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Billing and Coding Guidefor INFLECTRA INFLECTRA is a registered trademark of Pfizer Inc.Pfizer enCompass is a registered trademark of Pfizer Inc.Please see Important Safety Information throughout, Indications on page 14, and click for full Prescribing Information, including BOXED WARNINGand Medication Guide, also available at InflectraHCP.com.
Pfizer Inc. has developed this reference guide to assist healthcare providers (HCPs) with understanding coding for INFLECTRA (infliximab-dyyb)for Injection, the first infliximab biosimilar to be approved in the United States (US).The information provided in this document is intended for informational purposes only and is not a comprehensive description of potential codingrequirements for INFLECTRA. Coding and coverage policies change periodically and often without notice. The HCP is solely responsible for determiningcoverage and reimbursement parameters and appropriate coding for treatment of his/her patients. The information provided should not be considered aguarantee of coverage or reimbursement for INFLECTRA.IMPORTANT SAFETY INFORMATIONSERIOUS INFECTIONSPatients treated with infliximab products are at increased risk for developing serious infections that may lead to hospitalization or death. Most patients who developed these infections weretaking concomitant immunosuppressants such as methotrexate or corticosteroids. Discontinue INFLECTRA if a patient develops a serious infection or sepsis.Reported infections include: Active tuberculosis (TB), including reactivation of latent TB. Patients frequently presented with disseminated or extrapulmonary disease. Patients should be tested for latent TB beforeand during treatment with INFLECTRA .1,2 Treatment for latent infection should be initiated prior to treatment with INFLECTRA . Invasive fungal infections, including histoplasmosis, coccidioidomycosis, candidiasis, aspergillosis, blastomycosis, pneumocystosis, and cryptococcosis. Patients maypresent with disseminated, rather than localized, disease. Empiric anti-fungal therapy should be considered in patients at risk for invasive fungal infections who develop severe systemic illness. Bacterial, viral, and other infections due to opportunistic pathogens, including Legionella, Listeria, and Salmonella.The risks and benefits of treatment with INFLECTRA should be carefully considered prior to initiating therapy in patients with chronic or recurrent infection. Closely monitor patients forthe development of signs and symptoms of infection during and after treatment with INFLECTRA , including the possible development of TB in patients who tested negative for latent TBinfection prior to initiating therapy, who are on treatment for latent TB, or who were previously treated for TB infection.Risk of infection may be higher in patients greater than 65 years of age, pediatric patients, patients with co-morbid conditions and/or patients taking concomitant immunosuppressant therapy. In clinicaltrials, other serious infections observed in patients treated with infliximab included pneumonia, cellulitis, abscess, and skin ulceration.FDAAPPROVEDPlease see Important Safety Information throughout, Indications on page 14, and click for full Prescribing Information, including BOXED WARNINGand Medication Guide, also available at InflectraHCP.com.2
Pfizer enCompass provides reimbursement and patient support as well as information and resources related to patient access for INFLECTRA. With Pfizer enCompass,patients have access to a team of experienced Access Counselors trained to provide the following support: Verifying and confirming patient insurance benefits for INFLECTRA Prior authorization (PA) and appeals assistance Billing and coding assistance based on a payer’s published policy Financial assistance for eligible INFLECTRA patientsFor additional information, please contact a Pfizer enCompass Access Counselor at:1-844-722-6672,Monday–Friday,8 am–8 pm ETVisitwww.pfizerencompass.comIMPORTANT SAFETY INFORMATION (Continued)MALIGNANCIESLymphoma and other malignancies, some fatal, have been reported in children and adolescent patients treated with TNF blockers, including infliximab products. Approximately half ofthese cases were lymphomas, including Hodgkin’s and non-Hodgkin’s lymphoma. The other cases represented a variety of malignancies, including rare malignancies that are usually associated withimmunosuppression and malignancies that are not usually observed in children and adolescents. The malignancies occurred after a median of 30 months after the first dose of therapy. Most of the patientswere receiving concomitant immunosuppressants.Postmarketing cases of hepatosplenic T-cell lymphoma, a rare type of T-cell lymphoma, have been reported in patients treated with TNF blockers, including infliximab products. These caseshave had a very aggressive disease course and have been fatal. The majority of reported cases have occurred in patients with Crohn’s disease or ulcerative colitis and most were in adolescentand young adult males. Almost all of these patients had received treatment with azathioprine or 6-mercaptopurine concomitantly with a TNF-blocker at or prior to diagnosis. Carefully assessthe risks and benefits of treatment with INFLECTRA , especially in these patient types.FDAAPPROVEDPlease see Important Safety Information throughout, Indications on page 14, and click for full Prescribing Information, including BOXED WARNINGand Medication Guide, also available at InflectraHCP.com.3
