Codes and coverage

Codes and coverage

Supporting patient access

BMS Access Support® may help support patient access by conducting benefits reviews and offering prior authorization and appeals process assistance for enrolled patients. Additionally, the information below provides product-specific billing and diagnosis codes, reimbursement and coding guides, distribution information, and additional coverage support offerings. To view available coding and coverage information, please select your patient’s prescribed medication.

Additional eligibility criteria and terms may apply. Bristol Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.

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*BMS Access Support Data - Benefits review. Accessed August 2022.

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ABRAXANE® for Injectable Suspension

(paclitaxel protein-bound particles for injectable suspension) (albumin-bound)

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.

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Reimbursement and Coding Guide
for ABRAXANE

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Healthcare Common Procedure Coding System (HCPCS) Code1

Issued by CMS

J9264 CopyInjection, paclitaxel protein-bound particles, 1 mg

Providers and suppliers are required to report the JW modifier on Part B drug claims for discarded drugs and biologicals. Also, providers and suppliers must document the amount of discarded drugs or biologicals in Medicare beneficiaries’ medical records.2

Revenue Codes (for Use in the Hospital Outpatient Setting)3

0250 Copy General pharmacy
0258 Copy IV solutions; administration
0260 Copy IV therapy (required by Medicare for separate billable drugs)
0636 Copy Drugs requiring detailed coding; may be used to specify the drug given

Current Procedural Terminology (CPT)4,†

96413 Copy Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug

National Drug Codes (NDC)5

Issued by the FDA

Note: Payers require the submission of the 11-digit NDC on healthcare claim forms. Please use the 11-digit codes shown here.

68817-0134-50 Copy 100 mg of paclitaxel in a single-dose vial, individually packaged in a carton

International Classification of Diseases, Tenth Revision, Clinical Modification Diagnosis Codes (ICD-10-CM)6

