Drug & Administration compendia Treatment of Hepatocellular (Liver) Cancer and Renal Cell Carcinoma With each publication, ManagedCare Oncology s Drug & Administration Compendia highlights a single medication or a group of medications that could be utilized in the management of one of the featured oncology diseases. This section addresses such topics as: Associated ICD-9-CM codes Drugs that have been FDA-approved Drugs that are compendia-listed for off-label use based on clinical studies that suggest beneficial use in some cases Ancillary medications used in cancer treatment Reimbursement and coding information HCPCS/CPT codes and code description Current code price (AWP-based pricing) Most recent allowable (ASP + 6 percent), if applicable Possible CPT administration codes that can be utilized with each drug Associated ICD-9-CM Codes: Hepatocellular (Liver) Cancer 155 Malignant neoplasm of liver and intrahepatic bile ducts 155.0 Liver, primary Carcinoma: Hepatocellular Liver cell Liver, specified as primary Hepatoblastoma Renal Cell Carcinoma 189 Malignant neoplasm of kidney and other unspecified urinary organs Excludes Benign carcinoid tumor of kidney (209.64) Malignant carcinoid tumor of kidney (209.42) 189.0 Kidney, except pelvis Kidney NOS Kidney parenchyma 28 managedcareoncology Quarter 2 2012
FDA-Approved Medications Currently Available to Treat Hepatocellular (Liver) Cancer Allowable sorafenib (Nexavar) sorafenib (Nexavar) Compendia-Listed Off-Label Use Medications Currently Available to Treat Hepatocellular (Liver) Cancer Allowable cisplatin (Platinol AQ) doxorubicin (Adriamycin) epirubicin (Ellence) J9060 cisplatin, powder or solution, per 10 mg J9000 doxorubicin hydrochloride, 10 mg J9178 epirubicin hydrochloride, 2 mg $4.33 $1.80 96409, 96413, $13.20 $3.48 96409 $5.38 $1.70 96409, 96413 etoposide (VePesid) J8560 etoposide, oral, 50 mg $63.06 $47.13 N/A etoposide (Toposar) J9181 etoposide, 10 mg $0.53 $0.80 96413, floxuridine (FUDR) J9200 floxuridine, 500 mg $143.40 $68.04 96422, 96423, 96425 fluorouracil (Adrucil) J9190 fluorouracil, 500 mg $3.30 $1.52 96409 gemcitabine (Gemzar) J9201 gemcitabine hydrochloride, 200 mg $102.40 $35.17 96413 ifosfamide (Ifex) J9208 ifosfamide, 1 g $42.00 $31.70 96413, interferon alfa-2b (Intron-A) lanreotide acetate (Somatuline Depot) J9214 interferon alfa-2b, recombinant, 1 million units J1930 lanreotide, 1 mg (code reused by CMS effective 1/1/09) $21.90 $17.96 96372, 96401 $37.15 $33.24 96372 mitomycin (Mutamycin) J9280 mitomycin, 5 mg $67.20 $18.15 96409 mitoxantrone (Novantrone) octreotide acetate (Sandostatin) tamoxifen (Nolvadex) J9293 mitoxantrone hydrochloride, per 5 mg J2354 octreotide, nondepot form for subcutaneous or intravenous 25 mcg $90.00 $29.97 96409, 96413 $2.50 $1.65 96365, 96372, 96374 tamoxifen (Nolvadex) S0187 tamoxifen citrate, oral, 10 mg $1.89 S0187 not payable by N/A vincristine (Vincasar PFS) J9370 vincristine sulfate, 1 mg $5.60 $4.69 96409 *When billing a nonclassified medication using a CMS 1500 claim form, you must include both the HCPCS code (i.e., J8999 for Nexavar) in column 24D and the drug name, strength and National Drug Code (NDC) in box 19 to ensure appropriate reimbursement. managedcareoncology.com 29
