INSIDE THIS ISSUE
- New HCPCS® C-Codes Effective April 1, 2019 Now Available
- Quarterly ASP (Average Sales Price) Pricing File Revised for April 2019
- April 2019 NOC (Not Otherwise Classified) Pricing File
- Hospital OPPS (Outpatient Prospective Payment System) Update
- New Clinical and Billing Information
- Prioritize your Code Level Pricing
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 59 AWP Drug Code Price changes this month, 15 (25%) were price decreases. The table in the Drug Reimbursement Code Price Updates section includes all AWP drug Code Price changes for this month. Please note: These numbers represent AWP Code Price changes only. See below for examples of codes with significant price changes this month.
LOOK UP PRICES NOW:
- J2765 Injection, metoclopramide HCl, up to 10 mg 58%
- J0637 Injection, caspofungin acetate, 5 mg 28%
- J2800 Injection, methocarbamol, up to 10 mL 23%
- J7609 Albuterol, inhalation solution, compounded product, administered through DME, unit dose, 1 mg (Code Price is for active ingredient only and does not include compounding cost) 45%
- J3360 Injection, diazepam, up to 5 mg 42%
- J7611 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg (Code reinstated effective 4/1/2008) 31%
CMS (Centers for Medicare & Medicaid Services) created 8 new HCPCS® C-Codes effective as of April 1, 2019 for Medicare’s Hospital OPPS (Outpatient Prospective Payment System) billing. All new codes have been added to ReimbursementCodes.com. The following is a list of all new C-Codes with brand names listed (if applicable):
C9040– Injection, fremanezumab-vfrm, 1mg (Ajovy)
C9041– Injection, coagulation factor Xa (recombinant), inactivated (andexxa), 10 mg (Andexxa)
C9042– Injection, bendamustine hcl (belrapzo), 1 mg (Belrapzo)
C9043– Injection, levoleucovorin, 1 mg (Khapzory)
C9044– Injection, cemiplimab-rwlc, 1 mg (Libtayo)
C9045– Injection, moxetumomab pasudotox-tdfk, 0.01 mg (Lumoxiti)
C9046– Cocaine hydrochloride nasal solution for topical administration, 1 mg (Goprelto)
C9141– Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi), 1 i.u. (Jivi)
Quarterly ASP (Average Sales Price) Pricing File Revised for April 2019:
CMS recently provided notification that the following quarters had revisions to the ASP pricing file. Please note:Code(s) with revisions are noted in parenthesis.
July 2018 ASP Pricing File (Codes: J1561, J2790)
October 2018 ASP Pricing File (Codes: J0636, J1170, J1626, J2360, J2790, J3489, J7316, J7682
As per CMS, “the payment amounts in the quarterly ASP files are 106 percent of the Average Sales Price (ASP) calculated from data submitted by drug manufacturers. The quarter to quarter price changes are generally the result of updated data from the manufacturers of these drugs.”
Our data files and website have incorporated these changes. As a reminder, we display the most recent revised rate on the Medicare Allowable tab on the pricing screen. To view previous Medicare Allowable rates for a quarter (if revised), click on the appropriate Effective Date on the same screen. Please Note:ASP rate revisions are retroactive to the beginning of the quarter.
April 2019 NOC (Not Otherwise Classified) Pricing File
CMS released the April 1, 2019 NOC Pricing file.
To view the NOC pricing file on the website, search on a NOC (Not Otherwise Classified) code, product or NDC and click on the link “Listing of CMS ASP+6% rates for NOCs” under Additional Information on the left side of the screen.
Hospital OPPS (Outpatient Prospective Payment System) Update:
If billing under the Hospital OPPS (Outpatient Prospective Payment System) the April 1, 2019 – June 30, 2019 APC rates are now available on the Pricing tab under APC. The APC tab will also provide you with the APC and Status Indicator (SI), if established. Note: The only addition to the file is the Bendamustine HCl product by Eagle.
DRUG REIMBURSEMENT CODE PRICE UPDATES
This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 59 Drug Codes that required a recalculation of their AWP Code Price. Log in to 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 one new drug which needed to be added to our database. Our review of existing drugs in our database with clinical and billing information already assigned identified three drugs that required updating.
CABLIVI® (caplacizumab-yhdp) for injection, for intravenous or subcutaneous use –by Ablynx N.V
INFUGEM (gemcitabine in sodium chloride injection), for intravenous use –by Sun Pharmaceuticals
DUPIXENT® (dupilumab) injection, for subcutaneous use-by Regeneron Pharmaceuticals, Inc.
- Indications & Usage, ICD-10CM Codes, and Dosage & Administration
AIMOVIG™ (erenumab-aooe) injection, for subcutaneous use–by Amgen Inc
- ICD-10CM Codes
ZYKADIA™ (ceritinib) capsules for oral use –by Novartis Pharmaceuticals Corporation
- Indications & Usage, ICD-10CM Codes, and Dosage & Administration
Quick Price Change and Crosswalk Addition Reference
To quickly review price changes and crosswalk updates don’t forget to use the alert tab. Click the Bell on the left-hand side of your screen, this will bring up all the codes with WAC, AWP and crosswalk additions, as well as important changes to specific codes to be aware of. This can be used as an easy reference to keep you up to date on the latest pricing changes.
One such update effective this month is the refinement to J1560’s code description, for more information regarding this, please refer to the section entitled Important Update for HCPCS Code J1560 above.
Please let us know if you have any questions about the content or functionality of our site. Contact us to request the addition of a code to the site or share your suggestions for enhancements.
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