Metastatic Breast Cancer ICD-10 Codes

C50 Copy Malignant neoplasm of breast
C50.0 Copy Malignant neoplasm of nipple and areola
C50.01 Copy Malignant neoplasm of nipple and areola, female
C50.011 Copy Malignant neoplasm of nipple and areola, right female breast
C50.012 Copy Malignant neoplasm of nipple and areola, left female breast
C50.019 Copy Malignant neoplasm of nipple and areola, unspecified female breast
C50.1 Copy Malignant neoplasm of central portion of breast
C50.11 Copy Malignant neoplasm of central portion of breast, female
C50.111 Copy Malignant neoplasm of central portion of right female breast
C50.112 Copy Malignant neoplasm of central portion of left female breast
C50.119 Copy Malignant neoplasm of central portion of unspecified female breast
C50.2 Copy Malignant neoplasm of upper-inner quadrant of breast
C50.21 Copy Malignant neoplasm of upper-inner quadrant of breast, female
C50.211 Copy Malignant neoplasm of upper-inner quadrant of right female breast
C50.212 Copy Malignant neoplasm of upper-inner quadrant of left female breast
C50.219 Copy Malignant neoplasm of upper-inner quadrant of unspecified female breast
C50.3 Copy Malignant neoplasm of lower-inner quadrant of breast
C50.31 Copy Malignant neoplasm of lower-inner quadrant of breast, female
C50.311 Copy Malignant neoplasm of lower-inner quadrant of right female breast
C50.312 Copy Malignant neoplasm of lower-inner quadrant of left female breast
C50.319 Copy Malignant neoplasm of lower-inner quadrant of unspecified female breast
C50.4 Copy Malignant neoplasm of upper-outer quadrant of breast
C50.41 Copy Malignant neoplasm of upper-outer quadrant of breast, female
C50.411 Copy Malignant neoplasm of upper-outer quadrant of right female breast
C50.412 Copy Malignant neoplasm of upper-outer quadrant of left female breast
C50.419 Copy Malignant neoplasm of upper-outer quadrant of unspecified female breast
C50.5 Copy Malignant neoplasm of lower-outer quadrant of breast
C50.51 Copy Malignant neoplasm of lower-outer quadrant of breast, female
C50.511 Copy Malignant neoplasm of lower-outer quadrant of right female breast
C50.512 Copy Malignant neoplasm of lower-outer quadrant of left female breast
C50.519 Copy Malignant neoplasm of lower-outer quadrant of unspecified female breast
C50.6 Copy Malignant neoplasm of axillary tail of breast
C50.61 Copy Malignant neoplasm of axillary tail of breast, female
C50.611 Copy Malignant neoplasm of axillary tail of right female breast
C50.612 Copy Malignant neoplasm of axillary tail of left female breast
C50.619 Copy Malignant neoplasm of axillary tail of unspecified female breast
C50.8 Copy Malignant neoplasm of overlapping sites of breast
C50.81 Copy Malignant neoplasm of overlapping sites of breast, female
C50.811 Copy Malignant neoplasm of overlapping sites of right female breast
C50.812 Copy Malignant neoplasm of overlapping sites of left female breast
C50.819 Copy Malignant neoplasm of overlapping sites of unspecified female breast
C50.9 Copy Malignant neoplasm of breast of unspecified site
C50.91 Copy Malignant neoplasm of breast of unspecified site, female
C50.911 Copy Malignant neoplasm of unspecified site of right female breast
C50.912 Copy Malignant neoplasm of unspecified site of left female breast
C50.919 Copy Malignant neoplasm of unspecified site of unspecified female breast
C50.0 Copy Malignant neoplasm of nipple and areola
C50.02 Copy Malignant neoplasm of nipple and areola, male
C50.021 Copy Malignant neoplasm of nipple and areola, right male breast
C50.022 Copy Malignant neoplasm of nipple and areola, left male breast
C50.029 Copy Malignant neoplasm of nipple and areola, unspecified male breast
C50.1 Copy Malignant neoplasm of central portion of breast
C50.12 Copy Malignant neoplasm of central portion of breast, male
C50.121 Copy Malignant neoplasm of central portion of right male breast
C50.122 Copy Malignant neoplasm of central portion of left male breast
C50.129 Copy Malignant neoplasm of central portion of unspecified male breast
C50.2 Copy Malignant neoplasm of upper-inner quadrant of breast
C50.22 Copy Malignant neoplasm of upper-inner quadrant of breast, male
C50.221 Copy Malignant neoplasm of upper-inner quadrant of right male breast
C50.222 Copy Malignant neoplasm of upper-inner quadrant of left male breast
C50.229 Copy Malignant neoplasm of upper-inner quadrant of unspecified male breast
C50.3 Copy Malignant neoplasm of lower-inner quadrant of breast
C50.32 Copy Malignant neoplasm of lower-inner quadrant of breast, male
C50.321 Copy Malignant neoplasm of lower-inner quadrant of right male breast
C50.322 Copy Malignant neoplasm of lower-inner quadrant of left male breast
C50.329 Copy Malignant neoplasm of lower-inner quadrant of unspecified male breast
C50.4 Copy Malignant neoplasm of upper-outer quadrant of breast
C50.42 Copy Malignant neoplasm of upper-outer quadrant of breast, male
C50.421 Copy Malignant neoplasm of upper-outer quadrant of right male breast
C50.422 Copy Malignant neoplasm of upper-outer quadrant of left male breast
C50.429 Copy Malignant neoplasm of upper-outer quadrant of unspecified male breast
C50.5 Copy Malignant neoplasm of lower-outer quadrant of breast
C50.52 Copy Malignant neoplasm of lower-outer quadrant of breast, male
C50.521 Copy Malignant neoplasm of lower-outer quadrant of right male breast
C50.522 Copy Malignant neoplasm of lower-outer quadrant of left male breast
C50.529 Copy Malignant neoplasm of lower-outer quadrant of unspecified male breast
C50.6 Copy Malignant neoplasm of axillary tail of breast
C50.62 Copy Malignant neoplasm of axillary tail of breast, male
C50.621 Copy Malignant neoplasm of axillary tail of right male breast
C50.622 Copy Malignant neoplasm of axillary tail of left male breast
C50.629 Copy Malignant neoplasm of axillary tail of unspecified male breast
C50.8 Copy Malignant neoplasm of overlapping sites of breast
C50.82 Copy Malignant neoplasm of overlapping sites of breast, male
C50.821 Copy Malignant neoplasm of overlapping sites of right male breast
C50.822 Copy Malignant neoplasm of overlapping sites of left male breast
C50.829 Copy Malignant neoplasm of overlapping sites of unspecified male breast
C50.9 Copy Malignant neoplasm of breast of unspecified site
C50.92 Copy Malignant neoplasm of breast of unspecified site, male
C50.921 Copy Malignant neoplasm of unspecified site of right male breast
C50.922 Copy Malignant neoplasm of unspecified site of left male breast
C50.929 Copy Malignant neoplasm of unspecified site of unspecified male breast

