Tisotumab Vedotin-tftv, for Intravenous use (Tivdak™) HCPCS Code J9999: Billing Guidelines

Effective with date of service Sept. 22, 2021, the Medicaid and NC Health Choice programs cover tisotumab vedotin-tftv for use in the PADP when billed with HCPCS code J9999.

Effective with date of service Sept. 22, 2021, the Medicaid and NC Health Choice programs cover tisotumab vedotin-tftv for injection, for intravenous use (Tivdak™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic drugs.

Tivdak™ is available for injection: 40 mg as a lyophilized cake or powder in a single-dose vial for reconstitution.

Indicated for the treatment of adult patients with recurrent or metastatic cervical cancer with disease progression on or after chemotherapy.

Recommended Dose: 2 mg/kg (up to a maximum of 200 mg) given as an intravenous infusion over 30 minutes every three weeks 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 codes required for billing are: 
    • C53.0 - Malignant neoplasm of endocervix;
    • C53.1 - Malignant neoplasm of exocervix;
    • C53.8 - Malignant neoplasm of overlapping sites of cervix uteri;
    • C53.9 - Malignant neoplasm of cervix uteri, unspecified;
    • D06.0 - Carcinoma in situ of endocervix;
    • D06.1 - Carcinoma in situ of exocervix;
    • D06.7 - Carcinoma in situ of other parts of cervix;
    • D06.9 - Carcinoma in situ of cervix, unspecified
  • 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: $158.90
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 51144-0003-01
  • 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 NC 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

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