Billing Alert for Correct Submission of Herceptin (Trastuzumab) Claims
Herceptin® is dosed according to the patient’s weight in kilograms multiplied by the dose prescribed by the physician in mg/kg to allow calculation of the actual dose that is to be administered. The claim must have the number of units (based on the HCPCS code description) actually administered to the patient as the number of units billed. The number of units billed can be rounded up to the next multiple of the HCPCS unit if the calculation results in a fraction of a unit. In the case of Herceptin®, the HCPCS unit is 10 mg.
For example, if 144 mg was administered then 15 units should be noted on the claim as the amount billed. Providers insert the weight of the patient in kilograms and the number of mg/kg of the dose in the remarks field. (This is block 19 on the paper claim or the electronic equivalent loops and segments for electronic claims.)
Example: The patient weighs 85 kgs. (187 lbs.) The prescribed dosage for this treatment is 2mg/kg:
85 x 2 = 170 mg
Each unit is for 10 mg
170 ÷ 10 = 17 units
The claim should have '17' in the Quantity Billed field and '85 kgs, 2 mg/kg' in the remarks field.
Because Herceptin (trastuzumab) is now available in a single dose vial and some providers are still administering from the older multi dose vials, providers are required to include the NDC number on each claim line where the HCPCS modifier JW is appended indicating drug wastage. The NDC number is required to assure the drug was administered from a single dose vial and eligible for compensation for drug wastage.
View the Palmetto GBA Coverage Article, Herceptin (trastuzumab): Coverage and Billing (A53777) for full details regarding Herceptin®.
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