Coding and Billing Information
Understanding reimbursement procedures for ARISTADA
ARISTADA® (aripiprazole lauroxil) extended-release injectable suspension is an atypical antipsychotic. ARISTADA is only to be administered as an intramuscular injection by a healthcare professional. Because of this, reimbursement for ARISTADA differs from oral therapies dispensed to patients for self-administration. Place of service, type of payer, and benefit category are the 3 main considerations that affect coverage and reimbursement for treatment with ARISTADA.
For quick reference, coding and billing highlights may be found below.
More comprehensive information may be found in our Reimbursement Guide.
Coding and billing summary
This is not a guarantee of payment, coverage, or reimbursement. Alkermes does not provide any advice, recommendation, guarantee, or warranty relating to coverage, reimbursement, or coding for any product or service. Healthcare providers are responsible for determining coverage and reimbursement information and ensuring the accuracy and completeness of claim submissions for their patients. Coding, coverage, and reimbursement vary significantly by payer, patient, and setting of care and are subject to change. Additional information may exist. Actual coverage and reimbursement decisions are made by individual payers.
National Drug Codes (NDCs) for ARISTADA1
Healthcare Common Procedure Coding System (HCPCS) codes
On January 1, 2017, ARISTADA obtained a unique J-code: J1942 (Injection, aripiprazole lauroxil, 1 mg). This code can be used in most outpatient settings when billing for ARISTADA.2
|HCPCS Codes||Description||Settings of Care|
|J1942||Injection, aripiprazole lauroxil, 1 mg||Settings of care: Hospitals, community mental health systems, and physician offices|
Note: When billing for the J-code, it is important to bill for the appropriate dose. For example, if a 662-mg dose is administered to the patient, then "662" should be entered in the Service Unit field on the claim form.
American Psychiatric Association, Diagnostic and Statistical Manual (DSM) code set
Mental health professionals use the DSM standard classification of mental disorders in clinical practice and research. These codes are not intended for billing use unless directed by the payer.
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5): DSM code set
The DSM diagnosis codes for mental health disorders were updated, as of May 2013, in the DSM-5.3 DSM-5 codes and descriptors should be used as required by the payer.
|DSM-5 Code||Code Description|
Use ICD-10 codes for dates of service on or after Oct 1, 2015
|F20.9||Unspecified schizophrenia||Procedural Codes|
|CPT®6||96372||Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular*|
CMHCs=community mental health centers; ICD-10-CM=International Classification of Diseases, 10th Revision, Clinical Modification; CPT®=Common Procedural Terminology.
Copyright of the American Medical Association, 2016.
*ARISTADA is administered as an IM injection only.
Coding for treatment with ARISTADA: Claim Form CMS-1500/837P7,8 (physician offices and non–Medicare-certified CMHCs)
The 837P (Professional) is the standard format used by healthcare professionals and suppliers to transmit claims electronically. The form CMS-1500 is the standard paper claim form used to bill most insurance carriers, including Medicare, Medicaid, and commercial carriers when a paper claim is allowed. Data elements in the CMS uniform electronic billing specifications for 837P are consistent with the hard copy data set.
Healthcare professionals and other qualified providers should submit all electronic claims using the 837P claims format, following ANSI ASC X12N 837P Version 5010A1 electronic data interchange transaction standards. Healthcare providers in a physician’s office who treat Medicare beneficiaries may use Form CMS-1500 (02/12) for most payers who accept paper claims if a paper claim is necessary.
The following information highlights some of the key product-specific fields in the 837P and the coordinating location on the CMS-1500 for Medicare claims reporting purposes. Please check with other payers for specific details and processes for use of appropriate forms.
|Field/Category Name8||Example*||837P Loop ID, Segment/Data Element9||CMS-1500 (02/12) Field Number8|
|Procedures, Services, or Supplies (ie, HCPCS code)||J1942 (Injection, aripiprazole lauroxil, 1 mg)||Loop 2400/SV101||Field 24D|
|Procedures, Services, or Supplies (ie, CPT® Code)||96372 (therapeutic, prophylactic, or diagnostic injection)|
|Units||441 units for 441 mg
662 units for 662 mg
882 units for 882 mg
1064 units for 1064 mg
|Loop 2400/SV104||Field 24G|
|Diagnosis or Nature of Illness or Injury||F20.x
(Use ICD-10 codes for dates of service on or after Oct 1, 2015)
|Loop 2300/HI01-2 to HI12-2||Field 21|
CPT®=Current Procedural Terminology. Copyright of the American Medical Association, 2015.