Advanced Non-Small Cell Lung Cancer ICD-10 Codes

C34.1 Copy Malignant neoplasm of upper lobe, bronchus or lung
C34.10 Copy Malignant neoplasm of upper lobe, unspecified bronchus or lung
C34.11 Copy Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Copy Malignant neoplasm of upper lobe, left bronchus or lung
C34.2 Copy Malignant neoplasm of middle lobe, bronchus or lung
C34.3 Copy Malignant neoplasm of lower lobe, bronchus or lung
C34.30 Copy Malignant neoplasm of lower lobe, unspecified bronchus or lung
C34.31 Copy Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Copy Malignant neoplasm of lower lobe, left bronchus or lung
C34.8 Copy Malignant neoplasm of overlapping sites of bronchus and lung
C34.80 Copy Malignant neoplasm of overlapping sites of unspecified bronchus and lung
C34.81 Copy Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82 Copy Malignant neoplasm of overlapping sites of left bronchus and lung
C34.9 Copy Malignant neoplasm of unspecified part of bronchus or lung
C34.90 Copy Malignant neoplasm of unspecified part of unspecified bronchus or lung
C34.91 Copy Malignant neoplasm of unspecified part of right bronchus or lung
C34.92 Copy Malignant neoplasm of unspecified part of left bronchus or lung

Metastatic Pancreatic Adenocarcinoma ICD-10 Codes

C25 Malignant neoplasm of pancreas
C25.0 Malignant neoplasm of head of pancreas
C25.1 Malignant neoplasm of body of pancreas
C25.2 Malignant neoplasm of tail of pancreas
C25.3 Malignant neoplasm of pancreatic duct
C25.4 Malignant neoplasm of endocrine pancreas
C25.7 Malignant neoplasm of other parts of pancreas
C25.8 Malignant neoplasm of overlapping sites of pancreas
C25.9 Malignant neoplasm of pancreas, unspecified

Coding for ABRAXANE 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.

Please see U.S. Full Prescribing Information for ABRAXANE, including Boxed WARNING.

*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 provided under this heading does not provide a guarantee of reimbursement and should be considered together with all applicable coding guidance and standards. All of the coding information presented by this website is applicable to outpatient procedures only.

CPT codes and descriptions only are ©2023 by American Medical Association (AMA). All rights reserved. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association.

