Centers for Medicare & Medicaid Services (CMS) mandates that the JZ modifier be used to show that no units of a medicine were wasted as of July 1, 2023. The JZ modifier can be used as early as January 1, 2023, however it is not necessary until July 1, 2023.
6. Documentation Standards: Keep thorough medical records that contain the following information: a precise diagnosis and compliance with accepted norms (such as the American College of Rheumatology's criteria).
Weight of the patient, if it affects dosage.
A thorough medical history, particularly if previous therapies have been used.
Accurate documentation promotes medical necessity and makes reimbursement procedures run more smoothly.

7. Additional Resources: Refer to the "Rituxan Sample Coding" document for more in-depth information. It provides reimbursement assistance resources, example claim forms, and coding insights.
To guarantee correct billing, it's critical to keep abreast of payer-specific regulations and modifications to coding standards.