P: 1-844-445-8843, Option 3 F: 1-844-501-7161

HCPCS Coding in the Hospital Outpatient Department – Additional Considerations

Effective April 1, 2015, ILUVIEN has been assigned a unique HCPCS C-code, C9450. The descriptor of C9450 is “Injection, fluocinolone acetonide intravitreal implant, 0.01 mg.”

Effective January 1, 2016, ILUVIEN has been assigned a unique HCPCS J-code, J7313. The descriptor of J7313 is “Injection, fluocinolone acetonide intravitreal implant, 0.01 mg.”

It is important to note that the HCPCS billing unit for J7313 and C9450 is 0.01 mg. Each ILUVIEN implant contains a fixed dose of 0.19 mg and should be billed as 19 units using J7313 or C9450 for appropriate reimbursement.

While it is not required to include additional information in Box 19, it is recommended that you include the product NDC which is 68611-0190-02. You may also include the product description as a source of additional information for the payer: “Injection, fluocinolone acetonide intravitreal implant, 0.01 mg”.

See payer-specific guidelines or consult the ILUVIEN AccessPlus Program to determine the drug code that should be used.

Commonly Requested Information Includes:

• Drug name: ILUVIEN• National Drug Code (NDC): • 10- digit format: 68611-190-02 • 11- digit format: 68611-0190-02 • Dosage: One intravitreal implant containing 0.19 mg fluocinolone acetonide, each eye• Route of administration: Intravitreal injection (IVT)

ILUVIEN CODING: HOSPITAL OUTPATIENT DEPARTMENT (POS 22)

US-ILV-MMM-0047-03 6/16

Source for all coding sets provided in this guide may be accessed at www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/TransactionCodeSetsStands/CodeSets.html

The following table provides an overview of potential codes that may be used when billing for ILUVIEN in the hospital outpatient setting.

ILUVIEN Coding – Hospital Outpatient Department (POS 22 – Outpatient Hospital)

Type of Code Code Descriptor Notes

Patient Diagnosis

ICD-10-CM

Effective October 1, 2015

E08.311, E08.321, E08.331, E08.341, E08.351E09.311, E09.321, E09.331, E09.341, E09.351E10.311, E10.321, E10.331, E10.341, E10.351E11.311, E11.321, E11.331, E11.341, E11.351E13.311, E13.321, E13.331, E13.341, E13.351

Diabetes mellitus + ophthalmic complications + diabetic retinopathy + diabetic macular edema

In ICD-10-CM, a single code describes diabetic macular edema

Injection Procedure

CPT 67028 Intravitreal injection of pharmacologic agent, separate procedure

Use modifiers -RT and -LT to indicate which eye was injected

Drugs HCPCS C9450 Injection, fluocinolone acetonide intravitreal implant, 0.01 mg

Each ILUVIEN implant contains a fixed dose of 0.19 mg and should be billed as 19 units using J7313 (the HCPCS billing unit for J7313 is 0.01 mg). See payer-specific guidelines to determine drug code requirements

J7313

NDC 68611-190-02 (10- digit)68611-0190-02 (11- digit)

Fluocinolone acetonide intravitreal implant, 0.19 mg

See payer-specific guidelines for submitting 11- digit NDC

Cost Center Revenue 0250 (Commercial payers, Medicare, and others)

General pharmacy or biologicals See payer-specific guidelines to determine which revenue code should be used

0636 (Medicare only) Drug requiring detailed coding

Note: Providers should use clinical judgment when selecting codes and should use the codes that most accurately represent the services delivered. The coding information presented here should not be construed as legal advice or a guarantee of payment.

Please see enclosed full Prescribing Information.

P: 1-844-445-8843, Option 3 F: 1-844-501-7161

SAMPLE UB-04 (CMS-1450) CLAIM FORM (HOSPITAL OUTPATIENT DEPARTMENT BILLING)

ICD INDICATOR (Box 66)

“0” is used for ICD-10 codes.

REVENUE CODES (Box 42) AND DESCRIPTIONS (Box 43)

Product Code: 0636, Drugs requiring detailed coding or other revenue code as specified by payer.

Administration: Use most appropriate revenue code for cost center in which the service was performed.

TOTAL CHARGES (Box 47)

Report appropriate charges for product used and related procedures.

PRODUCT AND PROCEDURE CODES (Box 44)

Product Code: Use J7313, C9450, or other payer-specified code, as required by payer.

Procedure Code: Document ILUVIEN injection with CPT code 67028.

Document eye that was treated using modifiers (-RT) right side or (-LT) left side, as required by payer.

SERVICE UNITS (Box 46)

Report number of units used. (One implant = 19 units for J7313/C9450)

Report number of units here AND below in Box 80.

DIAGNOSIS CODES (Box 67)

Enter appropriate ICD-10-CM diabetic macular edema code: E08.311 -351; E09.311 -351;E10.311 -351; E11.311 -351;E13.311 -351

PRODUCT INFO (Box 80)

Include product NDC for ILUVIEN: 68611-0190-02Additional information (Optional): ILUVIEN, injection, fluocinolone acetonide intravitreal implant, 0.01mg, one implantReference vendor-specific requirements for Box 80 qualifiers.

Please see enclosed full Prescribing Information.

Note: This is a sample only and is being provided for illustrative purposes only. Providers should use clinical judgment when selecting codes and should use the codes that most accurately represent the services delivered. The coding information presented here should not be construed as legal advice or a guarantee of payment.