Back to Access & Reimbursement Support

This information is provided for educational purposes only. Bristol Myers Squibb cannot guarantee insurance coverage or reimbursement. Coverage and reimbursement may vary significantly by payer, plan, patient, and setting of care and may be subject to frequent change. It is the sole responsibility of the healthcare provider to select the proper codes and ensure the accuracy of all statements used in seeking coverage and reimbursement for an individual patient.

ABECMA® (idecabtagene vicleucel)

The accurate completion of reimbursement- or coverage-related documentation is the responsibility of the healthcare provider and patient. Bristol Myers Squibb makes no guarantee regarding reimbursement for any service or item.

ICD-10-CM Diagnosis Codes

ICD-10-CM Diagnosis Codes

The ICD-10-CM codes listed below for the approved indication for ABECMA are provided by Bristol Myers Squibb and should be verified with a patient’s payer. Some payers may specify which codes are covered under their policies. Please code to the level of specificity documented in the medical record.

ICD-10-CM Code1Description
C90.00Multiple myeloma not having achieved remission
C90.02Multiple myeloma in relapse
Z00.6*Encounter for examination for normal comparison and control in clinical research program
Z51.12Encounter for antineoplastic immunotherapy

*This code should be reported only for clinical trial cases. In the event that the CAR-T product is purchased in the usual manner but is being used for a clinical trial involving a different product (i.e., the clinical trial is for a non-CAR-T product) the provider may enter a Billing Note NTE02 (“Diff Prod Clin Trial”) on the electronic claim form (or a remark “Diff Prod Clin Trial” on a paper claim). To notify Medicare of expanded access use (EAU) of a CAR-T product, the provider may enter a Billing Note NTE02 “Expand Acc Use” on the electronic claim (or a remark “Expand Acc Use" on a paper claim).

1-888-805-4555
Contact Cell Therapy 360® for 24/7 on-call assistance with billing and coding information.

HCPCS Level II Product Codes

HCPCS Level II Product Codes

As a newly approved biologic, ABECMA does not have a unique HCPCS code at this time. Until a unique HCPCS code is assigned by CMS, ABECMA may be reported using one of the following unclassified/miscellaneous HCPCS codes per payer requirements.

HCPCS Code2
Description
Notes
C9399 Unclassified drugs or biologicals Medicare FFS*:
  • Required for claims billed by outpatient hospital facilities under the Outpatient Prospective Payment System (OPPS)3†
J3490 Unclassified drugs All payers:
  • Requirements may vary; refer to the specific payer policy
J3590 Unclassified biologics

Although specific payer requirements may vary, additional information is typically required for claims with unclassified/miscellaneous HCPCS codes, including:

  • Product name
  • Dosage (number of CAR-positive T cells per infusion)
  • NDC number(s)
  • Route of administration

*For Medicare Advantage patients, billing requirements may vary by plan.

For Medicare FFS claims billed by outpatient hospital facilities under the OPPS or those billed by off-campus provider-based departments (PBDs) under the Physician Fee Schedule, an appropriate modifier should be reported if ABECMA has been acquired under the 340B drug pricing program. JG modifier is required if a provider is subject to the 340B payment adjustment; a TB modifier is required if a provider is exempted from the 340B payment adjustment (eg, IPPS-exempt hospital).4,5

NDC Information

NDC Information

ABECMA is provided as a single dose for infusion containing a suspension of CAR-positive T cells in one or more infusion bags. The dose range is 300 to 460 x 106 CAR-positive T cells. ABECMA is supplied in one or more infusion bag(s) containing a frozen suspension of genetically modified autologous T cells in 5% dimethyl sulfoxide (DMSO) concentration.6 Each infusion bag of ABECMA (supplied in one of three sizes) is individually packed in a metal cassette. Please note that ABECMA is an autologous product; the manufactured dose, as well as the corresponding number and size of ABECMA infusion bags, for individual patients may vary.6

10-digit Format6
11-digit Format
Bag Size6
Description6
59572-515-01 59572-0515-01 50 mL infusion bag and metal cassette
59572-515-02 59572-0515-02 250 mL infusion bag and metal cassette
59572-515-03 59572-0515-03 500 mL infusion bag and metal cassette

Payers may require that the NDC number(s) is (are) documented on medical claims submitted for provider-administered therapies, including drugs and biologics billed with an unclassified/miscellaneous code or those with an assigned code.