IntroductionINFLECTRA was approved on April 5, 2016, under the 351(k) approval pathway as the first infliximab biosimilar in the US. For biosimilars such as INFLECTRA, theCenters for Medicare & Medicaid Services (CMS) has assigned Q-codes to identify and distinguish biosimilars from the reference biologic.Coverage for INFLECTRACoverage for INFLECTRA may vary across commercial payers, Medicare, and Medicaid and by treatment site of care. HCPs should confirm payer policies prior totreating patients with INFLECTRA.Coding OverviewIn the physician office and hospital outpatient department (HOPD) sites of care, Medicare Administrative Contractors (MACs), private commercial payers, andMedicaid typically recognize the following codes for reporting INFLECTRA on claim forms.ClaimInformationINFLECTRAType of CodeCode and DescriptorRelevant Sites of ServiceHCPCS code1*Q5103: Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mgPhysician office, HOPDHCPCS modifier1JW: Drug amount discarded/not administered to any patientPhysician office, HOPDNDCs210-digit: 0069-0809-0111-digit: 00069-0809-01Physician office, HOPDRevenue codes30260: IV therapy0636: Drugs requiring detailed codingHOPD*Effective for dates of service on or after April 1, 2018.HCPCS – Healthcare Common Procedure Coding System; HOPD – hospital outpatient department; NDC – National Drug Code.IMPORTANT SAFETY INFORMATION (Continued)MALIGNANCIES (Continued)In clinical trials of all TNF-blocking agents, more cases of lymphoma were observed compared with controls and the expected rate in the general population. However, patients with Crohn’s disease,rheumatoid arthritis, or plaque psoriasis may be at higher risk for developing lymphoma. In clinical trials of some TNF blockers, including infliximab products, more cases of other malignancies were observedcompared with controls. The rate of these malignancies among infliximab-treated patients was similar to that expected in the general population whereas the rate in control patients was lower thanexpected. Cases of acute and chronic leukemia have been reported with postmarketing TNF- blocker use. As the potential role of TNF-blocker therapy in the development of malignancies is not known,caution should be exercised when considering treatment of patients with a current or a past history of malignancy or other risk factors such as chronic obstructive pulmonary disease (COPD).FDAAPPROVEDPlease see Important Safety Information throughout, Indications on page 14, and click for full Prescribing Information, including BOXED WARNINGand Medication Guide, also available at InflectraHCP.com.4
Coding and Medicare Outpatient Prospective Payment System (OPPS) Reimbursement for INFLECTRA When Purchased Through the 340B DrugDiscount Program4,5The 340B Drug Discount Program is a federal drug pricing program that offers discounted drugs to facilities that serve as safety net providers (eg,disproportionate share hospitals). Effective April 1, 2020, INFLECTRA no longer has pass-through status. As such, when INFLECTRA is purchased through the340B Drug Discount Program, certain modifiers may be necessary to report with INFLECTRA’s Q-code on the claims form.ClaimInformationType of CodeINFLECTRAHCPCS modifiers1Code and DescriptorRelevant Sites of ServiceJG*: Drug or biological acquired with 340B Drug Pricing Program discountTB†: Drug or biological acquired with 340B Drug Pricing Program discount,reported for informational purposesHOPD* The “JG” modifier triggers a reduced reimbursement rate.†Not all 340B hospitals are subject to the reduced reimbursement rate. Certain non-qualifying 340B hospitals may be required to append modifier “TB” for informational purposes.See the CMS website for additional information on 340B modifiers at ice-Payment/HospitalOutpatientPPS.HCPCS – Healthcare Common Procedure Coding System; HOPD – hospital outpatient department; OPPS – Outpatient Prospective Payment System.IMPORTANT SAFETY INFORMATION (Continued)MALIGNANCIES (Continued)Melanoma and Merkel cell carcinoma have been reported in patients treated with TNF-blocker therapy, including infliximab products. Periodic skin examination is recommended for all patients, particularlythose with risk factors for skin cancer.A population-based retrospective cohort study found a 2- to 3-fold increase in the incidence of invasive cervical cancer in women with rheumatoid arthritis treated with infliximab compared to biologics-naïvepatients or the general population, particularly those over 60 years of age. A causal relationship between infliximab products and cervical cancer cannot be excluded. Periodic screening should continue inwomen treated with INFLECTRA .FDAAPPROVEDPlease see Important Safety Information throughout, Indications on page 14, and click for full Prescribing Information, including BOXED WARNINGand Medication Guide, also available at InflectraHCP.com.5
