Loncastuximab Tesirine-lpyl for Injection (Zynlonta™) HCPCS Code J9999: Billing Guidelines
Effective with date of service May 11, 2021, the Medicaid and NC Health Choice programs cover loncastuximab tesirine-lpyl for injection, for intravenous use (Zynlonta) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic drugs.
Zynlonta is available for injection as 10 mg of loncastuximab tesirine-lpyl as a lyophilized powder in a single-dose vial for reconstitution and further dilution.
Zynlonta is indicated for the treatment of adult patients with relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy, including diffuse large B-cell lymphoma (DLBCL) not otherwise specified, DLBCL arising from low grade lymphoma, and high-grade B-cell lymphoma.
Recommended Dose: Administer as an intravenous infusion over 30 minutes on Day 1 of each cycle (every 3 weeks).
- 0.15 mg/kg every 3 weeks for 2 cycles.
- 0.075 mg/kg every 3 weeks for subsequent cycles.
See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
- C83.30 - Diffuse large B-cell lymphoma, unspecified site;
- C83.31 - Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck;
- C83.32 - Diffuse large B-cell lymphoma, intrathoracic lymph nodes;
- C83.33 - Diffuse large B-cell lymphoma, intra-abdominal lymph nodes;
- C83.34 - Diffuse large B-cell lymphoma, lymph nodes of axilla and upper limb;
- C83.35 - Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb;
- C83.36 - Diffuse large B-cell lymphoma, intrapelvic lymph nodes;
- C83.37 - Diffuse large B-cell lymphoma, spleen;
- C83.38 - Diffuse large B-cell lymphoma, lymph nodes of multiple sites;
- C83.39 - Diffuse large B-cell lymphoma, extranodal and solid organ sites
- Providers must bill with HCPCS code: J9999 - Not otherwise classified, antineoplastic drugs
- One Medicaid and NC Health Choice unit of coverage is: 10 mg
- The maximum reimbursement rate per unit is: $25,380.00
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is:79952-0110-01
- The NDC units should be reported as “UN1”
- For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update and 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 NC Medicaid's PADP webpage.
NCTracks Call Center: 800-688-6696