References:

  1. American Medical Association. 2020 HCPCS Level II. Professional ed. Chicago, IL: American Medical Association; 2020.
  2. Medicare Claims Processing Manual. Chapter 17 – Drugs and Biologicals Revision 11572, August 25, 2022. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf. Accessed August 10, 2023.
  3. Palmetto GBA. Medicare Part A Billing Guide. May 2017. http://www.palmettogba.com/Palmetto/Providers.Nsf/files/Part_A_Billing_Guide.pdf/$File/Part_A_Billing_Guide.pdf. Accessed August 2, 2023.
  4. American Medical Association. CPT Professional 2020. Professional ed. Chicago, IL: American Medical Association; 2019.
  5. ABRAXANE for Injectable Suspension (paclitaxel protein-bound particles for injectable suspension) (albumin-bound) [package insert]. Princeton, NJ: Bristol-Myers Squibb Company.
  6. Centers for Medicare & Medicaid Services. ICD-10-CM tabular list of diseases and injuries. https://www.cms.gov/medicare/coding-billing/icd-10-codes/2023-icd-10-cm. Accessed August 2, 2023.

ABRAXANE may be purchased through the distributors listed below.

Specialty Distributor Phone Orders Fax Orders and Website
ASD Healthcare 1-800-746-6273 Fax: 1-800-547-9413
https://www.asdhealthcare.com
Cardinal Health Specialty Pharmaceutical Distribution 1-877-453-3972 https://specialtyonline.cardinalhealth.com
CuraScript Specialty Distribution 1-877-599-7748 https://www.curascriptsd.com
McKesson Plasma and Biologics 1-877-625-2566 Fax: 1-888-752-7626
https://connect.mckesson.com
McKesson Specialty 1-800-482-6700 https://mscs.mckesson.com
Morris & Dickson Specialty 1-800-710-6100 Fax: 1-318-524-3096
https://www.mdspecialtydist.com
Oncology Supply 1-800-633-7555 https://www.oncologysupply.com
Wholesalers Phone Orders Fax Orders and Website
Amerisource
Bergen Corporation
1-844-222-2273 https://abcorder.amerisourcebergen.com
Cardinal Health Inc. 1-800-964-5227 https://www.cardinalhealth.com/en/login.html
DMS Pharmaceutical Group, Inc. 1-877-788-1100 Fax: 1-847-518-1105
https://www.dmspharma.com
McKesson Corporation 1-855-625-7385 (independent chain pharmacies)
1-855-625-6285 (retail account)
1-855-625-4677 (hospitals and health systems)
https://connect.mckesson.com
Morris & Dickson Co., LLC 1-800-388-3833 https://www.mdwebportal.net
N.C. Mutual Wholesale Drug Co. 1-800-800-8551 https://orders.mutualdrug.com
Smith Drug Company Div Jm Smith Corporation 1-800-542-1216 https://egate.smithdrug.com/

Puerto Rico Hospitals and Oncology Clinics

Authorized Distributor Phone Orders Fax Orders and Website
Cardinal Puerto Rico (Borschow) 1-787-625-4200 https://www.cardinalhealth.pr
Cesar Castillo, Inc. 1-787-641-5242 (Hospitals)
1-787-641-5082 (Specialty Pharmacies)
Fax: 1-787-999-1614
https://www.facilfarmaciacci.com

Above information is accurate as of 12/23.

The ABRAXANE distribution program includes extended payment terms to Bristol Myers Squibb authorized ABRAXANE distributors. Healthcare providers and institutions should contact their ABRAXANE distributor to understand specific payment terms that may be available to them from their distributor.

Please see U.S. Full Prescribing Information for ABRAXANE, including Boxed WARNING.

FDA Approval Letters as Posted by the FDA:

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For the treatment of metastatic breast cancer after failure of combination chemotherapy for metastatic disease or relapse within 6 months of adjuvant chemotherapy. Prior therapy should have included an anthracycline unless clinically contraindicated

View Letter
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For the first-line treatment of locally advanced or metastatic non–small cell lung cancer, in combination with carboplatin, in patients who are not candidates for curative surgery or radiation therapy

View Letter
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For the first-line treatment of patients with metastatic adenocarcinoma of the pancreas, in combination with gemcitabine

View Letter

Please see U.S. Full Prescribing Information for ABRAXANE, including Boxed WARNING.