Article for Mitomycin (Mutamycin®, Mitomycin-C) – Related to LCD L25820 (A47581)

Contractor Information

 

Contractor Name 

National Government Services, Inc.  

Contractor Number 

Number

Type

State(s)

00130

FI

IN

00131

FI

IL

00160

FI

KY

00180

FI

ME

00181

FI

MA

00270

FI

NH, VT

00332

FI

OH

00450

FI

WI

00452

FI

MI

00453

FI

VA, WV

00630

Carrier

IN

00660

Carrier

KY

13101

MAC

CT – Part A

13102

MAC

CT – Part B

13201

MAC

NY – Part A

13202

MAC

NY – Part B

13282

MAC

NY- Part B

13292

MAC

NY – Part B

 

Contractor Type 

Carrier

Fiscal Intermediary

MAC – Part A

MAC – Part B

 

 

Article Information

 

Article ID Number 

A47581 

Article Type 

Article

Key Article 

Yes

Article Title

Mitomycin (Mutamycin®, Mitomycin-C) – Related to LCD L25820 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2008 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association.© 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

Primary Geographic Jurisdiction 

Number

Type

State(s)

00130

FI

IN

00131

FI

IL

00160

FI

KY

00180

FI

ME

00181

FI

MA

00270

FI

NH, VT

00332

FI

OH

00450

FI

WI

00452

FI

MI

00453

FI

VA, WV

00630

Carrier

IN

00660

Carrier

KY

13101

MAC

CT – Part A

13102

MAC

CT – Part B

13201

MAC

NY – Part A

13202

MAC

NY – Part B

13282

MAC

NY- Part B

13292

MAC

NY – Part B

 

Original Article Effective Date 

07/18/2008

 

Article Revision Effective Date 

01/01/2009

 

Article Text 

This article defines coding and coverage for Mitomycin including off-label indications. National Government Services Local Coverage Determination (LCD) “Coverage of Drugs and Biologicals for Label and Off-Label Uses” allows coverage for off-label indications only if the United States Pharmacopeia Drug Information (USP-DI), the American Hospital Formulary Services (AHFS) and/or Thomson Healthcare DrugPoints® (as described in the LCD) define such indications or if National Government Services has published an article or LCD expanding such coverage. Effective for dates of service on or after 11/25/2008, American Hospital Formulary Services (AHFS), Clinical Pharmacology, NCCN Drugs and Biologics Compendium and/or Thomson Micromedex DrugDex® compendium has replaced the USP-DI and Thomson Healthcare DrugsPoints®. Providers may request approval for additional off-label indications by submitting this request in writing with supporting medical literature. The aforementioned National Government Services LCD, which describes the requirements for such a request, can be accessed on our contractor Web site at www.NGSMedicare.com or on the Medicare Coverage Database at www.cms.hhs.gov/mcd.


Abstract:
Mitomycin is classified as an antitumor antibiotic. It inhibits DNA synthesis by causing cross-linking. It also inhibits RNA and protein synthesis.

Mitomycin concentrate may be used intravenously or as a topical bladder instillation.

Indications and Limitations:
Mitomycin is approved for the following indications:

  • Treatment of gastric and pancreatic carcinoma (Mitomycin for injection is not recommended as single-agent, primary therapy. It has been shown to be useful in the therapy of disseminated adenocarcinoma of the stomach or pancreas in proven combinations with other approved chemotherapeutic agents and as palliative treatment when other modalities have failed. Mitomycin is not recommended to replace appropriate surgery and/or radiation.
  • Bladder carcinoma (topical treatment of superficial transitional cell carcinoma of the urinary bladder)
  • Cervical squamous cell carcinomas
  • Breast carcinoma
  • Esophageal carcinoma
  • Head & neck carcinoma
  • Non-small cell lung carcinoma
  • Gallbladder
  • Advanced biliary carcinoma
  • Colorectal & anal carcinoma
  • Chronic myelocytic & myelomonocytic leukemias
  • For palliative treatment of adenocarcinoma of the stomach or pancreas unresponsive to surgery and/or radiotherapy, in combination with other agents


Indications expanded by this Article:
Prostatic carcinoma

Utilization:
It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Documentation Requirements:
Medical record documentation maintained by the ordering/referring physician must substantiate the medical need for the use of these chemotherapy drugs by clearly indicating the condition for which these drugs are being used. This might include the type of cancer, staging, if applicable, prior therapy and the patient’s response to that therapy. This documentation is usually found in the history and physical or in the office/progress notes.

If the provider of the service is other than the ordering/referring physician, that provider must maintain copies of the ordering/referring physician’s order for the chemotherapy drug. The physician must state the clinical indication/medical need for using the chemotherapy drug in the order.

Coding Guidelines:


For claims submitted to the carrier or Part B MAC:

Mitomycin should be billed using chemotherapy administration codes and is payable in the following places of service: office (11), skilled nursing home for patients in a Part A stay (31) [if the drug is supplied by the facility, no claims for the drug should be submitted to the Part B carrier.], nursing facility for patients not in a Part A stay (32) and independent clinic (49) only when supplied as an “incident to” service by the physician.

