CODING FOR XOFIGOa
Xofigo and its associated services may be reported with the codes listed below.
Healthcare Common Procedure Coding System (HCPCS) codes
In a freestanding center or hospital outpatient setting, Xofigo is reported using the product-specific HCPCS A-code, A9606 (radium Ra 223 dichloride, therapeutic, per microcurie).1
Please note that individual Medicare Administrative Contractors (MACs), private payors, or other payors or claims processors may have different coding requirements for radiopharmaceuticals in the freestanding center. Xofigo® Access Services can research payor-specific coding requirements in performing patient-specific benefit verifications.
Providers should confirm the appropriate coverage, coding, and reimbursement with the applicable payor or claims processor before submitting claims for an item or service. Providers must ensure that all claims submitted to payors are accurate, complete, and adequately supported by documentation in the medical record.
Payors differ on guidelines and criteria required for billing an office visit on the same day as other physician services. It is important to verify appropriate coding with a patient’s health insurance plan before submitting the CMS-1500 claim form for reimbursement. Additional information required by the payor may include:
- Xofigo Prescribing Information
- FDA approval letter for Xofigo
- Patient medical history
- Physician clinical notes on the patient’s condition
- Letter of medical necessity
- Invoice for Xofigo
- National Drug Code for Xofigo (Medicaid and/or commercial payors)
Current Procedural Terminology (CPT) codes
Physicians use CPT codes to report medical services provided in a freestanding center or hospital outpatient setting, including the administration of Xofigo.
Revenue codes for the UB-04 claim form
The UB-04 claim form also requires documentation of revenue codes associated with services provided to patients receiving Xofigo. Please confirm payor guidelines as other revenue codes, including 0636 (drugs requiring detailed coding), may also be appropriate when submitting a claim for Xofigo.
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10 CM) codes (as of October 1, 2015)
Appropriately coding and classifying the patient’s diagnosis and condition is important to support medical necessity for receiving Xofigo.
Xofigo is indicated for the treatment of patients with castration-resistant prostate cancer (CRPC), symptomatic bone metastases and no known visceral metastatic disease.
Evaluation and management (E/M) codes may also be used to describe services provided by the physician when the patient’s condition is significant and beyond the intravenous injection of Xofigo. If an E/M service is billed in addition to the intravenous injection of Xofigo, the modifier “-25” is necessary to indicate a significant and separately identifiable E/M service by the same physician on the same day. The provider must document the additional service in the patient’s medical record.
Comprehensive support right when you need it
Counselors are available from 9:00 AM to 7:00 PM ET, Monday through Friday:
- Call 1-855-6XOFIGO (1-855-696-3446)
- Fax 1-855-963-4463
aInformation provided on this page is for informational purposes only and does not guarantee that codes will be appropriate or that coverage and reimbursement will result. Customers should consult with their payors for all relevant coverage, coding, and reimbursement requirements. It is the sole responsibility of the provider to select proper codes and ensure the accuracy of all claims used in seeking reimbursement. Neither this resource nor Xofigo Access Services is intended as legal advice or as a substitute for a provider’s independent professional judgment.
- Centers for Medicare & Medicaid Services. HCPCS release and code sets. Alpha-numeric HCPCS items. 2016. http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS-Items/2016-Alpha-Numeric-HCPCS-File.html. Accessed September 6, 2016. Return to content
- American Medical Association. 2012 CPT Professional Edition. American Medical Association; 2011. Return to content
- Centers for Medicare & Medicaid Services. CMS Manual System. Pub. 100-04 Medicare Claims Processing. Transmittal 423. 2005. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R423CP.pdf. Accessed September 6, 2016. Return to content
- Centers for Medicare & Medicaid Services. CMS Manual System. Pub. 100-04 Medicare Claims Processing. Transmittal 167. 2004. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R167CP.pdf. Accessed September 6, 2016. Return to content
- Ingenix. 2014 International Classification of Diseases, 10th Revision, Clinical Modification Mappings. OPTUMInsight, Inc.; 2013. Return to content