## **What is HCPCS code J0717?**
HCPCS code J0717 is for "Injection, certolizumab pegol 1 mg."
Sold under the brand name Cimzia, certolizumab pegol is a tumor necrosis factor (TNF) inhibitor. It works by blocking TNF-alpha, a protein that causes inflammation and is involved in many autoimmune diseases.
Patients treated or those whose physician functions improved with this specific drug may have any of the following conditions:
- Severely active Rheumatoid Arthritis (RA), including cases with high rheumatoid factors
- Active Psoriatic Arthritis (PsA)
- Predominantly axial disease, both Non-radiographic pAxial Spondyloarthritis (nr-axSpA) and Ankylosing Spondylitis (AS)
- Crohn's disease
- Polyarticular juvenile idiopathic arthritis
- Severe plaque psoriasis
The code specifies the drug in 1 mg increments. Therefore, a provider must bill multiple units of J0717 to reflect the total dosage administered to the patient, which is often 200 mg or 400 mg.
Do note that the drug must not be continued if the patient develops a serious infection.
## **Documentation requirements**
Thorough documentation is crucial to justify the medical necessity of the treatment and ensure proper reimbursement. The patient's medical record should include:
- Diagnosis: A clear and accurate diagnosis of one of the conditions for which certolizumab pegol is indicated. If possible, include the disease severity of the active disease.
- Medical necessity: Evidence that the adult patient's condition meets the specific criteria for using this drug, often including a history of inadequate response to or intolerance of other conventional therapies like methotrexate or NSAIDs.
- Dosage and administration: The specific dose administered, the route of administration (subcutaneous), and the date and time of the injection.
- Physician supervision: Documentation that the injection was administered under the direct supervision of a physician or other qualified healthcare professional. This is a key requirement, as the code is not for self-administered drugs.
- Wastage: If any of the drug is discarded from a single-use vial, the amount of discarded drug must be documented in the patient's record.
## **Billing requirements**
Billing for J0717 requires careful attention to detail.
- Units: Bill the number of units that corresponds to the total milligrams of the drug administered. For example, if a 400 mg dose is given, bill for 400 units of J0717.
- JW modifier: If a portion of the drug from a single-use vial is discarded, use the JW modifier on a separate line item to report the amount of discarded drug. This modifier is used to ensure payment for both the administered and discarded portions.
- Administration codes: The administration of the injection is typically billed with a separate CPT code, such as those in the 9637x series (e.g., 96372 for therapeutic, prophylactic, or diagnostic injection).
- Prior authorization: Many payers, including Medicare and commercial plans, require prior authorization for certolizumab pegol. The documentation must be submitted and approved before the service is provided to avoid claim denials.
- Billing for drug and administration: The HCPCS code J0717 covers the cost of the drug itself, while the CPT code covers the service of administering the injection.
## **Other related codes**
- J0129: - Injection, abatacept (Orencia)
- J0135 - Injection, adalimumab (Humira)
- J1600 - Injection, golimumab (Simponi)
- J1745 - Injection, infliximab (Remicade, Inflectra)
- J1438 - Injection, etanercept (Enbrel)
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