HCPCS code J9395: Injection fulvestrant, 25 mg

Learn how to accurately use and bill for HCPCS code J9395 with the list of documentation and billing requirements found in our short guide.

Use Code

## **What is HCPCS code J9395?** J9395 is the HCPCS code for injection fulvestrant, reported per 25 mg. HCPCS code J9395 for injection fulvestrant, maintained by CMS, falls under chemotherapy drugs. Fulvestrant is a selective estrogen receptor degrader (SERD) used to treat hormone receptor-positive metastatic breast cancer, particularly in postmenopausal women who have failed prior endocrine therapy. The drug binds to estrogen receptors, leading to receptor degradation and inhibition of estrogen signaling, thereby slowing tumor progression. It is administered intramuscularly, typically in the gluteal muscle, with a standard dose of 500 mg (20 units of J9395) given on days 1, 15, and 29, and then monthly thereafter. Fulvestrant is commonly used as monotherapy or in combination with CDK4/6 inhibitors for advanced disease.

## **HCPCS code J9395 documentation requirements** To ensure proper billing and reimbursement, thorough documentation is essential. Key documentation requirements for HCPCS code J9395 include: - Medical necessity: The patient's medical record must clearly demonstrate that fulvestrant is a medically necessary treatment. This includes the patient's diagnosis of hormone receptor-positive, advanced or metastatic breast cancer, and often a history of disease progression after previous endocrine therapy. - Patient status: The patient's postmenopausal status must be documented, or if they are premenopausal, documentation of ovarian ablation/suppression is required. - Dosage and administration: The record should specify the dosage administered. The standard dose is typically 500 mg, which is 20 units of J9395 (since each unit is 25 mg). The documentation should also note the frequency of administration. - Injection details: The medical record should detail the administration of the drug, including the date, the route of administration (intramuscular injection into the buttocks), and the name and signature of the person who administered the injection. - NDC Number: The National Drug Code (NDC) of the specific drug product used should be included on the claim form. This helps with drug rebate programs and ensures the correct product is administered.

## **J9395 billing requirements** Billing for HCPCS code J9395 requires adherence to the following specific guidelines to avoid denials and ensure accurate payment: - Units: The code is billed in units of 25 mg. Therefore, for a 500 mg dose, you would bill 20 units (500 mg / 25 mg per unit = 20 units). - Diagnosis codes: The claim must be linked to an appropriate ICD-10-CM diagnosis code for breast cancer that supports the medical necessity of the treatment. - Prior authorization: Many payers, including Medicare and private insurance companies, require prior authorization for fulvestrant. It's crucial to obtain this before administering the drug to confirm coverage. - Modifiers: Depending on the specific circumstances and payer policies, certain modifiers might be required. - Compounded drugs: If a compounded version of fulvestrant is used, it cannot be billed with J9395.

## **Other relevant codes** - J9393 - Injection, fulvestrant (teva), 25 mg - J9394 - Injection, fulvestrant (fresenius kabi), 25 mg

Frequently asked questions

The brand name is Faslodex®. However, generic versions of fulvestrant are also available.

You should bill 20 units (500 mg divided by 25 mg per unit).

While it's not always required by every payer, it is a common requirement. It is best practice to check with the specific insurance company before administration to avoid claim denials.