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
Healthcare Common Procedure Coding System (HCPCS) Codes
5-digit alphanumeric code
|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)|
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
National Drug Codes (NDC)
Universal 11-digit product identifier for human drugs; each NDC identifies the labeler, product, and trade package size
|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|
5-digit codes that describe procedures and services performed by physicians and other healthcare providers (HCPs)
|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)|
ICD-10-CM Diagnosis Codes
Alphanumeric classification descriptive of diseases, injuries, and causes of death, used in hospital outpatient and physician settings
|Metastatic Urothelial Cancer
|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.
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.