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CODING AND BILLING
Reference Guide
For more information call the
Rapivab™ Reimbursement Hotline
1-844-RAPIVAB (1-844-727-4822)
Program Specialists are available from
9:00 AM to 5:00 PM EST,
Monday through Friday.
Separate Reimbursement for Rapivab™ (peramivir injection)
Setting of Care
Medicare
Medicaid
Private Payers
Yes
Varies
Varies
Yes
Varies
Varies
Hospital Outpatient
Departments include:
• Emergency Department (ED)
• Observation Setting
• Hospital provider-based clinics
Physician offices include:
• Urgent Care Clinics
• Private practices
• Free-standing Infusion Centers
Hospital Outpatient: Medicare reimburses for Rapivab™ separately when used in the
outpatient setting of care. Reimbursement will be processed through correct reporting
of an unclassified drug code using the corresponding units delineated in the instructions
below. Private insurers and state Medicaid agencies have varying reimbursement policies;
many will provide separate reimbursement for Rapivab™ in the outpatient setting.
Physician Offices: Medicare reimburses for Rapivab™ separately when used in physician
offices. Reimbursement will be processed through correct reporting of an unclassified drug
code using the corresponding units delineated in the instructions below. Private insurers
and state Medicaid agencies have varying reimbursement policies; many will provide
separate reimbursement for Rapivab™ in the physician office.
Please see Important Safety Information | Please see Full Prescribing Information
In addition to the list of relevant codes below, please refer to sample forms
in this document for guidance on completing these forms accurately.
What are the relevant codes for Rapivab™ in my setting of care?
Code Set
Setting of Care
Code and Description
HCPCS Codes
•H
ospital outpatient
At launch, report Rapivab™ with a nonspecific, unclassified HCPCS code.
Used to report RAPIVAB
department
•H
ospital outpatient
provider-based clinic
C9451 - Unclassified drugs or biologicals
(Required by Medicare; other payers also
may use it)
In addition, enter the drug-identifying
information as required by the payer.
Generally the following information is
required: the drug name (brand and
generic), NDC, dose, and method of
administration.
Example: Rapivab™ (peramivir injection)
NDC 61364-181-01, 600 mg via
IV infusion
• Urgent care clinic
• Physician office
At launch, report Rapivab™ with a
non-specific, unclassified HCPCS code.
J3490 - Unclassified drugs
In addition, enter the drug-identifying
information as required by the payer.
Generally the following is required: the
drug name (brand and generic), NDC, dose,
and method of administration.
Example: Rapivab™ (peramivir injection)
NDC 61364-181-01, 600 mg via
IV infusion
NDC
• Hospital outpatient department
Used to report RAPIVAB
•H
ospital outpatient
provider-based clinic
Most payers will require the NDC to identify
Rapivab™, especially while it is billed with
an unclassified code.
• Urgent care clinic
Vial (one): NDC 61364-181-01
Carton (three): NDC 61364-181-03
• Physician office
200 mg, peramivir, single-use vial
Claim form requirements for NDCs vary by
payer. See example claim forms that follow
for more detail.
Please see Important Safety Information | Please see Full Prescribing Information
What are the relevant codes for Rapivab™ in my setting of care?
Code Set
Setting of Care
Code and Description
Revenue Codes
• Hospital outpatient department
Used to attribute hospital
charges to specific cost
centers
•H
ospital outpatient
Revenue codes vary by service provided and
also vary depending on patient status.
provider-based clinic
0636 - Drugs Requiring Detailed Coding
Required by Medicare to obtain
pass-through payment for drugs in the
outpatient department.
0250 - Pharmacy, General
0260 - Intravenous Therapy, General
Some revenue codes are required to obtain
appropriate reimbursement for a specific
service performed in a specific setting of
care; for other services, revenue codes
may vary.
