# HCPCS Code J9267
## Definition
Healthcare Common Procedure Coding System (HCPCS) code J9267 is a billing code utilized to represent the pharmaceutical agent bevacizumab, marketed under the brand name Avastin. Specifically, J9267 is used to document the administration of bevacizumab in the dosage of 10 milligrams. This code is employed across various healthcare settings where bevacizumab is used as a therapeutic agent, enabling proper billing and reimbursement within the context of medical cancer therapy.
Bevacizumab is classified as a monoclonal antibody that inhibits vascular endothelial growth factor (VEGF), thereby impeding the formation of new blood vessels—a process known as angiogenesis. As a result, this code is most frequently associated with cancer treatments, particularly for patients with metastatic cancers such as colorectal cancer, ovarian cancer, and non-small-cell lung cancer. By standardizing the reporting of this drug’s usage, J9267 ensures consistency in claims processing and financial accountability.
The inclusion of J9267 in the HCPCS framework reflects its essential role in modern oncology pharmacotherapy. Its assignment underscores the need for accurate documentation in order to track drug utilization and costs in increasingly personalized treatment regimens. The explicit focus on dose-specific reporting also mitigates risks of discrepancies in claims processing.
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## Clinical Context
Clinically, bevacizumab is an adjunct therapy approved for use in several advanced malignancies, often in combination with other chemotherapeutic agents. It is frequently administered via intravenous infusion under the guidance of an oncologist, typically in outpatient settings such as infusion clinics or specialized cancer treatment centers. Its utility stems from its ability to limit tumor growth and metastasis by restricting blood supply to cancer cells.
The therapeutic application of bevacizumab often requires rigorous patient selection due to its potential to cause significant adverse effects, such as hypertension, thromboembolic events, or gastrointestinal perforations. Consequently, medical teams must evaluate its benefit-risk profile on a case-by-case basis. The precision of HCPCS code J9267 allows providers to delineate these medically complex treatments accurately in patient records and claims.
J9267 is most often used for patients who have demonstrated disease progression despite first-line therapies or who have advanced-stage cancer at initial diagnosis. Its usage must align with specific clinical guidelines and payer policies, ensuring that the treatment meets nationally recognized standards of care and medical necessity.
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## Common Modifiers
Modifiers appended to HCPCS code J9267 are frequently used to provide additional details about the circumstances of the treatment or the patient-specific context. A common example is the use of a modifier to indicate whether the administration was performed in a hospital outpatient department, an ambulatory infusion center, or a physician’s office setting.
Geographic indicators are also sometimes attached as modifiers when payers account for cost variations in dosage administration based on regional disparity. Similarly, modifiers may signal whether the treatment was part of a clinical trial, which has implications for reimbursement procedures.
Other common examples include modifiers to identify patient-specific factors, such as a prolonged intravenous infusion or adjustments for wastage of the drug when its full vial dosage could not be utilized. Accurate use of these modifiers ensures compliance with payer requirements and prevents claim rejections.
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## Documentation Requirements
Adequate documentation is a critical component when billing HCPCS code J9267 to substantiate medical necessity and ensure reimbursement. Providers must include detailed records of the diagnosis for which bevacizumab was administered, aligning with approved indications and payer-specific coverage policies. For example, the medical record should reflect the cancer type, staging, and progression status.
Additionally, documentation must specify the total dosage of bevacizumab administered and account for any leftover amounts that were discarded, if applicable. Infusion start and stop times, as well as the clinical rationale for treatment, should also be clearly noted in the patient record. Failure to include this information can raise flags during claims audits or cause delays in payment processing.
Healthcare providers must also include the National Drug Code (NDC) for bevacizumab in billing submissions to comply with payers’ requirements. Furthermore, any adverse events occurring during or after the infusion must be documented comprehensively, as these may inform coverage determinations or necessitate future pre-authorization for continued therapy.
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## Common Denial Reasons
Claims submitted using HCPCS code J9267 are often denied due to incomplete or inaccurate documentation. One of the most frequent reasons for denial is the failure to demonstrate medical necessity, particularly when bevacizumab is prescribed for off-label use without sufficient justification. Payers rely heavily on clinical guidelines, so deviations must be carefully substantiated to warrant approval.
Another common reason for denial is the improper use or omission of required modifiers. If the proper setting, waste reporting, or infusion specifications are not clearly conveyed, the payer may reject the claim or request additional information. Errors in dosage reporting, such as failure to align the billed quantity with the administered amount, also result in claim denials.
Administrative issues, such as failure to include the NDC code or submission of claims outside the authorized timeframe, can further complicate the approval process. Providers must remain vigilant about adherence to each payer’s specific policies and thoroughly review all claims prior to submission.
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## Special Considerations for Commercial Insurers
When billing commercial insurers for bevacizumab, providers may encounter policy variations in coverage criteria and reimbursement rates. Commercial insurers often impose stricter limitations on off-label use, requiring prior authorization or submission of peer-reviewed evidence to support medical necessity. These additional steps must be completed before treatment begins to avoid lapses in coverage.
Some commercial payers may also require providers to exhaust alternative therapies before approving reimbursement for bevacizumab. Providers should be prepared to furnish records reflecting the failure of prior treatments or contraindications to other options. Awareness of these expectations allows prescribers to streamline treatment planning and claims processing.
Additionally, insurance plans often impose specific rules regarding billing for multi-use vial wastage. It is imperative to differentiate claims for the actual administered drug amount from discarded portions, ensuring compliance with insurer wastage policies. Commercial insurers may request detailed explanations of dosage calculations and allocation.
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## Similar Codes
Several HCPCS codes bear similarities to J9267 in their function but differ in terms of the specific drug or dose they represent. For example, J9035 is a related code used to identify the administration of bevacizumab-awwb, a biosimilar to bevacizumab, at the same dosage of 10 milligrams. This code serves the same clinical purpose but may have different reimbursement rates or restrictions.
Other relevant codes include J9358, which pertains to a different monoclonal antibody used in oncology for inhibiting VEGF, known as ramucirumab. While these drugs share a mechanism of action, they are utilized in distinct clinical contexts, making accurate code selection essential for ensuring proper claims submission.
Additionally, codes such as J9312, which pertains to rituximab, may appear in similar treatment frameworks involving monoclonal antibodies but target entirely different pathways. Care must be taken to distinguish between these codes, not only for coding accuracy but also to align treatment with appropriate clinical guidelines and payer policies.