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YERVOY™ (ipilimumab) Billing and Diagnosis Codes
Healthcare providers should code healthcare claims based upon the service that is rendered, the patient's medical record, the coding requirements of each health insurer, and best coding practices. Coding guidance under this heading does not provide a guarantee of reimbursement and should be considered together with all applicable coding guidance and standards.
YERVOY is most frequently administered to patients on an outpatient basis and billed to health plans using the following claim formats: CMS-1500 and UB-04 (paper formats) and ASC 837P and ASC 837I (electronic formats). All the coding information presented by this website is applicable to outpatient procedures only.
- YERVOY was assigned a J-code effective January 1, 20121
- The new Healthcare Common Procedure Coding System (HCPCS) code, J9228, replaces HCPCS C-code C9284 (Injection, ipilimumab, 1 mg) and miscellaneous codes J9999, J3590, and J34901
- The rate of J-code adoption may vary by payer. Please contact the payer or Access Support for additional information
The accurate completion of reimbursement- or coverage-related documentation is the responsibility of the healthcare provider and patient.
Bristol-Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.
This coding guidance is not intended to provide specific directions on requesting prior authorization or submitting claims for YERVOY and does not provide a guarantee of receiving prior authorization or reimbursement.
Coding for YERVOY is dependent on the insurer and the care setting in which the drug will be administered.
Oncology practices need to make coding decisions based on the diagnosis and treatment of each patient and the specific insurer requirements.
National Drug Codes (NDCs) Listing for YERVOY
The NDCs for YERVOY, listed in the table below, are often necessary in addition to the appropriate J- or C-code when filing a claim for reimbursement. Billing for YERVOY should be reported by total dose in 1-mg increments.
This coding guide is not intended to provide specific directions on requesting prior authorization or submitting claims for YERVOY. Oncology practices need to make coding decisions on the diagnosis and treatment of each patient and the specific insurer requirements. The coding guidance does not provide a guarantee of receiving prior authorization or reimbursement.
YERVOY Diagnosis Coding
For Unresectable or Metastatic Melanoma Patients
Use the following ICD-9-CM diagnosis codes for unresectable or metastatic melanoma, the labeled indications for YERVOY.
Note: If infusion is the only reason for the patient encounter, physicians and hospitals should report V58.11 as the primary diagnosis. A diagnosis code from the following list would then be reported as the secondary diagnosis.
The ICD-9-CM diagnosis codes for malignant melanoma of the skin are3:
Malignant Melanoma of the Skin – 172
Malignant neoplasm of the rectum, rectosigmoid junction, and anus – 154a
- 172.0 Malignant melanoma of skin of lip
- 172.1 Malignant melanoma of skin of eyelid including canthus
- 172.2 Malignant melanoma of skin of ear and external auditory canal
- 172.3 Malignant melanoma of skin of other and unspecified parts of face
- 172.4 Malignant melanoma of skin of scalp and neck
- 172.5 Malignant melanoma of skin of trunk except scrotum
- 172.6 Malignant melanoma of skin of upper limb including shoulder
- 172.7 Malignant melanoma of skin of lower limb including hip
- 172.8 Malignant melanoma of other specified sites of skin
- 172.9 Malignant melanoma of skin, site unspecified
Malignant neoplasm of other and unspecified female genital organs – 184a
- 154.2 Malignant neoplasm of anal canal
- 154.3 Malignant neoplasm of anus, unspecified
Malignant neoplasm of the penis and other male genital organs–187a
- 184.0 Malignant neoplasm of vagina
- 184.1 Malignant neoplasm of labia majora
- 184.2 Malignant neoplasm of labia minora
- 184.4 Malignant neoplasm of vulva, unspecified
Secondary malignant neoplasms–196 – 198b
- 187.1 Malignant neoplasm of prepuce
- 187.4 Malignant neoplasm of penis, part unspecified
- 187.7 Malignant neoplasm of scrotum
- 187.9 Malignant neoplasm of male genital organ, site unspecified
Secondary malignant neoplasm, site unspecified – 199b
- 196.0 – 196.9 Secondary and unspecified malignant neoplasm of lymph nodes
- 197.0 – 197.8 Secondary malignant neoplasm of respiratory and digestive systems
- 198.0 – 198.8 Secondary malignant neoplasm of other specified sites
- 199.0 – 199.1 Malignant neoplasm without specification of site
- a Melanoma may originate in the anal-genital areas of the body.4
- b Please refer to the ICD-9-CM manual for specific sites and descriptors.
Billing for Partially-Used Vials
YERVOY is supplied as 50-mg or 200-mg single-use vials each containing 10mL or 40mL, respectively, of a 5 mg/mL, sterile, ipilimumab solution.2
If a patient requires less than a full vial, can the wasted drug be billed?
Each vial of YERVOY is labeled "Single Use." Medicare accepts billing for drug that is wasted from a single-use vial if certain conditions are met, including efficient use.
"CMS encourages providers to schedule patients in such a way that they can use drugs or biologics most efficiently, in a clinically appropriate manner"5
- Some Medicare Administrative Contractors (MACs) may require providers to report wasted drug as a separate line item on claim forms. The modifier "JW" is attached to the drug code on the line item for the wasted drug (e.g., J9228-JW). Thus, the amount administered is reported on one line with the appropriate units, and the amount wasted is reported on a second line with modifier –JW– with the appropriate units6
- Other MACs will accept this modifier, but most do not require it. If a practice opts to report modifier –JW– to a MAC that does not require it, the practice should pay close attention to the individual MAC's reporting requirements to determine whether the drug administered and the drug discarded should be reported as one line item or two7
This site is intended to provide reimbursement support.
Please visit www.YERVOY.com for detailed product and clinical information.
- Alpha-numeric HCPCS. Centers for Medicare & Medicaid Services Web site. http://www.cms.gov/HCPCSReleaseCodeSetsDownloads/12anweb.zip. Accessed December 8, 2011.
- YERVOY (ipilimumab) [package insert]. Princeton, NJ: Bristol-Myers Squibb; March 2011.
- Buck CJ, ed. 2011 ICD-9-CM Volumes 1 & 2: for Physicians. St. Louis, MO: Elsevier Inc.; 2011.
- Rogers RS III, Gibson LE. Mucosal, genital, and unusual clinical variants of melanoma. Mayo Clin Proc. 1997;72(4):362-366.
- Drugs and biologicals. Centers for Medicare and Medicaid Services. http://www.cms.gov/manuals/downloads/clm104c17.pdf. Accessed December 8, 2011.
- Drug wastage. Trailblazer Health Enterprises. http://www.trailblazerhealth.com/Publications/Job%20Aid/Drug%20Wastage.pdf. Accessed December 8, 2011.
- Publication 100-20: discarded drugs and biologicals at contractor discretion. Centers for Medicare and Medicaid Services.
http://www.cms.gov/transmittals/downloads/R758OTN.pdf. Revised August 20, 2010. Accessed December 8, 2011.