ICD-9-CM
Diagnosis†#
Codes used to report
diagnoses
• Hospital outpatient department
• Hospital outpatient
provider-based clinic
Rapivab™ is indicated for the treatment of
acute uncomplicated influenza in patients 18
years and older who have been symptomatic
for no more than 2 days.
• Urgent care clinic
• 487.0 – Influenza, with pneumonia
• Physician office
• 487.1 – I nfluenza, with other respiratory
manifestations
• 487.8 –
Influenza, with other manifestations
•4
88.XX – Influenza due to identified flu
virus (avian, 2009 H1N1, novel)
CPT Codes#
• Hospital outpatient department
Infusion Service
Codes used to report
IV infusion
• Hospital outpatient
96365 Intravenous infusion, for therapy,
prophylaxis, or diagnosis; initial, up to 1 hour
provider-based clinic
• Urgent care clinic
• Physician office
† ICD-10-CM (diagnosis codes) and ICD-10-PCS (procedure codes) will replace ICD-9-CM effective October 1, 2015.
# This may not be an all-inclusive list; see payer-specific coverage policies for covered indication.
Please see Important Safety Information | Please see Full Prescribing Information
SAMPLE CMS - 1500 CLAIM FORM
For services provided in the physician office
This document is provided for your guidance only. Please
call Rapivab™ Reimbursement Hotline at 1-844-RAPIVAB
to verify coding and claim information for specific payers
SAMPLE
Box 21 – Diagnosis Codes
Enter the appropriate ICD-9-CM
diagnosis codes (see example)
Box 19 – Appropriate area for drug
name, NDC code, total units billed and
any additional information the payer
requires.
Example:
487.0 – Influenza, with pneumonia
The example shown includes the 11
digit NDC code required by payers.
487.1 – Influenza, with other
respiratory manifestations
487.8 – Influenza, with other
manifestations
488.XX – Influenza due to identified
flu virus (avian, 2009 H1N1,
novel)
Box 24 – Procedures, Services, or Supplies
Enter the NDC code beginning with “N4” and the appropriate
HCPCS code
Example:
J3490 – Unclassified Drug Code with N4 61364-181-01
Example Procedure Code:
96365 – Intravenous Infusion, for therapy, prophylaxis, or
diagnosis (specify substance or drug); initial, up
to 1 hour
Please see Important Safety Information | Please see Full Prescribing Information
SAMPLE CMS-1450 CLAIM FORM
For services provided in hospital setting
This document is provided for your guidance only. Please
call Rapivab™ Reimbursement Hotline at 1-844-RAPIVAB
to verify coding and claim information for specific payers
SAMPLE
Revenue Code, Description, HCPCS (Fields 42-44)
Enter the appropriate revenue code and description
corresponding to the HCPCS code in field 44
Example Revenue Codes:
Medicare: Please use revenue code 636
- drugs requiring detailed coding
Field 66 - Diagnosis Code
Enter the appropriate ICD-9-CM
diagnosis code (see example)
Example:
487.0 – Influenza, with pneumonia
Non-Medicare: May require revenue code 250
- general pharmacy
487.1
Example HCPCS:
Medicare: C9399 – Unclassified drugs or biologicals
487.8 – Influenza, with other
manifestations
Non-Medicare: J3490 – Unclassified Drug Code
- Please indicate the number of units in Box 80
488.XX – Influenza due to identified
flu virus (avian, 2009 H1N1,
novel)
Example Procedure Codes:
96365 - Intravenous Infusion, for therapy,
prophylaxis, or diagnosis (specify substance
or drug); initial, up to 1 hour
– Influenza, with other
respiratory manifestations
Note: E
nter the appropriate diagnosis
as reflected in the patient’s
medical record
Box 80 Comments:
Rapivab™ (peramivir injection)
NDC 61364-181-01
200 mg single use vial, total 600 mgs
Administered IV
Please see Important Safety Information | Please see Full Prescribing Information
GLOSSARY
CMS=Centers for Medicare & Medicaid Services; CPT=Current Procedural Terminology; HCPCS=Healthcare Common Procedure Coding System;
ICD-9-CM=International Classification of Diseases, Ninth Revision, Clinical Modification; NDC=National Drug Code.
