Mitomycin for Pyelocalyceal Solution (Jelmyto™) HCPCS Code J9999: Billing Guidelines

Effective with date of service June 17, 2020, the Medicaid and NC Health Choice programs cover mitomycin for pyelocalyceal solution (Jelmyto™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic drugs.

Strength/package size for pyelocalyceal solution: a carton contains the following:

• Two 40 mg (each) single-dose vials of mitomycin for pyelocalyceal solution
• One vial of 20 mL sterile hydrogel for reconstitution

Indicated for the treatment of adult patients with low-grade Upper Tract Urothelial Cancer (LG-UTUC).

Recommended Dose (see full prescribing information for further detail):  

• The dose of Jelmyto™ to be instilled is 4 mg per mL via ureteral catheter or nephrostomy tube, with total instillation volume based on volumetric measurements using pyelography, not to exceed 15 mL (60 mg of mitomycin).
• Instill Jelmyto™ once weekly for six weeks. For patients with a complete response 3 months after Jelmyto™ initiation, Jelmyto™ instillations may be administered once a month for a maximum of 11 additional instillations.

For Medicaid and NC Health Choice Billing

• The ICD-10-CM diagnosis code(s) required for billing is/are: 

• Providers must bill with HCPCS code: J9999 - Not otherwise classified, antineoplastic drugs
• One Medicaid and NC Health Choice unit of coverage is: 1 mg 
• The maximum reimbursement rate per unit is: $288.58
• Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 72493-0101-40, 72493-0103-03
• The NDC units should be reported as “UN1”
• For additional information, refer to the January 2012 Special Bulletin National Drug Code Implementation Update
• For additional information regarding NDC claim requirements related to the PADP, refer to the PADP Clinical Coverage Policy 1B, Attachment A, H.7 on Medicaid's website
• Providers shall bill their usual and customary charge for non-340B drugs
• PADP reimburses for drugs billed for Medicaid and Health Choice beneficiaries by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the “UD” modifier on the drug detail.
• The fee schedule for the PADP is available on Medicaid's PADP web page

Contact

NCTracks Contact Center: 800-688-6696