A9699, Radiopharmaceutical, therapeutic, not otherwise classified
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Every Part A claim for NOC/unlisted drug, biologic, and radiopharmaceutical codes must include the appropriate NOC code and the appropriate diagnosis.
- Every claim must include the appropriate revenue codes for the drug and for IV infusion when applicable.
- Every claim must indicate the drug name, the National Drug Code (NDC) number, and the total dosage administered.
- For claim submission, the required documentation must be included in the remarks field (Field Locator 80) on the UB-04 (CMS 1450) or the equivalent 5010 electronic claim field.
Key Coverage Criteria
- For claims using not otherwise classified (NOC)/unlisted HCPCS codes J3490, J3590, J9999, A4641, or A9699 with limited or specific indications, submit required documentation in the claim remarks field (Field Locator 80 on the UB-04) or the equivalent 5010 electronic claim field so Palmetto GBA can ascertain FDA labeling indications have been met.
- For oncology drugs or oncology radiopharmaceuticals submitted with NOC codes prior to assignment of a unique HCPCS code, include the diagnosis code that corresponds to the specific FDA label indication or, if no adequate diagnosis code exists, include a specific narrative description of the indication (e.g., 'squamous cell carcinoma').
- Coverage of injectable oncology medications is based on NCCN Compendium Categories of Evidence and Consensus (1, 2A, 2B = proven/medically necessary; 3 = unproven/not medically necessary); if NCCN is unavailable, base decisions on FDA labeling.
- Clinical treatment planning (CPT® 77261, 77262, 77263): One unit of CPT® 77261, 77262, or 77263 is necessary for an episode of care (clinical treatment planning is performed after the initial consultation and before simulation).
- Simulation (CPT® 77280, 77285, 77290): For non-IMRT plans, one unit of CPT® 77280, 77285, or 77290 is allowed per phase of treatment; verification simulation reported with one unit of CPT® 77280. (+77293 respiratory motion management simulation is allowed when treatment area moves with continuous respiration and requires acquisition of multiple data sets.)
- Respiratory motion management simulation (CPT® +77293): Performed when the treatment area moves with continuous respiration; +77293 is an add-on code, allowed once per episode of care and only on same date of service as primary procedure (e.g., with 77295, 77301).
13 Active Policies
EVICORE-RADIATION-ONCOLOGY-CODING-MANUAL, EviCore Radiation Oncology Coding Manual
A54880, Billing and Coding: Additional Claim Documentation Requirements for Not Otherwise Classified (NOC) Drugs and Biological Products with Specific FDA Label Indications
UMR-POL-UMR-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage
SUREST-POL-SUREST-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage
Related Codes
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