Relevant Billing Codes for PADCEVTM (enfortumab vedotin-ejfv)

Properly coding claims can help facilitate timely claims processing and reduce the risk of denied claims. Coding requirements vary by payer.1 The coding systems in the following tables can assist you in coding for PADCEVa:


PERMANENT J-CODE FOR PADCEV EFFECTIVE JULY 1, 2020

HCPCS Code2 Description Billing Unit Payer and Settings of Care
J9177 Injection, enfortumab vedotin-ejfv, 0.25 mg 0.25 mg = 1 billing unit Most payers (eg, Commercial, Medicare, and Medicaid) and care settings (eg, hospital outpatient and physician office)
1 billing unit of J9177 equals 0.25 mg of enfortumab vedotin-ejfv.2 As a result, 80 units equals 1 single-dose 20 mg vial and 120 units equals 1 single-dose 30 mg vial. Actual units reported will vary by dosage required for each individual patient.

For dates of service prior to July 1, 2020, use the unspecified HCPCS codes to bill for PADCEV, which include: J3490, J3590, J9999, and C9399 (Medicare Hospital Outpatient Prospective Payment System [OPPS] Claims).3 Additional information needed may vary by payer and may include the drug name and generic name, total dosage administered, method of administration, and the NDC.4,5
Code6 Code Description
51144-0020-01 20 mg solution in a single-dose vial for intravenous infusion
51144-0030-01 30 mg solution in a single-dose vial for intravenous infusion
Note that the product’s NDC has been “zero-filled” to ensure creation of an 11-digit code that meets Health Insurance Portability and Accountability Act (HIPAA) standards.7
Code8 Code Description
96413 Chemotherapy administration, intravenous infusion technique, up to 1 hour, single or initial substance/drug
96415 Chemotherapy administration, intravenous infusion technique, each additional hour (list separately in addition to code for primary procedure)
Metastatic Urothelial Cancer
ICD-10-CM Codes9
Code Description
C65.1 Malignant neoplasm of right renal pelvis
C65.2 Malignant neoplasm of left renal pelvis
C65.9 Malignant neoplasm of unspecified renal pelvis
C66.1 Malignant neoplasm of right ureter
C66.2 Malignant neoplasm of left ureter
C66.9 Malignant neoplasm of unspecified ureter
C67.0 Malignant neoplasm of trigone of bladder
C67.1 Malignant neoplasm of dome of bladder
C67.2 Malignant neoplasm of lateral wall of bladder
C67.3 Malignant neoplasm of anterior wall of bladder
C67.4 Malignant neoplasm of posterior wall of bladder
C67.5 Malignant neoplasm of bladder neck
C67.6 Malignant neoplasm of ureteric orifice
C67.8 Malignant neoplasm of overlapping sites of bladder
C67.9 Malignant neoplasm of bladder, unspecified
C68.0 Malignant neoplasm of urethra

IMPORTANT INFORMATION: The coding, coverage, and payment information contained herein is gathered from various resources, general in nature, and subject to change without notice. Third-party payment for medical products and services is affected by numerous factors. It is always the provider’s responsibility to determine the appropriate healthcare setting and to submit true and correct claims conforming to the requirements of the relevant payer for those products and services rendered. Pharmacies (or any other provider submitting a claim) should contact third-party payers for specific information on their coding, coverage, and payment policies. Information and materials provided by PADCEV Support SolutionsSM are to assist providers, but the responsibility to determine coverage, reimbursement, and appropriate coding for a particular patient and/or procedure remains at all times with the provider and information provided by PADCEV Support Solutions, Astellas or Seattle Genetics should in no way be considered a guarantee of coverage or reimbursement for any product or service.

aAmerican Medical Association. Current Procedural Terminology (CPT). Professional edition, 2019. All rights reserved. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

References

1. Beck DE, Margolin DA, Physician coding and reimbursement. Ochsner J 2007;7:8-15.

2. Centers for Medicare & Medicaid Services. Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS) Application Summaries and Coding Decisions (04-14-2020). https://www.cms.gov/files/document/2020-hcpcs-application-summary-quarter-1-2020-drugs-and-biologicals-updated-04142020.pdf. Accessed 04-22-2020.

3. Centers for Medicare & Medicaid Services. 2019 alpha numeric HCPCS file. https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS-Items/2019-Alpha-Numeric-HCPCS-File.html. Accessed 06-10-2019.

4. Centers for Medicare & Medicaid Services. Medicare claims processing manual chapter 17 – drugs and biologicals. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf. Accessed 06-10-2019.

5. Wisconsin Physicians Service. Government Health Administrators. Billing and describing not otherwise classified (NOC) codes (08-27-2019). https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/not-otherwise-classified-billing. Accessed 08-29-2019.

6. PADCEV [package insert]. Northbrook, IL: Astellas Pharma US, Inc.

7. U.S. Food and Drug Administration. National Drug Code Database Background Information. https://www.fda.gov/drugs/development-approval-process-drugs/national-drug-code-database-background-information. Accessed 09-08-2019.

8. American Medical Association. CPT® 2019 Professional. Chicago, IL: American Medical Association; 2018.

9. Centers for Medicare & Medicaid Services. ICD-10-CM tabular list of diseases and injuries. https://www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-CM.html. Accessed 06-10-2019.

PADCEVTM is a trademark jointly owned by Agensys, Inc. and Seattle Genetics, Inc.