Effective with date of service Jan. 30, 2023, the Medicaid and NC Health Choice programs cover bendamustine hydrochloride injection, for intravenous use (Baxter) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic.
Strength/Package Size: Injection: 100 mg/4 mL (25 mg/mL) in a multiple-dose vial.
Indicated for treatment of adult patients with Chronic lymphocytic leukemia (CLL). Efficacy relative to first line therapies other than chlorambucil has not been established. Indolent B-cell non-Hodgkin lymphoma (NHL) that has progressed during or within six months of treatment with rituximab or a rituximab-containing regimen
Recommended Dose: For CLL 100mg/m2 infused intravenously over 30 minutes on Days 1 and 2 of a 28-day cycle, up to 6 cycles. For NHL 120mg/m2 infused intravenously over 60 minutes on Days 1 and 2 of a 21-day cycle, up to 8 cycles. See full prescribing information for further information.
For Medicaid and NC Health Choice Billing
- ICD-10-CM Diagnosis Codes Required for Billing
- C82.01 - Follicular lymphoma grade I, lymph nodes of head, face, and neck;
- C82.02 - Follicular lymphoma grade I, intrathoracic lymph nodes;
- C82.03 - Follicular lymphoma grade I, intra-abdominal lymph nodes;
- C82.04 - Follicular lymphoma grade I, lymph nodes of axilla and upper limb;
- C82.05 - Follicular lymphoma grade I, lymph nodes of inguinal region and lower limb;
- C82.06 - Follicular lymphoma grade I, intrapelvic lymph nodes;
- C82.07 - Follicular lymphoma grade I, spleen;
- C82.08 - Follicular lymphoma grade I, lymph nodes of multiple sites;
- C82.09 - Follicular lymphoma grade I, extranodal and solid organ sites;
- C82.11 - Follicular lymphoma grade II, lymph nodes of head, face, and neck;
- C82.12 - Follicular lymphoma grade II, intrathoracic lymph nodes;
- C82.13 - Follicular lymphoma grade II, intra-abdominal lymph nodes;
- C82.14 - Follicular lymphoma grade II, lymph nodes of axilla and upper limb;
- C82.15 - Follicular lymphoma grade II, lymph nodes of inguinal region and lower limb;
- C82.16 - Follicular lymphoma grade II, intrapelvic lymph nodes;
- C82.17 - Follicular lymphoma grade II, spleen;
- C82.18 - Follicular lymphoma grade II, lymph nodes of multiple sites;
- C82.19 - Follicular lymphoma grade II, extranodal and solid organ sites;
- C82.21 - Follicular lymphoma grade III, unspecified, lymph nodes of head, face, and neck;
- C82.22 - Follicular lymphoma grade III, unspecified, intrathoracic lymph nodes;
- C82.23 - Follicular lymphoma grade III, unspecified, intra-abdominal lymph nodes;
- C82.24 - Follicular lymphoma grade III, unspecified, lymph nodes of axilla and upper limb;
- C82.25 - Follicular lymphoma grade III, unspecified, lymph nodes of inguinal region and lower limb;
- C82.26 - Follicular lymphoma grade III, unspecified, intrapelvic lymph nodes;
- C82.27 - Follicular lymphoma grade III, unspecified, spleen;
- C82.28 - Follicular lymphoma grade III, unspecified, lymph nodes of multiple sites;
- C82.29 - Follicular lymphoma grade III, unspecified, extranodal and solid organ sites;
- C82.31 - Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck;
- C82.32 - Follicular lymphoma grade IIIa, intrathoracic lymph nodes;
- C82.33 - Follicular lymphoma grade IIIa, intra-abdominal lymph nodes;
- C82.34 - Follicular lymphoma grade IIIa, lymph nodes of axilla and upper limb;
- C82.35 - Follicular lymphoma grade IIIa, lymph nodes of inguinal region and lower limb;
- C82.36 - Follicular lymphoma grade IIIa, intrapelvic lymph nodes;
- C82.37 - Follicular lymphoma grade IIIa, spleen;
- C82.38 - Follicular lymphoma grade IIIa, lymph nodes of multiple sites;
- C82.39 - Follicular lymphoma grade IIIa, extranodal and solid organ sites;
- C82.41 - Follicular lymphoma grade IIIb, lymph nodes of head, face, and neck;
- C82.42 - Follicular lymphoma grade IIIb, intrathoracic lymph nodes;
- C82.43 - Follicular lymphoma grade IIIb, intra-abdominal lymph nodes;
- C82.44 - Follicular lymphoma grade IIIb, lymph nodes of axilla and upper limb;
- C82.45 - Follicular lymphoma grade IIIb, lymph nodes of inguinal region and lower limb;
- C82.46 - Follicular lymphoma grade IIIb, intrapelvic lymph nodes;
- C82.47 - Follicular lymphoma grade IIIb, spleen;
