Margetuximab-cmkb Injection, for Intravenous Use (Margenza™) HCPCS Code J9999: Billing Guidelines

Tuesday, May 4, 2021

Effective with date of service March 11, 2021, the North Carolina Medicaid and NC Health Choice programs cover margetuximab-cmkb injection, for intravenous use (Margenza) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic drugs.

Margenza is indicated, in combination with chemotherapy, for the treatment of adult patients with metastatic HER2­ positive breast cancer who have received two or more prior anti-HER2 regimens, at least one of which was for metastatic disease.

Recommended Dose: 15 mg/kg, administered as an intravenous infusion every three weeks (21-day cycle) until disease progression or unacceptable toxicity. See full prescribing information for further detail.

For Medicaid and NC Health Choice Billing

  • The ICD-10-CM diagnosis code(s) required for billing are:  
    • C50.011 Malignant neoplasm of nipple and areola, right female breast;
    • C50.012 Malignant neoplasm of nipple and areola, left female breast;
    • C50.019 Malignant neoplasm of nipple and areola, unspecified female breast;
    • C50.021 Malignant neoplasm of nipple and areola, right male breast;
    • C50.022 Malignant neoplasm of nipple and areola, left male breast;
    • C50.029 Malignant neoplasm of nipple and areola, unspecified male breast;
    • C50.111 Malignant neoplasm of central portion of right female breast;
    • C50.112 Malignant neoplasm of central portion of left female breast;
    • C50.119 Malignant neoplasm of central portion of unspecified female breast;
    • C50.121 Malignant neoplasm of central portion of right male breast;
    • C50.122 Malignant neoplasm of central portion of left male breast;
    • C50.129 Malignant neoplasm of central portion of unspecified male breast;
    • C50.211 Malignant neoplasm of upper-inner quadrant of right female breast;
    • C50.212 Malignant neoplasm of upper-inner quadrant of left female breast;
    • C50.219 Malignant neoplasm of upper-inner quadrant of unspecified female breast;
    • C50.221 Malignant neoplasm of upper-inner quadrant of right male breast;
    • C50.222 Malignant neoplasm of upper-inner quadrant of left male breast;
    • C50.229 Malignant neoplasm of upper-inner quadrant of unspecified male breast;
    • C50.311 Malignant neoplasm of lower-inner quadrant of right female breast;
    • C50.312 Malignant neoplasm of lower-inner quadrant of left female breast;
    • C50.319 Malignant neoplasm of lower-inner quadrant of unspecified female breast;
    • C50.321 Malignant neoplasm of lower-inner quadrant of right male breast;
    • C50.322 Malignant neoplasm of lower-inner quadrant of left male breast;  
    • C50.329 Malignant neoplasm of lower-inner quadrant of unspecified male breast;
    • C50.411 Malignant neoplasm of upper-outer quadrant of right female breast;
    • C50.412 Malignant neoplasm of upper-outer quadrant of left female breast;
    • C50.419 Malignant neoplasm of upper-outer quadrant of unspecified female breast;
    • C50.421 Malignant neoplasm of upper-outer quadrant of right male breast;
    • C50.422 Malignant neoplasm of upper-outer quadrant of left male breast;
    • C50.429 Malignant neoplasm of upper-outer quadrant of unspecified male breast;
    • C50.511 Malignant neoplasm of lower-outer quadrant of right female breast;
    • C50.512 Malignant neoplasm of lower-outer quadrant of left female breast;
    • C50.519 Malignant neoplasm of lower-outer quadrant of unspecified female breast;
    • C50.521 Malignant neoplasm of lower-outer quadrant of right male breast;
    • C50.522 Malignant neoplasm of lower-outer quadrant of left male breast;
    • C50.529 Malignant neoplasm of lower-outer quadrant of unspecified male breast;
    • C50.611 Malignant neoplasm of axillary tail of right female breast;
    • C50.612 Malignant neoplasm of axillary tail of left female breast;
    • C50.619 Malignant neoplasm of axillary tail of unspecified female breast; 
    • C50.621 Malignant neoplasm of axillary tail of right male breast;
    • C50.622 Malignant neoplasm of axillary tail of left male breast;
    • C50.629 Malignant neoplasm of axillary tail of unspecified male breast;
    • C50.811 Malignant neoplasm of overlapping sites of right female breast;
    • C50.812 Malignant neoplasm of overlapping sites of left female breast;
    • C50.819 Malignant neoplasm of overlapping sites of unspecified female breast;
    • C50.821 Malignant neoplasm of overlapping sites of right male breast;
    • C50.822 Malignant neoplasm of overlapping sites of left male breast;
    • C50.829 Malignant neoplasm of overlapping sites of unspecified male breast;
    • C50.911 Malignant neoplasm of unspecified site of right female breast;
    • C50.912 Malignant neoplasm of unspecified site of left female breast;
    • C50.919 Malignant neoplasm of unspecified site of unspecified female breast;
    • C50.921 Malignant neoplasm of unspecified site of right male breast;
    • C50.922 Malignant neoplasm of unspecified site of left male breast;
    • C50.929 Malignant neoplasm of unspecified site of unspecified male breast
  • 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: $8.97
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 74527-0022-01, 74527-0022-02, 74527-0022-03
  • 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 Call Center: 800-688-6696