INSIDE THIS ISSUE
• Large Price Changes
• New HCPCS C-Codes Effective April 1, 2018
• New HCPCS Q-Codes Effective April 1, 2018
• HCPCS Q-Code Description Change Effective April 1, 2018
• Deleted HCPCS Q-Code Effective April 1, 2018
• Part B Biosimilar Biological Product Payment Effective April 1, 2018
• Implementation of the Transitional Drug Add-On Payment Adjustment – Parsabiv and Sensipar
Drug Reimbursement Code Price Updates
•New/Updated Billing and Clinical Information
Large Price Changes:
We identify and report on the codes with the most substantial pricing increases or decreases each month and detail the rationale for the change.
Of the 58 AWP Drug Code Price changes this month, 15 (26%) were price decreases. The table in the Drug Reimbursement Code Price Updates section includes all AWP drug Code Price changes for this month. See below for examples of codes with significant price changes this month.
J0500 Injection, dicyclomine HCl, up to 20mg
• Decrease of 28% due to decrease for 2 generic NDCs
J1953 Injection, levetiracetam, 10 mg
• Decrease of 14% due to 2 new generic NDCs entering market
A9505 Thallium Tl-201 thallous chloride, diagnostic, per millicurie
• Increase of 375% due to inactivation of lowest brand NDC
Q9963 High osmolar contrast material, 350-399 mg/mL iodine concentration, per mL
• Increase of 187% due to inactivation of lowest brand NDC
S0078 Injection, fosphenytoin sodium, 750 mg
New HCPCS Drug C-Codes Effective April 1, 2018:
CMS created 8 new HCPCS drug C-codes effective April 1, 2018 for Medicare’s Hospital OPPS (Outpatient Prospective Payment System) billing. These new C-Codes were released by CMS after we performed our March update. These new codes will appear with our April 1, 2018 update.
C9462 Injection, delafloxacin, 1 mg
C9463 Injection, aprepitant, 1 mg
C9464 Injection, rolapitant, 0.5 mg
C9465 Hyaluronan or derivative, Durolane, for intra-articular injection, per dose
C9466 Injection, benralizumab, 1 mg
C9467 Injection, rituximab and hyaluronidase, 10 mg
C9468 Injection, factor IX (antihemophilic factor, recombinant), glycopegylated, Rebinyn, 1 IU
C9469 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg
New HCPCS Drug Q-Codes effective April 1, 2018:
CMS created 2 new drug Q-codes to replace Q5102 effective April 1, 2018 (see additional information below). These new codes appear with our March 1, 2018 update to give you time to update your system(s).
Code Description Change HCPCS Q-Code effective April 1, 2018
CMS has revised the code description for Q5101 to include the trade name of the product effective for April 1, 2018. This revision is due to the new Medicare Part B policy changes for biosimilar biological products (see additional information below).
New Q5101 Injection, filgrastim-sndz, biosimilar, (Zarxio), 1 microgram
Deleted HCPCS Q-Code effective March 31, 2018
Effective for claims with dates of service on or after April 1, 2018 HCPCS Code Q5102 (which describes both currently available versions of infliximab biosimilars) will be replaced with two new HCPCS codes, Q5103 and Q5104 (see above for details).
Q5102 Injection, infliximab, biosimilar, 10 mg will be deleted, effective March 31, 2018.
Part B Biosimilar Biological Product Payment and Required Modifiers Update for Dates of Service on or after April 1, 2018:
CMS has updated the Medicare Part B policy for biosimilar biological products effective for dates of service on or after April 1, 2018.
Effective January 1, 2018, newly approved biosimilar biological products with a common reference product name will no longer be billable under the same HCPCS code.
Effective for claims with dates of service on or after April 1, 2018, HCPCS code Q5102 (see code description above) will be replaced with two new HCPCS Q-codes, Q5103 and Q5104 (see code descriptions above). Also, beginning on April 1, 2018 the use of modifiers that describe the manufacturer of a biosimilar (eg., ZA, ZB and ZC) are no longer required on biosimilar HCPCS codes for Medicare claims.
Please note: The biosimilar modifier requirement for HCPCS code Q5102 remains in effect until the code is deleted effective March 31, 2018.
Please click on the link for full details regarding the new policy
Implementation of the Transitional Drug Add-On Payment Adjustment (TDAPA) – PARSABIV (J0606) and Sensipar (J0604):
CMS released information for End-Stage Renal Disease (ESRD) facilities submitting claims to Medicare Administrative Contractors (MACs) for certain ESRD drugs provided to Medicare beneficiaries.
This policy directs the MACS to implement the Transitional Drug Add-On Payment Adjustment (TDAPA). This information is to provide you with more descriptive examples for Parsabiv (J0606) and Sensipar (J0604).
The payment limits for ESRD PPS TDAPA Drugs and Biologicals effective January 1, 2018 through March 31, 2018 are noted below. Please note: Brand names are noted in parenthesis and italics.
• J0604 Cinacalcet, oral, 1 mg, (for ESRD on dialysis) (Sensipar), Payment limit $0.909 per 1 mg
• J0606 Injection, etelcalcetide, 0.1 mg (Parsabiv), Payment limit $3.466 per 0.1 mg
Please see the following links for further details regarding this policy:
DRUG REIMBURSEMENT CODE PRICE UPDATES
This month, during our review of the 2978 Reimbursement HCPCS/CPT® Codes in our system, we identified 58 Drug Codes that required a recalculation of their AWP Code Price. Log into www.reimbursementcodes.com to view the pricing updates for these codes.
DRUGS/DEVICES: NEW/UPDATED BILLING & CLINICAL INFORMATION
As new drugs come to market we review them for possible inclusion in our database. When a new drug is added to the database, we develop detailed clinical and billing information for the drug if appropriate.
During the past month, our review identified four new drugs which needed to be added to our database. Our review of existing drugs in our database with clinical and billing information already assigned identified four drugs that required updating.
ERLEADA™ (apalutamide) tablets, for oral use – by Janssen Biotech
GIAPREZA™ (angiotensin II) Injection for Intravenous Infusion – by La Jolla Pharmaceutical
LUTATHERA® (lutetium Lu 177 dotatate) injection, for intravenous use– by Advanced Accelerator Applications USA, Inc.
SINUVA™ (mometasone furoate) sinus implant – by Intersect ENT
IMFINZI® (durvalumab) injection, for intravenous use – by AstraZeneca
• Indications & Usage, Dosage & Administration and Warnings & Precautions, ICD-10-CM Codes
SIMPONI® (golimumab) injection, for subcutaneous use – by Janssen Biotech
• Warnings and Precautions
ZYDELIG® (idelalisib) tablets, for oral use – by Gilead Sciences
• Indications & Usage, Dosage & Administration, Boxed Warning and Warnings & Precautions
ZYTIGA® (abiraterone acetate) tablets for oral use– by Janssen Biotech
• Indications & Usage, Dosage & Administration and Warnings & Precautions
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