DISCLAIMER
The use of this guide is strictly for reimbursement purposes. This guide provides a summary of coding, coverage, and payment of Rapivab™ (peramivir
injection) for its FDA (Food and Drug Administration) approved uses as indicated in the prescribing information. The information contained in this
document is not intended for purposes of providing clinical practice guidelines for use of Rapivab™. Please see the package insert for more information.
BioCryst Pharmaceuticals specifically disclaims liability or responsibility for the results or consequences of any actions taken in reliance on information
in this guide. BioCryst Pharmaceuticals cannot guarantee nor is responsible for, the payment of any claim. The coding, coverage, and payment for
Rapivab™ may vary by payer, plan, patient, and setting of care. For more information, healthcare professionals should check with individual payers for
specific coding, coverage and payment requirements in the use of Rapivab™. It is the sole responsibility of the healthcare professional to properly code
and ensure the accuracy of all claims used in seeking reimbursement. All services must be medically appropriate and properly supported in the patient’s
medical records.
INDICATION
Rapivab is indicated for the treatment of acute uncomplicated influenza in patients 18 years and older who have been symptomatic for no more than 2 days.
• E fficacy of Rapivab was based on clinical trials in which the predominant influenza virus type was influenza A; a limited number of subjects infected
with influenza B virus were enrolled.
• Influenza viruses change over time. Emergence of resistance substitutions could decrease drug effectiveness. Other factors (for example, changes in
viral virulence) might also diminish clinical benefit of antiviral drugs. Prescribers should consider available information on influenza drug susceptibility
patterns and treatment effects when deciding whether to use Rapivab.
• Efficacy could not be established in patients with serious influenza requiring hospitalization.
IMPORTANT SAFETY INFORMATION
Contraindications
None
Warnings and Precautions
• R are cases of serious skin reactions, including Stevens-Johnson syndrome and erythema multiforme have occurred with Rapivab. Appropriate
treatment should be instituted if a serious skin reaction occurs or is suspected.
• Patients with influenza may be at an increased risk of hallucinations, delirium and abnormal behavior early in their illness. There have been postmarketing reports (from Japan) of delirium and abnormal behavior leading to injury in patients with influenza who were receiving neuramini dase
inhibitors, including Rapivab. Because these events were reported voluntarily during clinical practice, estimates of frequency cannot be made, but
they appear to be uncommon. Patients with influenza should be closely monitored for signs of abnormal behavior.
• S erious bacterial infections may begin with influenza-like symptoms or may coexist with or occur as complications during the course of influenza.
Rapivab has not been shown to prevent such complications.
Adverse Reactions
• The most common adverse reaction (incidence >2%) is diarrhea (8% Rapivab vs. 7% placebo).
• Lab abnormalities (incidence >2%) occurring more commonly than placebo were elevated ALT 2.5 times the upper limit of normal (3% vs. 2%),
elevated serum glucose greater than 160 mg/dL (5% vs 3%), elevated CPK more than 6 times the upper limit of normal (4% vs. 2%) and neutrophils
less than 1.0 x 109/L (8% vs. 6%).
Concurrent use with Live Attenuated Influenza Vaccine
Antiviral drugs may inhibit viral replication of a live attenuated influenza vaccine (LAIV). The concurrent use of Rapivab with LAIV intranasal has not
been evaluated. Because of the potential for interference between these two products, avoid use of LAIV within 2 weeks before or 48 hours after
administration of Rapivab unless medically indicated.
#
This may not be an all-inclusive list; see payer-specific coverage policies for covered indication.
Please see Important Safety Information | Please see Full Prescribing Information
Rapivab™ is a registered trademark of BioCryst Pharmaceuticals, Inc. © Copyright 2014 BioCryst Pharmaceuticals, Inc.