 

Coverage Topic 

Chemotherapy (Inpatient)
Chemotherapy (Outpatient)
Prescription Drugs
 

 

Coding Information

 

Bill Type Codes: 

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

11x

Hospital-inpatient (including Part A)

13x

Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)

85x

Special facility or ASC surgery-rural primary care hospital (eff 10/94)

 

CPT/HCPCS Codes 

 

J9280

MITOMYCIN, 5 MG

J9290

MITOMYCIN, 20 MG

J9291

MITOMYCIN, 40 MG

 

ICD-9 Codes that are Covered 

 

140.0 - 140.1

MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF LOWER LIP VERMILION BORDER

140.3 - 140.6

MALIGNANT NEOPLASM OF UPPER LIP INNER ASPECT - MALIGNANT NEOPLASM OF COMMISSURE OF LIP

140.8 - 140.9

MALIGNANT NEOPLASM OF OTHER SITES OF LIP - MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER

141.0 - 141.6

MALIGNANT NEOPLASM OF BASE OF TONGUE - MALIGNANT NEOPLASM OF LINGUAL TONSIL

141.8 - 141.9

MALIGNANT NEOPLASM OF OTHER SITES OF TONGUE - MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED

142.0 - 142.2

MALIGNANT NEOPLASM OF PAROTID GLAND - MALIGNANT NEOPLASM OF SUBLINGUAL GLAND

142.8 - 142.9

MALIGNANT NEOPLASM OF OTHER MAJOR SALIVARY GLANDS - MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED

143.0 - 143.1

MALIGNANT NEOPLASM OF UPPER GUM - MALIGNANT NEOPLASM OF LOWER GUM

143.8 - 143.9

MALIGNANT NEOPLASM OF OTHER SITES OF GUM - MALIGNANT NEOPLASM OF GUM UNSPECIFIED

144.0 - 144.1

MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH - MALIGNANT NEOPLASM OF LATERAL PORTION OF FLOOR OF MOUTH

144.8 - 144.9

MALIGNANT NEOPLASM OF OTHER SITES OF FLOOR OF MOUTH - MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED

145.0 - 145.6

MALIGNANT NEOPLASM OF CHEEK MUCOSA - MALIGNANT NEOPLASM OF RETROMOLAR AREA

145.8 - 145.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED PARTS OF MOUTH - MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED

146.0 - 146.9

MALIGNANT NEOPLASM OF TONSIL - MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE

147.0 - 147.3

MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX - MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX

147.8 - 147.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX - MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE

148.0 - 148.3

MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX - MALIGNANT NEOPLASM OF POSTERIOR HYPOPHARYNGEAL WALL

148.8 - 148.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF HYPOPHARYNX - MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE

149.0 - 149.1

MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED - MALIGNANT NEOPLASM OF WALDEYER'S RING

149.8 - 149.9

MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE LIP AND ORAL CAVITY - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY

150.0 - 150.5

MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS

150.8 - 150.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS - MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE

151.0 - 151.6

MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED

151.8 - 151.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE

153.0 - 153.9

MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE

154.0 - 154.3

MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION - MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE

154.8

MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS

155.0-155.2

MALIGNANT NEOPLASM of liver, primary - MALIGNANT NEOPLASM of liver, not specified as primary or secondary

156.0 - 156.2

MALIGNANT NEOPLASM OF GALLBLADDER - MALIGNANT NEOPLASM OF AMPULLA OF VATER

156.8 - 156.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF GALLBLADDER AND EXTRAHEPATIC BILE DUCTS - MALIGNANT NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE

157.0 - 157.4

MALIGNANT NEOPLASM OF HEAD OF PANCREAS - MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS

157.8 - 157.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS - MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED

160.0 - 160.5

MALIGNANT NEOPLASM OF NASAL CAVITIES - MALIGNANT NEOPLASM OF SPHENOIDAL SINUS

160.8 - 160.9

MALIGNANT NEOPLASM OF OTHER ACCESSORY SINUSES - MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED

161.0 - 161.3

MALIGNANT NEOPLASM OF GLOTTIS - MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGES

161.8 - 161.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARYNX - MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED

162.0

MALIGNANT NEOPLASM OF TRACHEA

162.2 - 162.5

MALIGNANT NEOPLASM OF MAIN BRONCHUS - MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG

162.8 - 162.9

MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG - MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED

163.0

MALIGNANT NEOPLASM of parietal pleura

163.1

MALIGNANT NEOPLASM of visceral pleura

163.8

MALIGNANT NEOPLASM of other specified sites of pleura

163.9

MALIGNANT NEOPLASM of pleura, unspecified

171.0

MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK

171.2-171.9

MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF UPPER LIMB INCLUDING SHOULDER - MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED

174.0 - 174.6

MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST

174.8 - 174.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE

175.0

MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST

175.9

MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST

180.0

MALIGNANT NEOPLASM OF ENDOCERVIX

180.1