Wiki What administration code would you use for Benlysta (Belimumab) J0490

[Beckywin]

Hello! There is much discussion on our team of how to validate the administration code (chemo or non-chemo) for our complex biological/monoclonal antibody). What administration code would you use for Benlysta - J0490. Also please share how your teams are validating the admistration code for these types of drugs. thank you!!

 

[ahrx13]

Hello! There is much discussion on our team of how to validate the administration code (chemo or non-chemo) for our complex biological/monoclonal antibody). What administration code would you use for Benlysta - J0490. Also please share how your teams are validating the admistration code for these types of drugs. thank you!!

A method I use is to verify the generic name of the drug. Benlysta's generic name is belimumab, and from what I've found the '-mab' ending of the drug indicates it is a monoclonal antibody therapy, and therefore 96413 can be used for Benlysta as a complex drug/biological/monoclonal antibody. It still varies by payer but I've had good luck with this method.

If a drug doesn't end with -mab and I'm unsure how complex it is, I will look up the manufacturer's billing guide, sometimes they have advice on which code may possibly be used.

 

[tkermode]

Hello! There is much discussion on our team of how to validate the administration code (chemo or non-chemo) for our complex biological/monoclonal antibody). What administration code would you use for Benlysta - J0490. Also please share how your teams are validating the admistration code for these types of drugs. thank you!!

Medicare Claims Processing Manual, Chapter 12, 30.5.D says that monoclonal antibodies are considered complex drugs and should be reported with 96401.

I would follow that instruction unless you have a guideline that says something else.

 

[rachaelwilleford]

Honestly depends on the payer. Coding guidelines state that there has to be increased monitoring, side effects, etc. and Medicare adopted this language in their IOM manual. Read the introductory guideline language for the chemotherapy codes. This is a pretty grey area, and not all of the immunotherapies require what's outlined in the guidelines. Unfortunately, there's not really a checklist out there.