This detailed article of codes related to prostate cancer is intended to assist practice managers and other healthcare providers and payers to ensure the proper use of coding and billing information associated with the treatment of patients with prostate cancer.
The following sections include:
- Associated ICD-10-CM codes used for the classification of prostate cancer
- Drugs that have been approved by the FDA for the treatment of prostate cancer
- Drugs that are Compendia-listed for off-label use for prostate cancer based on clinical studies that suggest beneficial use in some cases. Please note: If a check mark appears in the FDA column, it will NOT appear in the Compendia off-label use column
- Corresponding HCPCS/CPT® codes and code descriptions
- Possible CPT® administration codes for the drugs
Associated ICD-10-CM Codes
C61 | Malignant neoplasm of prostate |
Generic (brand) name | HCPCS code—code description | FDA approved for prostate cancer | Compendia off-label uses for prostate cancer | Possible CPT® administration codes |
abiraterone acetate (Zytiga) | J8999* - Prescription drug, oral, chemotherapeutic, not otherwise specified | ✔ | N/A | |
abiraterone acetate (Zytiga) | C9399* - Unclassified drugs or biologicals (Hospital outpatient use only) | ✔ | N/A | |
bacillus Calmette-Guérin (BCG Vaccine) | 90585 - Bacillus Calmette-Guérin vaccine (BCG) for tuberculosis, live, for percutaneous use | ✔ | 90471, 90472 | |
bacillus Calmette-Guérin (Tice BCG) | 90586 - Bacillus Calmette-Guérin vaccine (BCG) for bladder cancer, live, for intravesical use | ✔ | 51720 | |
bacillus Calmette-Guérin (Tice BCG) | J9031 - bCG (intravesical), per installation | ✔ | 51720 | |
bevacizumab (Avastin) | J9035 - Injection, bevacizumab, 10 mg | ✔ | 96413, 96415 | |
bicalutamide (Casodex) | J8999* - Prescription drug, oral, chemotherapeutic, not otherwise specified | ✔ | N/A | |
cabazitaxel (Jevtana) | J9043 - Injection, cabazitaxel, 1 mg | ✔ | 96413 | |
cisplatin (Platinol AQ) | J9060 - Injection, cisplatin, powder or solution, per 10 mg | ✔ | 96409, 96413, 96415 | |
cyclophosphamide (Cytoxan) | J8530 - Cyclophosphamide, oral, 25 mg | ✔ | N/A | |
cyclophosphamide (Cytoxan) | J9070 - Cyclophosphamide, 100 mg | ✔ | 96409, 96413, 96415 | |
degarelix (Firmagon) | J9155 - Injection, degarelix, 1 mg | ✔ | 96402 | |
dexamethasone (Decadron) | J8540 - Dexamethasone, oral, 0.25 mg | ✔ | N/A | |
docetaxel (Taxotere, Docefrez) | J9171 - Injection, docetaxel, 1 mg | ✔ | 96413 | |
enzalutamide (Xtandi) | C9399* - Unclassified drugs or biologicals (Hospital outpatient use only) | ✔ | N/A | |
enzalutamide (Xtandi) | J8999* - Prescription drug, oral, chemotherapeutic, not otherwise specified | ✔ | N/A | |
epirubicin (Ellence) | J9178 - Injection, epirubicin hydrochloride, 2 mg | ✔ | 96409, 96413 | |
estradiol valerate (Delestrogen) | J1380 - Injection, estradiol valerate, up to 10 mg | ✔ | 96372 | |
estramustine (Emcyt) | J8999* - Prescription drug, oral, chemotherapeutic, not otherwise specified | ✔ | N/A | |
estrogen (eg, estradiol, conjugated estrogen, esterified estrogen) | J8499* - Prescription drug, oral, nonchemotherapeutic, not otherwise specified | ✔ | N/A | |
finasteride (eg, Proscar) | S0138 - Finasteride, 5 mg | ✔ | N/A | |
flutamide (Eulexin) | J8999* - Prescription drug, oral, chemotherapeutic, not otherwise specified | ✔ | N/A | |
flutamide (Eulexin) | S0175 - Flutamide, oral, 125 mg | ✔ | N/A | |
goserelin acetate (Zoladex) | J9202 - Goserelin acetate implant, per 3.6 mg | ✔ | 96372, 96402 | |
histrelin (Vantas) | J9225 - Histrelin implant (Vantas), 50 mg | ✔ | 11981, 11982, 11983 | |
ixabepilone (Ixempra) | J9207 - Injection, ixabepilone, 1 mg | ✔ | 96413, 96415 | |
