Reimbursement

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

Dose 11-digit NDC
441 mg 65757-0401-03
662 mg 65757-0402-03
882 mg 65757-0403-03
1064 mg 65757-0404-03

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
295.90 Schizophrenia
Diagnostic Codes
ICD-10-CM5

Use ICD-10 codes for dates of service on or after Oct 1, 2015
F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.5 Residual schizophrenia
F20.89 Other schizophrenia
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
Revenue Code
  • Medicare, revenue code 0636 (drugs that require detailed coding)
  • For non-Medicare payers, revenue code 0250 (general pharmacy)
  • Injection services may be reported with revenue code 0510 (clinic, general service)
Loop 2400,
SV201
Field 42
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,
SV202-2
Field 44
CPT® Code 96372 (therapeutic, prophylactic or diagnostic injection)*
Service Units 441 units for 441 mg
662 units for 662 mg
882 units for 882 mg
1064 units for 1064 mg
Loop 2400,
SV205
Field 46
Diagnosis F20.x
(Use ICD-10 for dates of service on or after Oct 1, 2015)
Loop 2300, HI01-2
(HI01-1=BK)
Fields
67A-Q

CPT®=Current Procedural Terminology
Copyright of the American Medical Association, 2015.

*ARISTADA is administered as an IM injection only.

Reimbursement Guide

If you need more information about coding, coverage, or payment for treatment with ARISTADA, consult the Reimbursement Guide.

Download

J-Code Information

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.