Specific requirements for NDC reporting may vary; however, the 11-digit format is generally preferred for medical claims. Some payers may require reporting the 11-digit NDC number, along with the NDC qualifier, basis of measure, and quantity.7 For example, the ABECMA NDC number(s) reported in this format would include:

NDC Qualifier
11-digit NDC
Quantity Qualifier
Quantity for a Single Dose
N4 59572-0515-01
59572-0515-02
59572-0515-03
UN 1

ICD-10-PCS Inpatient Procedure Codes

ICD-10-PCS Inpatient Procedure Codes*

For Medicare FFS, the following CAR T cell therapy-designated ICD-10-PCS codes may be reported for inpatient facility services associated with ABECMA administration. Please note that starting in FY 2021, CMS has assigned unique ICD-10-PCS codes to newly approved CAR T cell therapies.8 It is expected that product-specific ICD-10-PCS codes will be assigned for ABECMA administration later in 2021.

ICD-10-PCS Code9
Description
Notes for Medicare FFS
XW033C3 Introduction of engineered autologous chimeric antigen receptor T cell immunotherapy into peripheral vein, percutaneous approach, new technology group 3 Under the Inpatient Prospective Payment System (IPPS) for FY 2021, these codes are assigned to MS-DRG 018 (Chimeric Antigen Receptor [CAR] T-cell Immunotherapy), with the average national base payment rate of $239,928 (the exact rate may vary widely based on hospital-specific adjustments).8,10‡§
XW043C3 Introduction of engineered autologous chimeric antigen receptor T cell immunotherapy into central vein, percutaneous approach, new technology group 3

For commercial plans and other payers, depending on specific policies, in addition to the codes listed above, the following ICD-10-PCS codes may apply.

ICD-10-PCS Code9
Description
Notes for Commercial Plans & Other Payers
6A550Z1 Pheresis of leukocytes, single Requirements may vary; refer to the specific payer policy.
6A551Z1 Pheresis of leukocytes, multiple

*Site/setting of care decisions are at the sole discretion of the treating physician.

For Medicare Advantage patients, billing requirements and reimbursement methodology may vary by plan.

The estimated average does not include outlier, new technology add-on payment (NTAP), pass-through payments, or other applicable hospital-specific adjustments.

§CAR T cell therapies are not eligible for NTAP in FY 202110; for FY 2022, NTAP eligibility decisions will be made on a case-by-case basis.

Hospital Revenue Codes

Hospital Revenue Codes*

The following CAR T cell therapy-designated revenue codes may be reported with accompanying line items billed for services associated with ABECMA.

Revenue Code11
Description
Notes for Medicare FFS*
0871 Cell/gene therapy—cell collection Charges for services associated with cell collection and cell processing/storage can be reported under 0871, 0872, and 0873, as separate line items for tracking purposes only. Alternatively, these charges can be reported with ABECMA charges under 0891, as a single line item.12†‡
0872 Cell/gene therapy—specialized biologic processing and storage—prior to transport
0873 Cell/gene therapy—storage and processing after receipt of cells from manufacturer
0874 Cell/gene therapy—infusion of modified cells
0891 Pharmacy—specialized processed drugs—FDA approved cell therapy

*Site/setting of care decisions are at the sole discretion of the treating physician.

For Medicare FFS patients, when the charges for collection and preparation of the CAR T cells are included with the charges for the CAR T product (as a single line item under 0891), the reported date of service must be based on the date of CAR T administration. When cell collection and/or cell processing/storage services are initiated and furnished in the hospital outpatient setting, but the CAR T cell therapy is administered in the inpatient setting, all related charges must be reported on the inpatient claim with the date of CAR T administration as the date of service (reported as separate line items for tracking purposes under 0871, 0872, and 0873 or as a single line item along with CAR T product charges under 0891). For more information, please see Medicare Transmittal 10796.13

For Medicare FFS patients, 3-day payment window policy applies to outpatient services furnished by a hospital or an entity wholly owned or wholly operated by the hospital. Note that for IPPS-exempt hospitals, 1-day payment window applies.14

CPT® Codes

CPT® Codes for Outpatient Hospital Services*

The following CAR T cell therapy-designated CPT Category III codes may be reported for outpatient hospital facility services associated with ABECMA. Please note that only one of these CPT Category III codes (CPT code 0540T) is separately payable by Medicare under the Hospital Outpatient Prospective Payment System (OPPS).4,15

CMS has not assigned relative value units to these Category III CPT codes, with the exception of the CPT code 0540T under the OPPS.15 As such, they may not be payable by non-Medicare payers.

