Tebentafusp-tebn Injection, for Intravenous Use (Kimmtrak®) HCPCS Code J9999: Billing Guidelines
Effective with date of service Feb. 25, 2022, the Medicaid and NC Health Choice programs cover tebentafusp-tebn injection.

Effective with date of service Feb. 25, 2022, the Medicaid and NC Health Choice programs cover tebentafusp-tebn injection.

Effective with date of service Feb. 25, 2022, the Medicaid and NC Health Choice programs cover tebentafusp-tebn injection, for intravenous use (Kimmtrak®) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic drugs.

Strength/Package Size: Injection: 100 mcg/0.5 mL solution in a single-dose vial

Indicated for the treatment of HLA-A*02:01-positive adult patients with unresectable or metastatic uveal melanoma.

Recommended Dose: 20 mcg intravenously on Day 1, 30 mcg intravenously on Day 8, 68 mcg intravenously on Day 15, and 68 mcg intravenously once every week thereafter. See full prescribing information for further detail.

For Medicaid and NC Health Choice Billing

  • The ICD-10-CM diagnosis codes required for billing are: 
    • C69.31 - Malignant neoplasm of right choroid;
    • C69.32 - Malignant neoplasm of left choroid;
    • C69.41 - Malignant neoplasm of right ciliary body;
    • C69.42 - Malignant neoplasm of left ciliary body;
    • C69.61 - Malignant neoplasm of right orbit;
    • C69.62 - Malignant neoplasm of left orbit
  • Providers must bill with HCPCS code: J9999 - Not otherwise classified, antineoplastic drugs
  • One Medicaid and NC Health Choice unit of coverage is: 1 mcg
  • The maximum reimbursement rate per unit is: $202.61
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 80446-0401-01
  • 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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