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Reimbursement Coding

This section provides general coding information related to the use of Activase and it is intended for informational purposes only. Please consult the Centers for Medicare & Medicaid Services (CMS) for specific information and requirements.

The submission and completion of reimbursement- or coverage-related documentation are the responsibility of the patient and healthcare provider. Genentech, Inc. and its affiliates make no representation or guarantees concerning reimbursement for any service or item.

In addition to information provided on this page, there are helpful links and resources relevant to coding:

Genentech is neither affiliated with nor endorses any of the above organizations.

Hospital Inpatient

Hospitals use International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to identify the diagnoses and procedures associated with inpatient stays.

ICD-9-CM diagnosis codes are used to identify diseases and conditions, and provide documentation for any procedures performed on a patient. All appropriate ICD-9-CM diagnosis codes should be reported on the claim form. ICD-9-CM procedure codes are used to identify services or treatment provided to patients in the hospital inpatient setting. ICD-9-CM diagnosis and procedure codes should be reported to the highest level of specificity. Some payers may require additional coding and patient-specific clinical information to determine coverage and payment for the inpatient stay.

Hospitals should code all diagnoses and procedures appropriately. Please consult payers to verify appropriate codes and learn about payer coverage policies, reimbursement rates, or billing requirements.

ICD-9-CM diagnosis code

Hospital Outpatient

On claim forms, hospitals use International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to report patient diagnoses and Healthcare Common Procedural Coding System (HCPCS) Level II codes and American Medical Association (AMA) Current Procedural Terminology (CPT®*) to report items and procedures provided during outpatient encounters. ICD-9-CM diagnosis codes are used to identify diseases and conditions, and provide justification for any procedures performed on the patient. All appropriate ICD-9-CM diagnosis codes should be reported on the claim form. ICD-9-CM diagnosis codes should be reported to the highest level of specificity.

Medicare may require additional coding and patient-specific clinical information to determine coverage and payment for the outpatient visit. CPT codes are 5-digit number codes created by the AMA to designate specific procedures performed.

HCPCS Level II codes are used to identify items like drugs and supplies, as well as services not described by CPT codes. The HCPCS codes used to identify drugs are often referred to as J codes.

  • *CPT is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All rights reserved. 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.

Physician Services

A CMS-1500 claim form that reflects the administration of Activase when used in acute ischemic stroke by a physician may include the following codes. Please note that because the hospital provides Activase, the hospital would bill the payer for Activase. The physician would only bill for services provided, such as the administration of Activase.

The coding reference provided below outlines the basic codes that may be applicable to physician billing for treatment of an acute ischemic stroke case involving Activase. The following codes are not inclusive of all applicable codes that may be included on the claim for an individual patient. Physicians should document and bill all appropriate ICD-9-CM diagnosis and procedure codes:

ICD-9-CM diagnosis codes CPT* codes
Stroke
433.x1 Occlusion and stenosis of precerebral arteries
434.x1 Occlusion of cerebral arteries
Pulmonary embolism
415.11 Iatrogenic pulmonary embolism and infarction
415.19 Pulmonary embolism and infarction, other
Stroke
CPT 37195 Thrombolysis, cerebral, by
intravenous infusion
Pulmonary embolism
CPT 37201 Transcatheter therapy, infusion for thrombolysis other than coronary
  • *All Current Procedural Terminology (CPT) five-digit numeric codes, descriptions, numeric modifiers, instructions, guidelines, and other material are Copyright 2010 American Medical Association. All rights reserved.

Stroke Conditions and Critical Care Services

Patient diagnoses and services furnished by the attending physician(s) must be documented appropriately at all times. It is the responsibility of the neurologist to report the ICD-9-CM diagnosis codes and CPT®* codes that most accurately identify the patient's stroke condition and all services provided to them, respectively.

To assist neurologists in coding appropriately, the American Academy of Neurology has provided the following resources as guides to understanding coding for cerebrovascular diseases and critical care services provided to stroke patients.

Genentech is neither affiliated with nor endorses any of the above organizations.

Please note that in this case, critical care services refer specifically to the evaluation and management of a critically ill patient. The neurologist may also bill for the administration of Activase if used in stroke treatment. The appropriate billing code may vary based on indication. Neurologists should thus confirm the appropriate codes with each payer (eg, Medicare or private/commercial payer).