Coding for INFLECTRA Administration and Physician ServicesCurrent Procedural Terminology (CPT ) codes define specific medical procedures performed by physicians.6 The following codes may be used to report theadministration of INFLECTRA.ClaimInformationType of CodeCPT codes6Procedures,services, andsuppliesCode and DescriptorRelevant Sites of Services96413: Chemotherapy administration, IV infusion technique; up to 1 hour, single or initialsubstance/drug96415: Chemotherapy administration, IV infusion technique; each additional hour (listseparately in addition to code for primary procedure)Physician office, HOPDE/M codes699212–99215: Established patient visitPhysician officeHCPCS code1G0463: Hospital outpatient clinic visit for assessment and management of a patientHOPDCPT modifier625: Significant, separately identifiable E/M service by the same physician or other qualifiedhealthcare professional on the same day of the procedure or other servicePhysician office, HOPDRevenue codes30500: Outpatient services, general0510: Clinic, generalHOPDE/M – evaluation and management; CPT – Current Procedural Terminology; HCPCS – Healthcare Common Procedure Coding System; HOPD – hospital outpatient department.IMPORTANT SAFETY INFORMATION (Continued)CONTRAINDICATIONSINFLECTRA is contraindicated in patients with moderate to severe (NYHA Class III/IV) congestive heart failure (CHF) at doses greater than 5 mg/kg. Higher mortality rates at the 10 mg/kg dose and higherrates of cardiovascular events at the 5 mg/kg dose have been observed in these patients. INFLECTRA should be used with caution and only after consideration of other treatment options. Patients should bemonitored closely. Discontinue INFLECTRA if new or worsening CHF symptoms appear. INFLECTRA should not be (re)administered to patients who have experienced a severe hypersensitivity reaction or topatients with hypersensitivity to murine proteins or other components of the product.FDAAPPROVEDPlease see Important Safety Information throughout, Indications on page 14, and click for full Prescribing Information, including BOXED WARNINGand Medication Guide, also available at InflectraHCP.com.6
Diagnosis Coding for INFLECTRAINFLECTRA was approved for the following indications: Moderately to severely active Crohn’s disease* Moderately to severely active rheumatoid arthritis† Moderately to severely active pediatric Crohn’s disease* Active ankylosing spondylitis Moderately to severely active ulcerative colitis* Active psoriatic arthritis Moderately to severely active pediatric ulcerative colitis* Chronic severe plaque psoriasis§,IIBased on FDA approval, the following International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis codes may be appropriatewhen submitting a claim for INFLECTRA. HCPs are responsible for determining appropriate codes based upon actual patient circumstances.Claim InformationIndicationCode and DescriptorCrohn’s diseaseK50.00–K50.919: Crohn’s diseaseUlcerative colitisK51.00–K51.919: Ulcerative colitisRheumatoid arthritisM06.0–M06.9: Other specified rheumatoid arthritisAnkylosing spondylitisM45.0–M45.9: Ankylosing spondylitisPsoriatic arthritisL40.50–L40.53: Psoriatic arthritisPlaque psoriasisL40.0: Plaque psoriasisDiagnosis7* In patients who have had an inadequate response to conventional therapy.†In combination with methotrexate.§Patients who are candidates for systemic therapy and when other systemic therapies are medically less appropriate.IIINFLECTRA should be administered to patients who will be closely monitored and have regular follow-up visits with a physician.IMPORTANT SAFETY INFORMATION (Continued)HEPATITIS B REACTIVATIONTNF blockers, including infliximab products, have been associated with reactivation of hepatitis B virus (HBV) in patients who are chronic carriers. Some cases were fatal. Patients should be tested for HBVinfection before initiating INFLECTRA . For patients who test positive, consult a physician with expertise in the treatment of hepatitis B. Exercise caution when prescribing INFLECTRA for patients identifiedas carriers of HBV and monitor closely for active HBV infection during and following termination of therapy with INFLECTRA . Discontinue INFLECTRA in patients who develop HBV reactivation and initiateantiviral therapy with appropriate supportive treatment. Exercise caution when considering resumption of INFLECTRA and monitor patients closely.FDAAPPROVEDPlease see Important Safety Information throughout, Indications on page 14, and click for full Prescribing Information, including BOXED WARNINGand Medication Guide, also available at InflectraHCP.com.7