*All examples indicated should also include any placeholder digits required by the 837P format.
Hospital outpatient or partial hospitalization coding for treatment with ARISTADA: Claim Form UB-04/CMS-1450/837I
The 837I (Institutional) is the standard format used by institutional providers to transmit claims electronically. The form UB-04, also known as the CMS-1450, is the standard claim form to bill Medicare Administrative Contractors (MACs) when a paper claim is allowed. Data elements in the CMS uniform electronic billing specifications for 837I are consistent with the hard copy data set.10
The 837I and UB-04 also may be suitable for billing various government and some commercial insurers. Please check with Medicaid programs and private payers for specific details and processes.
|Field/Category Name||Example||837I Loop ID, Segment/Data Element11||UB-04/CMS-1450|
|Description||Medicare requirements for claims crossing over to Medicaid include the NDC qualifier N4 followed by the 11-digit NDC in positions 01-13 (ie, N465757-XXXX-03)||Check with payer (instructions may vary)||Field 43|
|HCPCS Code||J1942 (Injection, aripiprazole lauroxil, 1 mg)||Loop 2400,
|CPT® Code||96372 (therapeutic, prophylactic or diagnostic injection)*|
441 units for 441 mg
662 units for 662 mg
882 units for 882 mg
1064 units for 1064 mg
(Use ICD-10 for dates of service on or after Oct 1, 2015)
|Loop 2300, HI01-2
CPT®=Current Procedural Terminology
Copyright of the American Medical Association, 2015.
If you need more information about coding, coverage, or payment for treatment with ARISTADA, consult the Reimbursement Guide.Download
For provider entities wanting to buy and bill ARISTADA (J1942), a handy coding sheet is available for reference and download.Download
References: 1. ARISTADA (aripiprazole lauroxil) [package insert] Waltham, MA: Alkermes; 2017.
2. CMS 2017 Healthcare Common Procedure Coding System (HCPCS) code set: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Downloads/2017-Alpha-Numeric-Index.pdf. Accessed November 22, 2016.
3. Centers for Medicare & Medicaid Services. Health Care Procedure Coding System. 2015 Annual Alpha Numeric HCPCS File. https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS-Items/2015-Alpha-Numeric-HCPCS-File-%C2%A0.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending. Accessed May 22, 2015.
4. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. DSM-V™ Arlington, VA: American Medical Association: 2013.
5. 2015 ICD-10-CM, Complete Official Draft Code Set, Clinical Modification. Salt Lake City, UT: AAPC; 2014.
6. CPT® 2015 Professional Edition: Current Procedural Terminology. Atlanta, GA: American Medical Association; 2014.
7. Centers for Medicare & Medicaid Services. Medicare Prescription Drug Benefit Manual. Chapter 26 - Completing and Processing Form CMS-1500 Data Set. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf. Publication 100-04. Accessed May 13, 2015
8. National Uniform Claim Committee. June 2013. http://www.nucc.org/images/stories/PDF/1500_claim_form_instruction_manual_2012_02-v2.pdf. Accessed November 22, 2016.
9. Palmetto GBA. ANSI 837 v5010 to CMS-1500 Crosswalk. http://www.palmettogba.com/Palmetto/Providers.Nsf/files/CMS1500_ANSI837v5010_Crosswalk.pdf/$File/CMS1500_ANSI837v5010_Crosswalk.pdf. Accessed November 22, 2016.
10. Centers for Medicare & Medicaid Services. Medicare Prescription Drug Benefit Manual. Chapter 25 - Completing and Processing the Form. CMS-1450 Data Set. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c25.pdf. Accessed November 22, 2016.
11. Palmetto GBA. ASC 8371 version 5010A2 Institutional Health Care Claim to the CMS-1450 Claim Form Crosswalk. http://www.palmettogba.com/Palmetto/Providers.Nsf/files/EDI_837I_v5010A2_crosswalk.pdf/$File/EDI_837I_v5010A2_crosswalk.pdf. Accessed November 22, 2016.