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:

Code Code Description Notes
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
00469-0617-73 1 mg
00469-0657-73 5 mg
00469-0617-11 1 mg 10 blister cards of 10 capsules
Code Code Description
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
Code Code Description Notes
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.
0260 IV Therapy-General
0636 Drugs requiring detailed coding
Code Code Description Notes
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
Code Code Description Notes
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.

References

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.