Article - Billing and Coding: Bevacizumab and biosimilars (A52370)

CMS National Coverage PolicyN/AArticle TextThis article contains billing and coding guidelines that complement the Local Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and Off-Label Uses.Coding Information:When billing for metastatic (secondary) disease, only use the code for the primary malignancy if still present, and only use the related personal history of Z code if not.For claims submitted to the Part B MAC:NON-OPHTHALMOLOGIC GUIDELINESBevacizumab should be reported with HCPCS code J9035 (injection, bevacizumab, 10 mg). The number of services should reflect multiples of 10 mg provided.Bevacizumab-awwb should be reported with HCPCS code Q5107 (injection, bevacizumab-awwb, biosimilar, (MVASI), 10 mg).Bevacizumab-bvzr should be reported with HCPCS code Q5118 (injection, bevacizumab-bvzr, biosimilar, (ZIRABEV), 10 mg).Effective 01/01/2023, HCPCS code Q5126 should be used to report bevacizumab-maly, biosimilar, (ALYMSYS1), 10 mg. Effective 10/01/2022 through 12/31/2022, bevacizumab-maly should be reported with HCPCS code C9142 (injection, bevacizumab-maly, biosimilar, (ALYMSYS), 10 mg).Effective 04/01/2023, HCPCS code Q5129 should be used to report bevacizumab-adcd (Vegzelma). Effective 09/27/2022 through 03/31/2023 HCPCS code J3590 should be reported.OPHTHALMOLOGIC GUIDELINESClaims for small dose bevacizumab and biosimilars for the treatment of approved ophthalmologic indications, for providers who bill the Part B MAC, should be submitted using HCPCS code C9142, J9035, Q5107 or Q5118 (bill one unit per eye).HCPCS code C9257 (injection, bevacizumab, 0.25 mg) should be reported for treatment of approved ophthalmologic indications when billed in an ambulatory surgical center setting.The claim for the intravitreal injection should be coded using CPT code 67028. The appropriate site modifier (RT, LT or 50) must be appended to indicate if the service was performed unilaterally or bilaterally. Claims without a modifier will be returned to the provider unprocessed.If the drug is denied as not reasonable and necessary, the associated injection code will also be denied.For claims submitted to the Part A MAC:NON-OPHTHALMOLOGIC GUIDELINESBevacizumab should be reported with HCPCS code J9035 (injection, bevacizumab, 10 mg). The number of services should reflect multiples of 10 mg provided.Bevacizumab-awwb should be reported with HCPCS code Q5107 (injection, bevacizumab-awwb, biosimilar, (MVASI), 10 mg).Bevacizumab-bvzr should be reported with HCPCS code Q5118 (injection, bevacizumab-bvzr, biosimilar, (ZIRABEV), 10 mg).Effective 01/01/2023, HCPCS code Q5126 should be used to report bevacizumab-maly, biosimilar, (ALYMSYS1), 10 mg. Effective 10/01/2022 through 12/31/2022, bevacizumab-maly should be reported with HCPCS code C9142 (injection, bevacizumab-maly, biosimilar, (ALYMSYS), 10 mg).Effective 04/01/2023, HCPCS code Q5129 should be used to report bevacizumab-adcd (Vegzelma). Effective 09/27/2022 through 03/31/2023 HCPCS code J3590 should be reported.OPHTHALMOLOGIC GUIDELINESFor providers who bill the Part A MAC, claims for bevacizumab should be reported using HCPCS code C9257 (injection, bevacizumab, 0.25 mg) for treatment of approved ophthalmologic indications.Bevacizumab-awwb should be reported with HCPCS code Q5107 (injection, bevacizumab-awwb, biosimilar, (MVASI), 10 mg).Bevacizumab-bvzr should be reported with HCPCS code Q5118 (injection, bevacizumab-bvzr, biosimilar, (ZIRABEV), 10 mg).Effective 01/01/2023, HCPCS code Q5126 should be used to report bevacizumab-maly, biosimilar, (ALYMSYS1), 10 mg. Effective 10/01/2022 through 12/31/2022, bevacizumab-maly should be reported with HCPCS code C9142 (injection, bevacizumab-maly, biosimilar, (ALYMSYS), 10 mg).The claim for the intravitreal injection should be coded using CPT code 67028. The appropriate site modifier (RT, LT or 50) must be appended to indicate if the service was performed unilaterally or bilaterally. Claims without a modifier will be returned to the provider unprocessed.If the drug is denied as not reasonable and necessary, the associated injection code will also be denied.Utilization:Dose and frequency should be in accordance with the FDA label or recognized compendia (for off-label uses). When services are performed in excess of established parameters, they may be subject to review for medical necessity.FDA and Compendia ReviewAmerican Society of Health-System Pharmacists, Inc.AHFS Drug Information.Bethesda, MD:2007.Clinical Pharmacology Web site. http://www.clinicalpharmacology.com. Accessed 06/06/2023.Lexi-Drugs Web site. http://online.lexi.com. Accessed 06/06/2023.Micromedex DrugDex. http://www.micromedexsolutions.com/home/dispatch. Accessed 06/06/2023.National Comprehensive Cancer Network Web site. http://www.nccn.org/index.asp. Accessed 06/02/2023.U.S. Food and Drug Administration (FDA) Web site. http://www.accessdata.fda.gov/scripts/cder/daf/. Accessed 08/07/2019.United States Pharmacopoeia (USP), Volume I; Drug Information for the Health Care Professional, 2007.