New J-code supports reimbursement for gemcitabine intravesical system

Effective coordination across clinical and administrative teams is critical as urology practices prepare to adopt the gemcitabine intravesical system, according to urologist and coding expert Jonathan Rubenstein, MD, of Chesapeake Urology in Towson, Maryland. The therapy—approved by the FDA for adults with non–muscle invasive bladder cancer (NMIBC) that is unresponsive to BCG and includes carcinoma in situ (CIS) with or without papillary tumors—will have a dedicated J-code, J9183, available starting April 1. Rubenstein noted that providers should use this code when submitting claims to support appropriate reimbursement for the treatment.

“Once we actually get a J code for a medication, it really solidifies the amount of reimbursement that's going to occur,” Rubenstein told Urology Times in a recent interview.

When introducing a newly approved intravesical therapy such as the gemcitabine intravesical system, practices should begin with multidisciplinary discussions involving physicians, pharmacy staff, prior authorization teams, and billing specialists. Rubenstein emphasized that each group needs to understand the medication’s indications, administration requirements, expected costs, and payment pathways before the first dose is administered. Training clinicians and other providers on the nuances of drug preparation and delivery is equally important, as intravesical therapies can differ in how they are handled and administered.

Clear documentation is also essential for supporting reimbursement. Rubenstein recommends using electronic medical record tools that allow providers to quickly document bladder cancer risk category, pathology findings, recurrence status, and whether the disease is BCG-unresponsive. Maintaining well-organized notes—including biopsy results, tumor grade and stage, and prior therapies—helps illustrate the patient’s treatment journey and allows staff and payers to confirm eligibility for therapy more easily.

Finally, Rubenstein stressed the importance of educating billing teams about the clinical terminology associated with bladder cancer treatment. By outlining the key terms and documentation elements needed for coverage, physicians can help billing staff verify that claims are submitted correctly and reduce delays in reimbursement.

Urology Times: How can urology practices effectively coordinate between clinical staff, pharmacy teams, and billing departments when introducing a newly approved intravesical therapy such as the gemcitabine intravesical system?

Rubenstein: In my group, we have discussions across the different parts of our [practice] because, again, the pharmacy, prior authorization, billing staff, and physicians all need to be aware of what the medicine is, what it's used for, what the indications are, what the likely payments are, and how much it costs before instilling even the first dose. Then we need to train the physicians and other providers on the nuances of giving that medication. Each one can be given a little differently. Some need certain preparations, some do not. And so, again, the preparation in advance is what's really important to make sure everybody's on the same page. It’s no different than a football team preparing to play in the Super Bowl. You have to make sure the offense, the defense, and the coordinators all understand what the game plan is moving forward. Otherwise, there's no chance for success.

Urology Times: What documentation best practices help support efficient reimbursement for newer NMIBC treatments while minimizing administrative burden on physicians?

Rubenstein: Many people have electronic medical record systems [where] you can click on certain buttons, [which]…allow easy documentation of low-risk, intermediate-risk, high-risk bladder cancer, what the pathology is, whether it's recurrent, BCG unresponsive—especially if we need to see CIS in there. These all should be documented in the chart. People always talk about copying notes. I disagree with copying notes, but I don't mind people pulling forward old notes into a new note to continue the patient's journey on the note. Because if we have it well documented earlier in the note about the patients—their biopsy results, their grade, their stage, and the treatments that they're getting—can easily then tell the story of when the patients progressing into, say, a non–muscle invasive BCG unresponsive high-grade bladder cancer with CIS and can just be written out in the notes. It will just make everybody be able to find that information as quickly as possible, as easily as possible, reduce the risk of audits, and improve the time for the claim being paid.

Urology Times: What educational or training priorities should practices focus on to help billing teams feel confident when incorporating innovative NMIBC treatments into routine care?

Rubenstein: The billing staff are great at billing, [but] they may not understand the criteria and what [exactly] bladder cancer is and why it's being treated this way. They’re not clinicians; they're not urologists, and so some of the language that's being used by physicians, we can't take it for granted that an excellent billing staff member will understand the clinical [terminology]. We really need to set them up for success. We have to describe for them the key words that they need to look for, to double check that they're doing it right. Then we need to include those words in our documentation. That's the only way this can work. This is a team that needs to work together. As much as we would love for our billing staff to [be able to] understand the nuances of urology, they just may not have that background enough to understand that. And we really need to set them up for success so we can explain to them, “These are the key words you need to look for to make sure that this is authorized appropriately.” It can only help us [to do] the best we possibly can and make sure that everything gets out the door correctly.