Relevant Codes for Prograf® (tacrolimus)
Properly coding claims will help facilitate timely claims processing and reduce the risk of denied claims. Coding requirements vary by payer.1 The coding systems in the following tables will assist you in proper coding for Prograf a:
National Drug Code (NDC)
Universal 10-digit product identifier for human drugs; each NDC identifies the labeler, product, and trade package size
|00469-3016-01||5 mg/mL (equivalent of 5 mg of anhydrous tacrolimus per mL)||Supplied as a sterile solution in a 1-mL ampule, in boxes of 10 ampules|
|00469-0607-73||0.5 mg||100-count bottle|
|00469-0617-11||1 mg||10 blister cards of 10 capsules|
ICD-10-CM Diagnosis Codes2
Numeric classification descriptive of diseases, injuries, and causes of death, used in hospital outpatient and physician office setting
|T86.11||Kidney transplant rejection|
|T86.12||Kidney transplant failure|
|T86.21||Heart transplant rejection|
|T86.22||Heart transplant failure|
|T86.41||Liver transplant rejection|
|T86.42||Liver transplant failure|
|Z48.21||Encounter for aftercare following heart transplant|
|Z48.22||Encounter for aftercare following kidney transplant|
|Z48.23||Encounter for aftercare following liver transplant|
|Z94.0||Kidney transplant status|
|Z94.1||Heart transplant status|
|Z94.4||Liver transplant status|
4-digit codes that all hospitals use to capture cost data by department
|0250||Pharmacy-General||Some payers, such as Medicare, require certain combinations of revenue codes and HCPCS or CPTb codes to facilitate claims processing. Confirm requirements with local payer policies.|
|0636||Drugs requiring detailed coding|
5-digit alphanumeric code
|J7507||Tacrolimus, immediate release, oral, per 1 mg||HCPCS code J7507 (tacrolimus, immediate release, oral, 1 mg) should be billed in units of 1 mg. Please note that the billing unit is different for HCPCS code J7508 (tacrolimus, extended release, oral, 0.1 mg).
Pharmacies that dispense immunosuppressive drugs to Medicare beneficiaries who were enrolled in Medicare Part A at the time of their transplant, but where Medicare did not pay for the transplant, must identify the date of transplantation. Pharmacies must have the transplantation date on file and include the "KX" modifier on the Medicare claim when billing for immunosuppressive drug.4
|J7525||Tacrolimus, parenteral, 5 mg|
|Q0510||Pharmacy supply fee for initial immunosuppressive drug(s), first month following transplant (This fee is payable once per beneficiary per transplant.)|
|Q0511||Pharmacy supply fee for oral anti-cancer, oral antiemetic, or immunosuppressive drug(s); for the first prescription in a 30-day period|
|Q0512||Pharmacy supply fee for oral anti-cancer, oral antiemetic, or immunosuppressive drug(s); for a subsequent prescription in a 30-day period|
5-digit codes that describe procedures and services performed by physicians and other healthcare providers
|96365||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour||These codes are only appropriate for the injectable form of Prograf.|
|96366||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (list separately in addition to code for primary procedure)|
a IMPORTANT INFORMATION: The coding, coverage, and payment information contained herein is gathered from various resources, general in nature, and subject to change without notice. Third-party payment for medical products and services is affected by numerous factors. It is always the provider's responsibility to determine the appropriate healthcare setting and to submit true and correct claims conforming to the requirements of the relevant payer for those products and services rendered. Pharmacies (or any other provider submitting a claim) should contact third-party payers for specific information on their coding, coverage, and payment policies. Information and materials provided by Prograf Support Solutions are to assist providers and pharmacies, but the responsibility to determine coverage, reimbursement, and appropriate coding for a particular patient and/or procedure remains at all times with the provider and pharmacy, and information provided by Prograf Support Solutions or Astellas should in no way be considered a guarantee of coverage or reimbursement for any product or service.
b Current Procedural Terminology (CPT), Professional Edition, 2016. American Medical Association, 2015. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no responsibility for the data contained herein. CPT is a registered trademark of the American Medical Association.
1. Beck DE, Margolin DA. Physician coding requirement. Ochsner J. 2007;7:8-15.
2. Centers for Medicare & Medicaid Services. 2017 ICD-10-CM and GEMs. www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html. Accessed 12-07-2016.
3. Centers for Medicare & Medicaid Services. CMS manual system. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending. Accessed 12-06-2016.
4. Centers for Medicare & Medicaid Services. MLN Matters: Adjudicating Claims for Immunosuppressive Drugs when Medicare Did Not Pay for the Original Transplant. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5916.pdf (07-06-2013). Accessed 04-21-2016.