ketoconazole (Nizoral) | J8499* - Prescription drug, oral, nonchemotherapeutic, not otherwise specified | ✔ | N/A | |
leuprolide acetate (Eligard, Lupron Depot) | J9217 - Leuprolide acetate (for depot suspension), 7.5 mg | ✔ | 96402 | |
leuprolide acetate (Lupron) | J9218 - Leuprolide acetate, per 1 mg | ✔ | 96402 | |
medroxyprogesterone (Depo-Provera) | J1050 - Injection, medroxyprogesterone acetate, 1 mg | ✔ | 96372, 96402 | |
megestrol acetate (Megace) | J8999* - Prescription drug, oral, chemotherapeutic, not otherwise specified | ✔ | N/A | |
megestrol acetate (Megace) | S0179 - Megestrol acetate, oral, 20 mg | ✔ | N/A | |
melphalan (Alkeran) | J8600 - Melphalan, oral, 2 mg | ✔ | N/A | |
melphalan (Alkeran) | J9245 - Injection, melphalan hydrochloride, 50 mg | ✔ | 96409, 96413 | |
methylprednisolone (Medrol) | J7509 - Methylprednisolone, oral, per 4 mg | ✔ | N/A | |
methylprednisolone (Depo-Medrol) | J1020 - Injection, methylprednisolone acetate, 20 mg | ✔ | 11900, 11901, 20600, 20605, 20610, 96372 | |
methylprednisolone (Depo-Medrol) | J1030 - Injection, methylprednisolone acetate, 40 mg | ✔ | 11900, 11901, 20600, 20605, 20610, 96372 | |
methylprednisolone (Depo-Medrol) | J1040 - Injection, methylprednisolone acetate, 80 mg | ✔ | 11900, 11901, 20600, 20605, 20610, 96372 | |
methylprednisolone (Solu-Medrol) | J2920 - Injection, methylprednisolone sodium succinate, up to 40 mg | ✔ | 96365, 96366, 96372, 96374 | |
methylprednisolone (Solu-Medrol) | J2930 - Injection, methylprednisolone sodium succinate, up to 125 mg | ✔ | 96365, 96366, 96372, 96374 | |
mitoxantrone (Novantrone) | J9293 - Injection, mitoxantrone hydrochloride, per 5 mg | ✔ | 96409, 96413 | |
nilutamide (Nilandron) | J8999* - Prescription drug, oral, chemotherapeutic, not otherwise specified | ✔ | N/A | |
paclitaxel (Taxol) | J9267 - Injection, paclitaxel, 1 mg | ✔ | 96413, 96415 | |
prednisolone (eg, Orapred, Millipred) | J7510 - Prednisolone, oral, per 5 mg | ✔ | N/A | |
prednisone (Deltasone) | J7512 - Prednisone, immediate release or delayed release, oral, 1 mg | ✔ | N/A | |
radium Ra dichloride (Xofigo) | A9606 - Radium Ra-223 dichloride, therapeutic, per microcurie | ✔ | 79101 | |
sipuleucel-T (Provenge) | Q2043 - Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion (Code Price is per 250 mL) | ✔ | 96413, 96415 | |
topotecan (Hycamtin) | J9351 - Injection, topotecan, 0.1 mg | ✔ | 96413 | |
trastuzumab (Herceptin) | J9355 - Injection, trastuzumab, 10 mg | ✔ | 96413, 96415 | |
triptorelin (Trelstar Depot, Trelstar) | J3315 - Injection, triptorelin pamoate, 3.75 mg | ✔ | 96372, 96402 | |
vinBLAStine (Velban) | J9360 - Injection, vinblastine sulfate, 1 mg | ✔ | 96409 | |
vinorelbine (Navelbine) | J9390 - Injection, vinorelbine tartrate, per 10 mg | ✔ | 96409 | |
*When billing a nonclassified medication using a CMS 1500 claim form you must include both the HCPCS code (eg, J8999 Zytiga) in Item 24D and the drug name, strength, and NDC (National Drug Code) in Item 19 or 24A shaded area in order to ensure appropriate reimbursement. Please note: Check with payer regarding correct placement of medication information. |
||||
References • HCPCS Level II Expert 2017 • Current Procedural Terminology (CPT®) 2017 • CPT® Copyright © 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association • ICD-10-CM for Professionals Volumes 1 & 2 2017 • FDA-approved indication (product Prescribing Information) • Compendia references available upon request • www.ReimbursementCodes.com powered by RJ Health Systems International, LLC, Rocky Hill, CT • CMS (Centers for Medicare & Medicaid Services) |
||||
HCPCS indicates Healthcare Common Procedure Coding System; PAP-GM-CSF, prostatic acid phosphatase granulocyte-macrophage colony-stimulating factor. |