Buy-and-Bill: HCP Purchases INFLECTRA and Submits a Claim for Reimbursement for INFLECTRA and the Administration ServicePhysician Office Sample Claim Form: CMS-1500DISCLAIMER: This sample form isintended as a reference for the codingand billing of INFLECTRA. This formis not intended to be directive andthe use of the recommended codesdoes not guarantee reimbursement.Healthcare providers may deemother codes or policies moreappropriate and should select thecoding options that most accuratelyreflect their internal guidelines, payerrequirements, practice patients, andservices rendered.X000- ‐00- ‐0000Doe,John,S010150123MainStreetXAnytownItem 24D: Specify appropriate HCPCS andCPT codes and modifiers; for example: Drug: Q5103 for INFLECTRA Administration: 96413, 96415 for m 19: If additional information isrequired to describe INFLECTRA (eg,NDC), this information may be capturedin Item 19MedicareSAMPLEDr.SmithItem 21: Specify appropriateICD-10-CM diagnosis code(s)Doe,John,SX1234567890K50.00Item 24G: Specify the billing units. Forexample, 10 units 100 mg of infliximabbiosimilar (INFLECTRA). To bill 400 mg,enter 40 tem 24E: Enter reference to thediagnosis for the CPT and HCPCS codesfrom Item 21Dr.Smith321SouthStreetAnytown,AS10101IMPORTANT SAFETY INFORMATION (Continued)HEPATOTOXICITYPLEASE PRINT OR TYPEAPPROVED OMB- ‐0938- ‐1197 FORM 1500 (02- ‐12)Severe hepatic reactions, including acute liver failure, jaundice, hepatitis, and cholestasis have been reported in patients receiving infliximab products postmarketing. Some cases were fatal or required livertransplant. Aminotransferase elevations were not noted prior to discovery of liver injury in many cases. Patients with symptoms or signs of liver dysfunction should be evaluated for evidence of liver injury. Ifjaundice and/or marked liver enzyme elevations (eg, 5 times the upper limit of normal) develop, INFLECTRA should be discontinued, and a thorough investigation of the abnormality should be undertaken.FDAAPPROVEDPlease see Important Safety Information throughout, Indications on page 14, and click for full Prescribing Information, including BOXED WARNINGand Medication Guide, also available at InflectraHCP.com.8
Buy-and-Bill: HCP Purchases INFLECTRA and Submits a Claim for Reimbursement for INFLECTRA and the Administration ServiceHospital Outpatient Sample Claim Form: UB-04DISCLAIMER: This sample form isintended as a reference for the codingand billing of INFLECTRA. This formis not intended to be directive andthe use of the recommended codesdoes not guarantee reimbursement.Healthcare providers may deemother codes or policies moreappropriate and should select thecoding options that most accuratelyreflect their internal guidelines, payerrequirements, practice patients, andservices rendered.Form Locator (FL) 42 and 43: Specifyrevenue codes and describe procedures; forexample: 0260: IV therapy 0636: Drugs requiring specificidentification - detailed coding(for INFLECTRA)FL 67: Specify appropriateICD-10-CM diagnosis 01- ‐01- quiringdetailedcoding- ‐Q5103INFLECTRAAS10101USFL 46: Specify the billing units. Forexample, 10 units 100 mg ofinfliximab biosimilar (INFLECTRA). To bill400 mg of drug, enter 40 unitsMM-DD-YY 40FL 44: Specify appropriate HCPCS andCPT codes and modifiers, for example: Drug: Q5103 for INFLECTRA Administration: 96413, 96415 for drugadministrationMedicareK50.00IMPORTANT SAFETY INFORMATION (Continued)HEMATOLOGIC EVENTSCases of leukopenia, neutropenia, thrombocytopenia, and pancytopenia (some fatal) have been reported. The causal relationship to infliximab-product therapy remains unclear. Exercise caution in patientswho have ongoing or a history of significant hematologic abnormalities. Advise patients to seek immediate medical attention if they develop signs and symptoms of blood dyscrasias or infection. Considerdiscontinuation of INFLECTRA in patients who develop significant hematologic abnormalities.FDAAPPROVEDPlease see Important Safety Information throughout, Indications on page 14, and click for full Prescribing Information, including BOXED WARNINGand Medication Guide, also available at InflectraHCP.com.9
Acquisition of INFLECTRA Through a Specialty Pharmacy: HCP Acquires INFLECTRA Through a Specialty Pharmacy and Submits a Claimfor Reimbursement Only for the Administration of INFLECTRAPhysician Office Sample Claim Form: CMS-1500DISCLAIMER: This sample form isintended as a reference for the codingand billing of INFLECTRA. This formis not intended to be directive andthe use
Type of Code Code and Descriptor Relevant Sites of Service INFLECTRA HCPCS code1* Q5103: Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg Physician office, HOPD HCPCS modifier1 JW: Drug amount discarded/not administered to any patient Physician office, HOPD NDCs2 10-digit: 00
