Editor’s Note: Our coding and reimbursement column shows oncologists how to avoid headaches and maximize revenue by helping billing staff report accurate claims.
The Centers for Medicare and Medicaid Services (CMS) recently released updates to the Healthcare Common Procedure Coding System (HCPCS) Level II file that went into effect on Jan. 1, 2024. These changes include multiple new codes for drugs used to treat lung cancer, breast cancer, leukemia, and lymphoma, as well as four new principal illness navigation codes.
Here’s what oncologists should know to ensure maximum reimbursement and compliance.
New Codes Introduced for Drugs That Combat Cancer Therapies’ Adverse Effects
CMS added several new injection codes for drugs that combat adverse effects caused by cancer medicines. For example, you will see C9145 [Injection, aprepitant, (aponvie), 1 mg], which is used to prevent acute and delayed nausea and vomiting caused by chemotherapy.
The following three codes are now available for injections used to treat neutropenia caused by cancer medicines:
J1449 [Injection, eflapegrastim-xnst, 0.1 mg]
Q5130 [Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg]
Q5127 [Injection, pegfilgrastim-fpgk (stimufend), biosimilar, 0.5 mg]
Lung Cancer Drug Codes Expand
This quarter also saw the addition of the following pemetrexed injections, a folate analog used to treat non-small cell lung cancer (NSCLC):
J9294 [Injection, pemetrexed (hospira), not therapeutically equivalent to J9305, 10 mg]
J9296 [Injection, pemetrexed (accord), not therapeutically equivalent to J9305, 10 mg]
J9297 [Injection, pemetrexed (sandoz), not therapeutically equivalent to J9305, 10 mg]
J9322 [Injection, pemetrexed (bluepoint), not therapeutically equivalent to J9305, 10 mg]
J9323 [Injection, pemetrexed (hospira), not therapeutically equivalent to J9305, 10 mg]
J9324 [Injection, pemetrexed (pemrydi rtu), 10 mg]
Practices can also report J9347 [Injection, tremelimumab-actl, 1 mg] when treating patients with NSCLC that has spread to other parts of the body and is not associated with EGFR or ALK gene abnormalities.
“Do Not Rely on Your Coding Software”
CMS added multiple codes for leukemia treatments. These include J9255 [Injection, methotrexate (accord) not therapeutically equivalent to J9250 or J9260, 50 mg].
The following codes have been added for bendamustine injections, which can also be used to treat indolent B-cell non-Hodgkin lymphoma and chronic lymphocytic leukemia.
J9056 [Injection, bendamustine hydrochloride (vivimusta), 1 mg]
J9058 [Injection, bendamustine hydrochloride (apotex), 1 mg]
J9059 [Injection, bendamustine hydrochloride (baxter), 1 mg]
“There are a lot of new drugs on the list this year. We recommend that you do not rely on your coding software to determine if waste can be reported for a drug,” said Angie Wood, CPC, senior physician auditor and educator at Pinnacle Enterprise Risk Consulting Services. ”Instead, you should look at the box to see what type of vial it is. If it says single-dose vial, you can report waste with modifier JW (Drug amount discarded/not administered to any patient). You report the dose given on the first line without a modifier and report the amount wasted on the second line with a JW modifier appended. However, if the box says multidose vial, you cannot report waste.”
“A good example of this is code J9059,” Wood added. “When we looked this code up in our coding software, modifier JW was listed as an appropriate modifier. So, we might assume that we could report waste. However, when we look at the actual box for the drug, it states it is a multidose vial. We would have been incorrect to assume we could report waste for this drug.”
Take Note of Lymphoma Injection Codes
This year, the HCPCS code set also gained several new codes to specify injections for the treatment of lymphoma. These include the following:
J9350 [Injection, mosunetuzumab-axgb, 1 mg]
J9321 [Injection, epcoritamab-bysp, 0.16 mg]
J9286 [Injection, glofitamab-gxbm, 2.5 mg]
Changes Rolled Out for Metastatic Breast Cancer Drugs
New codes for reporting injections used to treat metastatic breast cancer were also added. These include the following:
J9258 [Injection, paclitaxel protein-bound particles (teva) not therapeutically equivalent to J9264, 1 mg]
J9259 [Injection, paclitaxel protein-bound particles (american regent) not therapeutically equivalent to J9264, 1 mg]
J9196 [Injection, gemcitabine hydrochloride (accord), not therapeutically equivalent to J9201, 10 mg]
J9172 [Injection, docetaxel (ingenus) not therapeutically equivalent to J9171, 1 mg]
Key Updates Introduced for Principal Illness Navigation
CMS’s Medicare physician payment schedule final rule for 2024 introduced the following new HCPCS G-codes:
G0023 [Principal illness navigation services by certified or trained auxiliary personnel, including a patient navigator or certified peer specialist, under the direction of a physician or other practitioner; 60 minutes per calendar month]
G0024 [Principal illness navigation services; each additional 30 minutes per calendar month]
G0140 [Principal illness navigation – Peer Support by certified or trained auxiliary personnel, including a certified peer specialist, under the direction of a physician or other practitioner; 60 minutes per calendar month]
G0146 [Principal illness navigation – Peer Support; each additional 30 minutes per calendar month]
Principal illness navigation (PIN) services help patients identify and connect with appropriate clinical and support resources, according to a special November 2023 edition of CPT Assistant: Reporting CPT Codes for Oncology Navigation Services: The Cancer Moonshot. These codes describe services that help patients navigate serious, high-risk conditions such as cancer.
Codes G0023 and G0024 were created for PIN services that certified or trained auxiliary personnel provide under the direction of a physician or other practitioner. These personnel include patient navigators and certified peer specialists. Codes G0140 and G0146 were created for reporting PIN services provided by peer support specialists around behavioral health conditions.
“It is important to note that the PIN codes (G0023, G0024, G0140, and G0146) require an initiating evaluation and management [E/M] visit before they can be reported,” Wood said. “The final rule states that the same practitioner would furnish and bill for both the PIN initiating visit and the PIN services. The implications of this are that CMS will be expecting to see an initiating E/M visit prior to a PIN service. They will also expect both of those services to be reported by the same provider.”
Medicare has already started paying for the PIN codes, Wood confirmed.
The national nonfacility rate for G0023 is $79.24, for G0024 it is $49.44, for G0140 it is $79.24, and for G0146 it is $49.44, she said.