FDA-Approved Medications Currently Available to Treat Renal Cell Carcinoma Allowable aldesleukin (Proleukin) J9015 aldesleukin, per single-use vial $1,411.68 $1,097.99 96409 axitinib (Inlyta) axitinib (Inlyta) bevacizumab (Avastin) J9035 bevacizumab, 10 mg $71.61 $60.96 96413, everolimus (Afinitor) medroxyprogesterone J1051 medroxyprogesterone acetate, $11.12 $8.29 96402 (Depo-Provera) 50 mg pazopanib (Votrient) pazopanib (Votrient) sorafenib (Nexavar) sorafenib (Nexavar) sunitinib (Sutent) NDC level pricing NDC level pricing sunitinib (Sutent) temsirolimus (Torisel) J9330 temsirolimus, 1 mg $62.31 $52.18 96413 *When billing a nonclassified medication using a CMS 1500 claim form, you must include both the HCPCS code (i.e., J8999 for Nexavar) in column 24D and the drug name, strength and National Drug Code (NDC) in box 19 or 24A to ensure appropriate reimbursement. Please note: Check with payor regarding correct placement of medication information. 30 managedcareoncology Quarter 2 2012
Compendia-Listed Off-Label Use Medications Currently Available to Treat Renal Cell Carcinoma Allowable capecitabine (Xeloda) J8520 capecitabine, oral, 150 mg $9.77 $7.86 N/A capecitabine (Xeloda) J8521 capecitabine, oral, 500 mg $32.57 $26.02 N/A floxuridine (FUDR) J9200 floxuridine, 500 mg $143.40 $68.04 96422, 96423, 96425 fluorouracil (Adrucil) J9190 fluorouracil, 500 mg $3.30 $1.52 96409 gemcitabine (Gemzar) J9201 gemcitabine hydrochloride, $102.40 $35.17 96413 200 mg interferon alfa-2b (Intron-A) J9214 interferon alfa-2b, recombinant, $21.90 $17.96 96372, 96401 1 million units interferon alfa-n3 (Alferon N) J9215 interferon alfa-n3 (human $36.14 N/A 11900, 11901 leukocyte derived), 250,000 IU interferon gamma-1b J9216 interferon gamma-1b, $673.23 $430.93 96372 (Actimmune) 3 million units peginterferon alfa-2a (Pegasys) J3590* unclassified biologics NDC level pricing NDC level pricing 96372 peginterferon alfa-2a (Pegasys) S0145 pegylated interferon alfa-2a, 180 mcg per ml $740.27 S0145 not payable by pemetrexed (Alimta) J9305 pemetrexed, 10 mg $65.93 $54.96 96409 sargramostim (Leukine) J2820 sargramostim (GM-CSF), 50 mcg $47.36 $24.83 96365, 96366, 96372 thalidomide (Thalomid) vinblastine (Velban) J9360 vinblastine sulfate, 1 mg $3.18 $1.24 96409 *When billing a nonclassified medication using a CMS 1500 claim form, you must include both the HCPCS code (i.e., J8999 for Nexavar) in column 24D and the drug name, strength and National Drug Code (NDC) in box 19 or 24A to ensure appropriate reimbursement. Please note: Check with payor regarding correct placement of medication information. 96372 Ancillary Medications Used in Cancer Treatment Allowable aprepitant (Emend) J8501 aprepitant, oral, 5 mg $8.00 $6.17 N/A granisetron (Kytril) J1626 granisetron hydrochloride, $3.93 $1.12 96374 100 mcg granisetron (Kytril) Q0166 granisetron hydrochloride, 1 mg oral, $59.01 $1.26 N/A FDA-approved prescription antiemetic, for use as a complete therapeutic substitute for an IV antiemetic at time of chemotherapy treatment, not to exceed a 24-hour dosage regimen see also S0091 granisetron (Kytril) S0091 granisetron hydrochloride, 1 mg (For $59.01 S0091 not payable by N/A circumstances falling under the statute, use Q0166.) ondansetron (Zofran) J2405 ondansetron hydrochloride, $0.60 $0.12 96372, 96374 per 1 mg ondansetron (Zofran) Q0162 ondansetron 1 mg, oral, FDA-approved prescription antiemetic, for use as a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen see also S0119 $6.01 $0.07 N/A ondansetron (Zofran) S0119 ondansetron, oral, 4 mg (For circumstances falling under the statute, use Q0162.) $24.06 S0119 not payable by palonosetron (Aloxi) J2469 palonosetron hydrochloride, 25 mcg $44.52 $18.44 96374 N/A managedcareoncology.com 31
