Coding at a Glance
l The approved dosage of Krystexxa® (pegloticase) is 8 mg every 2 weeks
lKrystexxa admixed in 250 mL of 0.9% or 0.45% Sodium Chloride should only be administered by
intravenous infusion over no less than 120 minutes via gravity feed, syringe-type pump, or infusion pump
While all coding decisions should be made by the physician based on independent review of the
patient's condition, below is a list of codes you may find helpful.
The following codes for treatment and procedures applicable to this guideline are included below for
informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not
constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s
contract benefits in effect at the time of service to determine coverage or non-coverage of these
services as it applies to an individual member.
Patient
Diagnosis
ICD-10
Diagnosis
[For dates of service on or after 10/01/2015]
M1A.XXX0: Chronic Gout without tophi
M1A.XXX1: Chronic Gout with tophi
M10.XX: Gout
NDC
Drugs and
Biologics
HCPCS
60809-0801-01: Krystexxa (pegloticase)
J2507: Injection, pegloticase, 1 mg
(Note: the recommended dose for
adult patients is 8 mg every 2 weeks)
J1700: Injections, hydrocortisone acetate, up to 25 mg
J1710: Injection, hydrocortisone sodium phosphate, up to 50 mg
J1720: Injection, hydrocortisone sodium succinate, up to 100 mg
96365: Intravenous infusion, for therapy, prophylaxis, or diagnosis
(specify substance or drug); initial, up to 1 hour
CPT
+96366: Each additional hour (list separately in addition to code for primary
procedure) (Add-on code, cannot be used without code 96365)
96413: Chemotherapy administration, intravenous infusion technique;
up to 1 hour, single or initial substance/drug
Professional
Services
+96415: Each additional hour (list separately in addition to code for primary
procedure) (Add-on code, cannot be used without code 96413)
99211-99215: Office or other outpatient visit for the evaluation and
management of an established patient
0250: Pharmacy, no detailed coding
Hospital
Services and
Supplies
Revenue
Codes
0260: Intravenous therapy
0510: Clinic visit
0636: Pharmacy with detailed coding (requires HCPCS)
Please see Important Safety Information and Full Prescribing Information,
including Boxed Warning, also available at www.krystexxaconnect.com.
©2015 Crealta Pharmaceuticals LLC
KRY-P-1043.b (09/15)