Telestroke

The National Center for Health Statistics (NCHS) has issued an ICD-9-CM diagnosis V-code, effective October 1, 2008, to identify acute ischemic stroke patients who had been treated with t-PA at a different facility within 24 hours of admission to the current facility. Generally, ICD-9-CM "V-codes" identify factors, other than a disease or injury, which may be relevant to the patient's treatment. This new code may be relevant to healthcare providers using Activase for stroke treatment due to the growing occurrence of "drip and ship" scenarios in stroke management. The full descriptor for the code is provided below:

ICD-9-CM diagnosis codes CPT* codes
V45.88 Status post administration of t-PA (rt-PA) in a different facility within the last 24 hours prior to admission to current facility
0188T Remote, real-time interactive videoconferenced critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
0189T Each additional 30 minutes (list separately in addition to code for primary service)

For more information on the V-code, visit the American Academy of Neurology website.

  • *All Current Procedural Terminology (CPT) five-digit numeric codes, descriptions, numeric modifiers, instructions, guidelines, and other material are Copyright 2010 American Medical Association. All rights reserved.

Acute Ischemic Stroke Indication

Activase is indicated for the management of acute ischemic stroke in adults for improving neurological recovery and reducing the incidence of disability. Treatment should only be initiated within 3 hours after the onset of stroke symptoms, and after exclusion of intracranial hemorrhage by a cranial computerized tomography (CT) scan or other diagnostic imaging method sensitive for the presence of hemorrhage (see CONTRAINDICATIONS in the full prescribing information).

Acute Massive Pulmonary Embolism Indication

Activase is indicated in the management of acute massive pulmonary embolism (AMPE) in adults: (1) for the lysis of acute pulmonary emboli, defined as obstruction of blood flow to a lobe or multiple segments of the lungs; (2) for the lysis of pulmonary emboli accompanied by unstable hemodynamics, eg, failure to maintain blood pressure without supportive measures. The diagnosis should be confirmed by objective means, such as pulmonary angiography or noninvasive procedures such as lung scanning.

Important Safety Information

CONTRAINDICATIONS

Acute Ischemic Stroke (AIS):

  • Treatment should only be initiated within 3 hours after the onset of stroke symptoms, and after exclusion of intracranial hemorrhage by a cranial computerized tomography (CT) scan or other diagnostic imaging method sensitive for the presence of hemorrhage [See CONTRAINDICATIONS in the full prescribing information].
  • Activase therapy in patients with AIS is contraindicated in certain situations (eg, suspicion of subarachnoid hemorrhage on pretreatment evaluation), recent (within 3 months) intracranial or intraspinal surgery, history of intracranial hemorrhage, uncontrolled hypertension at time of treatment, active internal bleeding, known bleeding diathesis (eg, current use of oral anticoagulants, administration of heparin within 48 hours of onset of stroke, platelet count <100,000/mm3) [See CONTRAINDICATIONS in the full prescribing information].

Pulmonary Embolism (PE):

  • Activase therapy in patients with PE is contraindicated in certain situations (eg, active internal bleeding, history of cerebrovascular accident, recent intracranial or intraspinal surgery or trauma, severe uncontrolled hypertension) [See CONTRAINDICATIONS in the full prescribing information].

WARNINGS

The risks of Activase therapy for all approved indications may be increased and should be weighed against the anticipated benefits in certain conditions [See WARNINGS in the full prescribing information].

Acute Ischemic Stroke (AIS):

  • Patients with severe neurological deficit (eg, NIHSS >22) at presentation. There is an increased risk of intracranial hemorrhage in these patients.
  • Patients with major early infarct signs on a computerized cranial tomography (CT) scan (eg, substantial edema, mass effect, or midline shift).

Treatment of patients with minor neurological deficit or with rapidly improving symptoms is not recommended [See WARNINGS in the full prescribing information].

Pulmonary Embolism (PE):

  • Treatment of PE with Activase has not been shown to constitute adequate clinical treatment of underlying deep vein thrombosis. The possible risk of reembolization due to the lysis of underlying deep venous thrombi should be considered.

PRECAUTIONS (AIS)

Orolingual angioedema has been observed in postmarketing experience in patients treated with Activase for AIS. Patients should be monitored during and for several hours after infusion for signs of orolingual angioedema.

ADVERSE REACTIONS

The most common complication during Activase therapy is bleeding. Should serious bleeding in a critical location (intracranial, gastrointestinal, retroperitoneal, pericardial) occur, Activase therapy should be discontinued immediately, along with any concomitant therapy with heparin. Death and permanent disability are not uncommonly reported in patients who have experienced stroke (including intracranial bleeding) and other serious bleeding episodes.

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