CPT Category III Code4
Description
Corresponding Hospital Revenue Code12‡
Medicare FFS Reimbursement Status Under OPPS in CY 20214,15†
Apheresis and Preparation
0537T Chimeric antigen receptor T-cell (CAR T) therapy; harvesting of blood-derived T lymphocytes for development of genetically modified autologous CAR T cells, per day 0871 Not recognized by OPPS§ (status indicator B)
0538T Chimeric antigen receptor T-cell (CAR T) therapy; preparation of blood-derived T lymphocytes for transportation (eg, cryopreservation, storage) 0872
0539T Chimeric antigen receptor T-cell (CAR T) therapy; receipt and preparation of CAR T cells for administration 0873
Administration
0540T Chimeric antigen receptor T-cell (CAR T) therapy; CAR T cell administration, autologous 0874 Paid under APC 5694 (status indicator S, CY 2021 national average payment rate is $310.75)

*Site/setting of care decisions are at the sole discretion of the treating physician.

For Medicare Advantage patients, billing requirements and reimbursement methodology may vary by plan.

See previous section for revenue code descriptions.

§CPT Category III codes 0537T, 0538T, and 0539T can be reported for tracking purposes only, as non-covered charges. For more information, please see Medicare Transmittal 10796.13

APC=Ambulatory Payment Classification; CAR=chimeric antigen receptor; CMS=Centers for Medicare and Medicaid Services; CPT=Current Procedural Terminology; CY=calendar year; FFS=fee-for-service; FY=fiscal year; HCPCS=Healthcare Common Procedure Coding System; ICD-10-CM=International Classification of Diseases, Tenth Revision, Clinical Modification; ICD-10-PCS=International Classification of Diseases, Tenth Revision, Procedure Coding System; IPPS=Inpatient Prospective Payment System; MS-DRG=Medicare Severity Diagnosis Related Group; NDC=National Drug Code; OPPS=Outpatient Prospective Payment System.

Online resources

Blank CMS 1450 and CMS 1500 claim forms can be found at CMS.gov.

Downloadable resources

ABECMA PA submission tip sheet ABECMA codes and sample claim forms

This information is provided for educational purposes only. Bristol Myers Squibb cannot guarantee insurance coverage or reimbursement. Coverage and reimbursement may vary significantly by payer, plan, patient, and setting of care and may be subject to frequent change. It is the sole responsibility of the healthcare provider to select the proper codes and ensure the accuracy of all statements used in seeking coverage and reimbursement for an individual patient.

References

  1. Centers for Medicare & Medicaid Services (CMS). 2021 ICD-10-CM Tabular List of Diseases and Injuries. https://www.cms.gov/medicare/icd-10/2021-icd-10-cm. Accessed January 6, 2021.
  2. CMS. January 2021 Alpha-Numeric HCPCS File. https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update. Accessed January 6, 2021.
  3. CMS. Medicare Claims Processing Manual, Chapter 17. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf. Accessed January 6, 2021.
  4. CMS. Fed Regist. December 29, 2020;85(249):85866-86305.
  5. CMS. January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS). MLN Matters MM11099. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11099.pdf. Accessed January 6, 2021.
  6. ABECMA [prescribing information]. Bristol‐Myers Squibb Company. 2021.
  7. CMS. Medicare Shared Systems Modifications Necessary to Capture and Crossover Medicaid Drug Rebate Data Submitted on Form UB 04 Paper Claims and Direct Data Entry (DDE) Claims. MLN Matters MM5950. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1496CP.pdf. Accessed January 6, 2021.
  8. CMS. FY 2021 IPPS Final Rule Tables. https://www.cms.gov/medicare/acute-inpatient-pps/fy-2021-ipps-final-rule-home-page. Accessed January 6, 2021.
  9. ICD-10 Procedure Coding System (ICD-10-PCS) 2021 Tables and Index. https://www.cms.gov/medicare/icd-10/2021-icd-10-pcs. Accessed January 6, 2021.
  10. CMS. Fed Regist. September 18, 2020; 85(182):58432-59107.
  11. NUBC. Summary of gene and cell therapy code changes. February 2020. https://www.nubc.org/system/files/media/file/2020/02/Cell-Gene%20Therapy%20Code%20Changes.pdf. Accessed January 6, 2021.
  12. CMS. Chimeric Antigen Receptor (CAR) T-Cell Therapy Revenue Code and HCPCS Setup Revisions. MLN Matters SE19009. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19009.pdf. Accessed January 6, 2021.
  13. CMS. Transmittal 10796, May 10, 2021. https://www.cms.gov/files/document/r10796ncd.pdf. Accessed June 21, 2021.
  14. CMS. Bundling of Payments for Services Provided to Outpatients Who Later Are Admitted as Inpatients: 3-Day Payment Window Policy and the Impact on Wholly Owned or Wholly Operated Physician Offices. MLN Matters MM7502. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2373CP.pdf. Accessed January 6, 2021.
  15. CMS. Hospital Outpatient Prospective Payment-Notice of Final Rulemaking with comment for CY2021 (Addenda B and D1). https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientppshospital-outpatient-regulations-and-notices/cms-1736-fc. Accessed January 6, 2021.