Skip to Main Content

Print | Bookmark | Email | Font Size: + |

June 8, 2021

Trilaciclib (Cosela™) Claim Filing Information

Trilaciclib (Cosela™) is a kinase inhibitor indicated to decrease the incidence of chemotherapy-induced myelosuppression in adult patients when administered prior to a platinum/etoposide-containing regimen or topotecan-containing regimen for extensive-stage small-cell lung cancer. It is for intravenous use only.

Coverage will be allowed when billed with ICD-10 code Z29.8 as the primary diagnosis plus one of the following ICD-10 codes as a secondary diagnosis - D61.810; D61.811; D61.818; D64.81; D70.1; D70.9; T45.1X5A; T45.1X5D; T45.1X5S; Z51.11.

The allowable will be based on 50mg @ $250.337 (i.e., 300mg = 6 units or number of services).

Not Otherwise Classified Claim Filing Instructions:

Claim Submission: Part A

  • Submit unlisted HCPCS code C9399
  • Include the name of the drug, the national drug code (NDC), and the exact dosage administered.
    • Electronic Media Claims (EMC): report this information in Loop 2300, NTE Segment (header level) or Loop/Element 2400 SV101-7, NTE Segment (line level). If additional space is needed, Loop 2400 NTE 02 may be utilized in addition to SV101-7.
    • Paper claims (if approved to submit paper claims): report this information in Form Locator 80 on the UB-04 Form.

Claim Submission: Part B

  • Submit unlisted HCPCS code J3490
  • Include the name of the drug, the national drug code (NDC), and the exact dosage administered.
    • Electronic Media Claims (EMC): report this information in Loop 2300, NTE Segment (header level) or Loop/Element 2400 SV101-7, NTE Segment (line level). If additional space is needed, Loop 2400 NTE 02 may be utilized in addition to SV101-7.
    • Paper claims (if you are approved to submit paper claims): report this information in Item 19 on the CMS-1500 claim form.

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved