Specialty Drug Reimbursement – Newsletter – September 2019 – Volume 19, Issue 9

INSIDE THIS ISSUE

CMS News

  • 2019-2020 Influenza Vaccine Season NDCs Now Available
  • New HCPCS Drug Q-Codes effective October 1, 2019
  • New HCPCS Drug J-Codes effective October 1, 2019
  • New HCPCS Drug Code Revisions and Discontinuations effective October 1, 2019

Drug Reimbursement Code Price Updates

  • 48 Drug Codes required a recalculation of their AWP Code Price

Drugs/Devices

  • New Clinical and Billing Information

CODE UPDATES

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 48 AWP Drug Code Price changes this month, 20 (23%) 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:

Price Decreases:

  • J9245 Injection, melphalan hydrochloride, 50 mg 26%
  • J3480 Injection, potassium chloride, per 2 mEq 17%
  • Q0177 Hydroxyzine pamoate, 25 mg, oral, FDA-approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at time of chemotherapy treatment, not to exceed a 48-hour dosage regimen (Indication not FDA-approved at this time) 14%

Price Increases:

  • Q4184 Cellesta, per square centimeter 52%
  • J7509 Methylprednisolone, oral, per 4 mg 46%
  • J1205 Injection, chlorothiazide sodium, per 500 mg 30%

CMS News:

2019-2020 Influenza Vaccine Season NDCs Now Available

New NDCs for the 2019-2020 Flu Vaccine Season are cross-walked to their appropriate CPT codes and are now available on ReimbursementCodes.com. Click here for a comprehensive list of NDCs crosswalked this month.

New HCPCS Drug Q-Codes effective October 1, 2019:

CMS (Centers for Medicare & Medicaid Services) has created 22 new drug Q-codes effective October 1, 2019.

These new codes were included in our September 1, 2019 release to give you time to update your internal systems.

Q4211 Amnion bio or Axobiomembrane, per square centimeter

Q4208 Novafix, per square centimeter

Q4209 Surgraft, per square centimeter

Q4205 Membrane graft or membrane wrap, per square centimeter

Q4206 Fluid flow or fluid GF, 1 cc

Q4220 BellaCell HD or Surederm, per square centimeter

Q4210 Axolotl graft or axolotl dualgraft, per square centimeter

Q4215 Axolotl ambient or axolotl cryo, 0.1 mg

Q4216 Artacent cord, per square centimeter

Q4222 Progenamatrix, per square centimeter

Q4165 Keramatrix or kerasorb, per square centimeter

Q4212 Allogen, per cc

Q4213 Ascent, 0.5 mg

Q4214 Cellesta cord, per square centimeter

Q4226 MyOwn skin, includes harvesting and preparation procedures, per square centimeter

Q4217 Woundfix, BioWound, Woundfix Plus, BioWound Plus, Woundfix Xplus or BioWound Xplus, per square centimeter

Q4218 Surgicord, per square centimeter

Q4219 Surgigraft-dual, per square centimeter

Q4221 Amniowrap2, per square centimeter

Q5116 Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg

Q5117 Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg

Q5118 Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg

New HCPCS Drug J-Codes effective October 1, 2019:

CMS (Centers for Medicare & Medicaid Services) has created 22 new drug J-codes effective October 1, 2019.

These new codes were included in our September 1, 2019 release to give you time to update your internal systems.

J3031 Injection, fremanezumab-vfrm, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)

J2798 Injection, risperidone, (perseris), 0.5 mg

J0121 Injection, omadacycline, 1 mg

J7331 Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg

J7314 Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01 mg

J0593 Injection, lanadelumab-flyo, 1 mg (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered)

J9313 Injection, moxetumomab pasudotox-tdfk, 0.01 mg

J1096 Dexamethasone, lacrimal ophthalmic insert, 0.1 mg

J1097 phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml

J0291 Injection, plazomicin, 5 mg

J0222 Injection, Patisiran, 0.1 mg

J9119 Injection, cemiplimab-rwlc, 1 mg

J1303 Injection, ravulizumab-cwvz, 10 mg

J7332 Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg

J1943 Injection, aripiprazole lauroxil, (aristada initio), 1 mg

J1944 Injection, aripiprazole lauroxil, (aristada), 1 mg

J9269 Injection, tagraxofusp-erzs, 10 micrograms

J7401 Mometasone furoate sinus implant, 10 micrograms

J9204 Injection, mogamulizumab-kpkc, 1 mg

J3111 Injection, romosozumab-aqqg, 1 mg

J9210 Injection, emapalumab-lzsg, 1 mg

J0122 Injection, eravacycline, 1 mg

New HCPCS Drug Code Revisions and Discontinuations effective October 1, 2019:

Code description revision and discontinuations updates will be available and become effective for October 1, 2019.