Code Descriptions Code Code Description 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections); one vaccine (single or combination vaccine/toxoid) (Do not use 90471 in conjunction with 90473.) 96401 Chemotherapy administration, subcutaneous or intramuscular; nonhormonal antineoplastic 96402 Chemotherapy administration, subcutaneous or intramuscular; hormonal antineoplastic 96409 Chemotherapy administration, intravenous, push technique; single or initial substance/drug 96413 Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure.) (Use in conjunction with 96413.) 96365 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); initial, up to one hour 96366 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure.) (Use 96366 in conjunction with 96365, 96367.) 96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 96374 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug 11900 Injection, intralesional; up to and including seven lesions 11901 Injection, intralesional; more than seven lesions 11981 Insertion, nonbiodegradable drug delivery implant 11982 Removal, nonbiodegradable drug delivery implant 11983 Removal with reinsertion, nonbiodegradable drug delivery implant 20600 Arthrocentesis, aspiration and/or injection; small joint or bursa (e.g., fingers, toes) 20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow, ankle, olecranon bursa) 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa) 51720 Bladder instillation of anticarcinogenic agent (including retention time) References HCPCS Level II Expert 2012. Current Procedural Terminology (CPT) 2012. American Medical Association. ICD-9-CM for Professionals, Volumes 1 and 2. Chicago: AMA Press. 2012. RJ Health Systems International, LLC. The Drug Reimbursement Coding and Pricing Guide. Volume 9, Number 2, Second Quarter, 2012. FDA-approved indication (product prescribing information). www.reimbursementcodes.com. Powered by RJ Health Systems International, LLC, Rocky Hill, Conn. CMS (Centers for & Medicaid Services) -Allowable Second Quarter 2012 Effective Dates. CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. This information was supplied by RJ Health Systems International, LLC, located in Rocky Hill, Conn. Prices and information supplied herein are effective as of April 1, 2012. 32 managedcareoncology Quarter 2 2012
Oncology-Related HCPCS Codes This reference chart will assist the Oncology Office (office manager, oncology nurse, physician and ancillary staff) and payor with the appropriate codes to utilize when billing or reimbursing for medication(s). generic (Brand) Name HCPCS Code Code Description FDA-Approved Uses Compendia-Listed Off-Label Uses Current Code Price (AWP-Based Pricing)* Allowable (ASP + 6%)** CPT Admin azacitidine (Vidaza) J9025 azacitidine, 1 mg Myeloid leukemia chronic (205.1_) Low-grade myelodysplastic syndrome lesions (238.72) High-grade myelodysplastic syndrome lesions (238.73) Myelodysplastic syndrome with 5q deletion (238.74) Myelodysplastic syndrome, unspecified (238.75) Malignant neoplasm of retroperitoneum and peritoneum specified parts of peritoneum (158.8) Malignant neoplasm of retroperitoneum and peritoneum peritoneum, unspecified (158.9) Malignant neoplasm of pleura (163._) Malignant neoplasm of thymus, heart and mediastinum heart (164.1) Myeloid leukemia acute (205.0_) Hereditary hemolytic anemias other thalassemia (282.49) Sickle-cell disease (282.6_) $6.18 $5.39 96401 96409 96413 cetuximab (Erbitux) J9055 cetuximab, 10 mg Malignant neoplasm of lip (140._) Malignant neoplasm of tongue (141._) Malignant neoplasm of major salivary glands (142._) Malignant neoplasm of gum (143._) Malignant neoplasm of floor of mouth (144._) Malignant neoplasm of other