- C82.48 - Follicular lymphoma grade IIIb, lymph nodes of multiple sites;
- C82.49 - Follicular lymphoma grade IIIb, extranodal and solid organ sites;
- C82.51 - Diffuse follicle center lymphoma, lymph nodes of head, face, and neck;
- C82.52 - Diffuse follicle center lymphoma, intrathoracic lymph nodes;
- C82.53 - Diffuse follicle center lymphoma, intra-abdominal lymph nodes;
- C82.54 - Diffuse follicle center lymphoma, lymph nodes of axilla and upper limb;
- C82.55 - Diffuse follicle center lymphoma, lymph nodes of inguinal region and lower limb;
- C82.56 - Diffuse follicle center lymphoma, intrapelvic lymph nodes;
- C82.57 - Diffuse follicle center lymphoma, spleen;
- C82.58 - Diffuse follicle center lymphoma, lymph nodes of multiple sites;
- C82.59 - Diffuse follicle center lymphoma, extranodal and solid organ sites;
- C82.61 - Cutaneous follicle center lymphoma, lymph nodes of head, face, and neck;
- C82.62 - Cutaneous follicle center lymphoma, intrathoracic lymph nodes;
- C82.63 - Cutaneous follicle center lymphoma, intra-abdominal lymph nodes;
- C82.64 - Cutaneous follicle center lymphoma, lymph nodes of axilla and upper limb;
- C82.65 - Cutaneous follicle center lymphoma, lymph nodes of inguinal region and lower limb;
- C82.66 - Cutaneous follicle center lymphoma, intrapelvic lymph nodes;
- C82.67 - Cutaneous follicle center lymphoma, spleen;
- C82.68 - Cutaneous follicle center lymphoma, lymph nodes of multiple sites;
- C82.69 - Cutaneous follicle center lymphoma, extranodal and solid organ sites;
- C82.81 - Other types of follicular lymphoma, lymph nodes of head, face, and neck;
- C82.82 - Other types of follicular lymphoma, intrathoracic lymph nodes;
- C82.83 - Other types of follicular lymphoma, intra-abdominal lymph nodes;
- C82.84 - Other types of follicular lymphoma, lymph nodes of axilla and upper limb;
- C82.85 - Other types of follicular lymphoma, lymph nodes of inguinal region and lower limb;
- C82.86 - Other types of follicular lymphoma, intrapelvic lymph nodes;
- C82.87 - Other types of follicular lymphoma, spleen;
- C82.88 - Other types of follicular lymphoma, lymph nodes of multiple sites;
- C82.89 - Other types of follicular lymphoma, extranodal and solid organ sites;
- C82.91 - Follicular lymphoma, unspecified, lymph nodes of head, face, and neck;
- C82.92 - Follicular lymphoma, unspecified, intrathoracic lymph nodes;
- C82.93 - Follicular lymphoma, unspecified, intra-abdominal lymph nodes;
- C82.94 - Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb;
- C82.95 - Follicular lymphoma, unspecified, lymph nodes of inguinal region and lower limb;
- C82.96 - Follicular lymphoma, unspecified, intrapelvic lymph nodes;
- C82.97 - Follicular lymphoma, unspecified, spleen;
- C82.98 - Follicular lymphoma, unspecified, lymph nodes of multiple sites;
- C82.99 - Follicular lymphoma, unspecified, extranodal and solid organ sites;
- C83.01 - Small cell B-cell lymphoma, lymph nodes of head, face, and neck;
- C83.02 - Small cell B-cell lymphoma, intrathoracic lymph nodes;
- C83.03 - Small cell B-cell lymphoma, intra-abdominal lymph nodes;
- C83.04 - Small cell B-cell lymphoma, lymph nodes of axilla and upper limb;
- C83.05 - Small cell B-cell lymphoma, lymph nodes of inguinal region and lower limb;
- C83.06 - Small cell B-cell lymphoma, intrapelvic lymph nodes;
- C83.07 - Small cell B-cell lymphoma, spleen;
- C83.08 - Small cell B-cell lymphoma, lymph nodes of multiple sites;
- C83.09 - Small cell B-cell lymphoma, extranodal and solid organ sites;
- C88.0 - Waldenstrom macroglobulinemia;
- C88.3 - Immunoproliferative small intestinal disease;
- C88.4 - Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma];
- CCL:
- C91.10 - Chronic lymphocytic leukemia of B-cell type not having achieved remission
- C91.12 - Chronic lymphocytic leukemia of B-cell type in relapse
- Providers must bill with HCPCS code: J9999 - Not otherwise classified, antineoplastic
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $25.27200
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 10019-0079-01
- 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 DHB'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 the NC Medicaid’s Fee Schedule & Covered Code portal.
Contact
NCTracks Call Center: 800-688-6696