The Role of Appropriate Coding
Chris Mancill
Director, Global Government Affairs
Amgen Inc.
Case Study: Coding for a New Product
 This session focuses on the important role of coding in
obtaining coverage and payment for new product
launches
 We will review a relevant and recent case study from
Amgen's experience
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Case Study: New Oncology Launch
 In advance of launching our new oncology therapeutic for colorectal
cancer (Vectibix™ (panitumumab)), Amgen performed a coding
assessment to determine potential gaps in coding
 Vectibix™ is a novel therapeutic that is administered intravenously by
a physician in her or his office or in the hospital outpatient setting
 The assessment was comprehensive in focus
 Coding across settings of care and payer types
 Coding for the product as well as the associated diagnoses and
procedures
 In some cases, code sets take time to catch up with new products
 The goal of our assessment was to ensure that patient access was
available once our product launched
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Background:
Codes Used in Medical Settings
CPT®
HCPCS
ICD-9-CM
Current Procedural
Terminology
Healthcare Common
Procedure Coding System
International Classification of
Diseases, Ninth Revision,
Clinical Modification
NDCs
National Drug Codes
Revenue Codes
Facility Cost Centers
Current Procedural Terminology (CPT®) codes copyright 2005 American Medical Association (AMA). All Rights Reserved. CPT® is a trademark of the AMA. No fee
schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS
Restrictions Apply to Government Use.
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Results of Our Coding Assessment
CPT®
HCPCS
ICD-9-CM
NDCs
Revenue Codes
CPT © 2005 American Medical Association. All rights reserved.
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Codes currently exist to
describe administration
Miscellaneous code exists at
launch; unique codes require
application after launch
Codes currently exist to
describe diagnoses
Codes assigned upon product
approval
Codes currently exist to
describe facility cost centers
Background:
HCPCS Coding
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J-Codes
Unique, Permanent Codes; All
Settings; All Payers
C-Codes
Unique, Temporary Codes;
Medicare Only1; OPPS Only
Q-Codes
Unique, Temporary Codes; All
Settings; Medicare Only
NOC Codes
Miscellaneous, Permanent
Codes; Often Setting Specific;
All Settings
Some other payers (e.g., some Blue Cross/Blue Shield plans) may accept HCPCS C-codes, but most do not.
Codes Available at Launch
 Two miscellaneous HCPCS codes available upon launch
 J9999 (NOC anti-neoplastic) for physician office
 C9399 (unclassified drugs or biologicals) for OPPS
 Specific HCPCS coding applications to be submitted upon
launch
 Temporary HCPCS C-code for use under OPPS
 Permanent HCPCS J-code
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Access is Available Immediately Upon Launch
 The two miscellaneous HCPCS codes permit access to be
available immediately upon launch
 J9999 (NOC anti-neoplastic) for physician office
 C9399 (unclassified drugs or biologicals) for OPPS
 The specific HCPCS codes will facilitate access by permitting
automating claims processing
 Amgen is educating oncologists and their office staff on the
use of miscellaneous codes
 Using these codes for new products is commonplace
 Physicians are familiar with the codes and the process for
new products
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Issues to Consider for Other Products
 Does the product fall into a Medicare benefit category?
 If the product is not physician administered, a new HCPCS
code may not be necessary.
 Does the product similar to others on the market currently?
 If so, is a new code warranted?
 Is the product’s method of administration novel?
 If the route of administration is novel, a new CPT® code for
its administration may also be needed.
 Is there a diagnosis code for the condition the product treats?
Is it sufficiently specific?
 If not, a new or revised ICD-9-CM code may be needed.
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Questions?
Chris Mancill
Director Global Government Affairs
Amgen Inc.
cmancill@amgen.com
(202) 585-9718
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