and unspecified parts of mouth (145._) Malignant neoplasm of oropharynx (146._) Malignant neoplasm of nasopharynx (147._) Malignant neoplasm of hypopharynx (148._) Malignant neoplasm of other and ill-defined sites within the lip, oral cavity and pharynx (149._) Malignant neoplasm of colon (153._) Malignant neoplasm of rectum, rectosigmoid junction and anus (154._) Malignant neoplasm of nasal cavities, middle ear and accessory sinuses (160._) Malignant neoplasm of larynx (161._) Malignant neoplasm of other and ill-defined sites head, face and neck (195.0) Secondary and unspecified malignant neoplasm of lymph nodes lymph nodes of head, face and neck (196.0) Malignant neoplasm of trachea, bronchus and lung (162._) $59.34 $50.42 96413 managedcareoncology.com 33
generic (Brand) Name HCPCS Code Code Description FDA-Approved Uses Compendia-Listed Off-Label Uses Current Code Price (AWP-Based Pricing)* Allowable (ASP + 6%)** CPT Admin clofarabine (Clolar) J9027 clofarabine, 1 mg Lymphoid leukemia acute (204.0_) Myeloid leukemia acute (205.0_) Low-grade myelodysplastic syndrome lesions (238.72) High-grade myelodysplastic syndrome lesions (238.73) Myelodysplastic syndrome with 5q deletion (238.74) Myelodysplastic syndrome, unspecified (238.75) $141.75 $122.54 96413 dactinomycin (Cosmegen) J9120 dactinomycin, 0.5 mg Malignant neoplasm of retroperitoneum and peritoneum retroperitoneum (158.0) Malignant neoplasm of bone and articular cartilage (170._) Malignant neoplasm of connective and other soft tissue (171._) Malignant neoplasm of placenta (181) Malignant neoplasm of testis undescended testis (186.0) Malignant neoplasm of testis other and unspecified testis (186.9) Malignant neoplasm of kidney and other and unspecified urinary organs kidney, except pelvis (189.0) Neoplasm of uncertain behavior of genitourinary organs placenta (236.1) Malignant melanoma of skin (172._) Kaposi s sarcoma (176._) Malignant neoplasm of ovary and other uterine adnexa (183._) Malignant neoplasm of other and unspecified female genital organs (184._) Malignant neoplasm of penis and other male genital organs (187._) Malignant neoplasm of eye (190._) Complications of transplanted organ kidney (996.81) Complications of transplanted organ heart (996.83) $684.36 $578.75 96409 decitabine (Dacogen) J0894 decitabine, 1 mg Low-grade myelodysplastic syndrome lesions (238.72) High-grade myelodysplastic syndrome lesions (238.73) Myelodysplastic syndrome with 5q deletion (238.74) Myelodysplastic syndrome, unspecified (238.75) Lymphoid leukemia acute (204.0_) Myeloid leukemia acute (205.0_) Myeloid leukemia chronic (205.1_) $39.31 $33.23 96413 degarelix (Firmagon) J9155 degarelix, 1 mg Malignant neoplasm of prostate (185) N/A $6.07 $2.96 96402 34 managedcareoncology Quarter 2 2012
generic (Brand) Name HCPCS Code Code Description FDA-Approved Uses Compendia-Listed Off-Label Uses Current Code Price (AWP-Based Pricing)* Allowable (ASP + 6%)** CPT Admin melphalan (Alkeran) J9245 melphalan hydrochloride, 50 mg Multiple myeloma and immunoproliferative neoplasms (203. ) Malignant neoplasm of retroperitoneum (158.0) Malignant neoplasm of bone and articular cartilage (170._) Malignant neoplasm of connective and other soft tissue (171._) Malignant melanoma of skin (172._) Malignant neoplasm of female breast (174._) Malignant neoplasm of male breast (175._) Malignant neoplasm of ovary and other uterine adnexa (183._) Malignant neoplasm of other and unspecified female genital organs (184._) Malignant neoplasm of prostate (185) Malignant neoplasm of testis (186._) Malignant