Code Discontinuations:

S1090 Mometasone furoate sinus implant, 370 micrograms – see also C2625 or J3490

J1942 Injection, aripiprazole lauroxil, 1 mg (For billing prior to 1/1/17 use J3490 or C9470 for OPPS billing)

 

Code Description Revisions:

J2794 Injection, risperidone, long acting, 0.5 mg

REVISION: J2794 Injection, risperidone (risperdal consta), 0.5 mg

 

J7311 Fluocinolone acetonide, intravitreal implant

REVISION: J7311 Injection, fluocinolone acetonide, intravitreal implant (retisert), 0.01 mg

 

J7313 Injection, fluocinolone acetonide intravitreal implant, 0.01 mg (For billing prior to 1/1/16 use C9450 or J3490)

REVISION: J7313 Injection, fluocinolone acetonide, intravitreal implant (Iluvien), 0.01 mg

 

Q4184 Cellesta, per square centimeter

REVISION: Q4184 Cellesta or cellesta duo, per square centimeter

 

Q4122 Dermacell, per square centimeter (Code Price is based on median pricing methodology)

REVISION: Q4122 Dermacell, dermacell awm or dermacell awm porous, per square centimeter


DRUG REIMBURSEMENT CODE PRICE UPDATES

This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 48 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:

90632 A4253 J2800 J9060
90633 B4158 J3095 J9120
90651 E0570 J3480 J9153
90672 J0295 J7030 J9245
90680 J0456 J7040 J9395
90707 J0795 J7050 Q0162
90710 J1030 J7120 Q0177
90716 J1040 J7308 Q4180
90732 J1120 J7336 Q4184
A4206 J1205 J7509 S0119
A4215 J1459 J7520 S0170
A4245 J2185 J9027 S5571

 


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 five 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 three drugs that required updating.

New:

KANJINTI™ (trastuzumab-anns) for injection, for intravenous use-by Amgen Inc.  

NUBEQA® (darolutamide) tablets, for oral use-by Orion Corp. for Bayer Healthcare Pharmaceuticals

VYLEESITM (bremelanotide) for subcutaneous use-by AMAG Pharmaceuticals, Inc.

TURALIO™ (pexidartinib) capsules, for oral use –by Daiichi Sankyo, Inc

INREBIC® (fedratinib) capsules, for oral use-by Celgene Inc.

 

Updated:

OTEZLA® (apremilast) tablets, for oral use –by Celgene Corporation

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

ZYTIGA® (abiraterone acetate) tablets, for oral use- by Janssen Biotech, Inc.

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

TASIGNA® (nilotinib) capsules, for oral use- by Novartis Pharmaceutical Corp.

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

View last month’s Newsletter


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RJ Health is a drug data, application & analytics provider to the pharmacy reimbursement market, who brings scalability to specialty drug innovation. We focus on specialty drug innovation (new approvals and additional indications), as well as normalizing reimbursement for drug classifications that have market forces at-play (generics / biosimilars, rebates, and CMS policy). The company provides industry standard pricing, coding, dosing, weight, age, and diagnosis data & analyses to pharmacy, market access, claims, billing, finance, and network management clientele. RJ Health ensures transparency between manufacturer, payor, provider, pharmacies and their respective solution vendors (PBMs, Payment Integrity, Revenue Cycle, EHR, etc…) – all licensees of RJ Health data. 

Our tools and data:

Assist in understanding drug pricing and healthcare reimbursement for drug claims

Enable organizations to look up and crosswalk NDCs and HCPCS codes – J codes, C codes and other

 Assist in calculating drug dosage accurately and ensure claims are reimbursed properly based on unit requirements

Ensure claim accuracy and crosswalk drug codes

Help organizations make the best decisions for drug formularies

Combine clinical diagnosis and procedural coding matched to the right drug and dosage, as well as the most cost-efficient specialty drug price


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