neoplasm of penis and other male genital organs (187._) Malignant neoplasm of eye (190._) Hodgkin s disease (201. ) Myeloid leukemia chronic (205.1_) Neoplasm of uncertain behavior of other and unspecified sites and tissues polycythemia vera (238.4) Disorders of plasma protein metabolism macroglobulinemia (273.3) Other and unspecified disorders of metabolism amyloidosis, unspecified (277.30) Other and unspecified disorders of metabolism other amyloidosis (277.39) Other hypertrophic and atrophic conditions of skin other specified hypertrophic and atrophic conditions of skin (701.8) $1,922.50 $1,352.09 96409 96413 panitumumab (Vectibix) J9303 panitumumab, 10 mg Malignant neoplasm of colon (153._) Malignant neoplasm of rectum, rectosigmoid junction and anus (154._) Malignant neoplasm of trachea, bronchus and lung (162._) $103.89 $87.22 96413 managedcareoncology.com 35
generic (Brand) Name HCPCS Code Code Description FDA-Approved Uses Compendia-Listed Off-Label Uses Current Code Price (AWP-Based Pricing)* Allowable (ASP + 6%)** CPT Admin vinorelbine tartrate (Navelbine) J9390 vinorelbine tartrate, per 10 mg Malignant neoplasm of trachea, bronchus and lung (162._) Malignant neoplasm of lip (140._) Malignant neoplasm of tongue (141._) Malignant neoplasm of major salivary glands (142._) Malignant neoplasm of gum (143._) Malignant neoplasm of floor of mouth (144._) Malignant neoplasm of other and unspecified parts of mouth (145._) Malignant neoplasm of oropharynx (146._) Malignant neoplasm of nasopharynx (147._) Malignant neoplasm of hypopharynx (148._) Malignant neoplasm of other and ill-defined sites within the lip, oral cavity and pharynx (149._) Malignant neoplasm of esophagus (150._) Malignant neoplasm of retroperitoneum (158.0) Malignant neoplasm of nasal cavities, middle ear and accessory sinuses (160._) Malignant neoplasm of larynx (161._) Malignant neoplasm of connective and other soft tissue (171._) Malignant neoplasm of female breast (174._) Malignant neoplasm of male breast (175._) Kaposi s sarcoma (176._) Malignant neoplasm of cervix uteri (180._) Malignant neoplasm of ovary and other uterine adnexa (183._) Malignant neoplasm of head, face and neck (195.0) Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck (196.0) Lymphosarcoma and reticulosarcoma and other specified malignant tumors of lymphatic tissue (200. ) Hodgkin s disease (201. ) Other malignant neoplasms of lymphoid and histiocytic tissue (202. ) Carcinoma in situ of lip, oral cavity and pharynx (230.0) Carcinoma in situ of esophagus (230.1) Carcinoma in situ of larynx (231.0) Neoplasm of uncertain behavior of connective and other soft tissue (238.1) $32.04 $10.75 96409 *Current code prices are effective as of 4/1/12. The code price is based on the Healthcare Common Procedure Coding System (HCPCS) code description. HCPCS codes are a component of the Centers for & Medicaid Services. The code price is an AWP-based pricing methodology developed by RJ Health Systems International, LLC, Rocky Hill, Conn. **Effective Oncology-Related J-Code References HCPCS Level II Expert 2012. Current Procedural Terminology (CPT) 2012. American Medical Association. ICD-9-CM for Professionals, Volumes 1 and 2. Chicago: AMA Press. 2012. Full prescribing information for each drug listed. www.reimbursementcodes.com. Powered by RJ Health Systems International, LLC, Rocky Hill, Conn. CMS (Centers for & Medicaid Services) -Allowable Second Quarter Effective Dates 4/1/12-6/30/12. CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 36 managedcareoncology Quarter 2 2012