INSIDE THIS ISSUE
- Large Price Changes
- New Q-Codes Effective October 1, 2018
- New C-Codes for Hospital OPPS use Effective October 1, 2018
- Medicare Influenza Vaccine Pricing 2018-2019 Season
- NEW Influenza CPT® Code 90689 Effective January 1, 2019
- Medicare Coverage Indicator Change for Q9994
Drug Reimbursement Code Price Updates
- New Clinical and Billing 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 48 AWP Drug Code Price changes this month, 15 (31%) were price decreases. The table in the Drug Reimbursement Code Price Updates section within our subscription website includes all AWP drug Code Price changes for this month. Below are examples of codes with significant price changes this month. Please log into our subscription site for details on specific prices and the rational for the change.
LOOK UP PRICES NOW:
- J2710 Injection, neostigmine methylsulfate, up to 0.5 mg: Decrease of 60%
- J0287 Injection, amphotericin B lipid complex, 10 mg: Decrease of 49%
- J2370 Injection, phenylephrine HCl, up to 1 mL: Decrease of 20%
- Q4117 Hyalomatrix, per square centimeter: Increase of 49%
- J7614 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg: Increase of 47%
- J9000 Injection, doxorubicin hydrochloride, 10 mg: Increase of 12%
New HCPCS Drug Q-Codes effective October 1, 2018:
CMS (Centers for Medicare & Medicaid Services) has created 2 new drug Q-codes effective October 1, 2018. However, CMS has indicated that Q5108 will be payable by Medicare retro-active to July 12, 2018.
- Q5108 Injection, pegfilgrastim-jmdb, biosimilar, (Fulphila), 0.5 mg
- Q5110 Injection, filgrastim-aafi, biosimilar, (Nivestym), 1 microgram
|NDC||NDC Strength||NDC package||WAC effective 9/24/18|
|00069-0291-01||300 mcg/0.5 mL||1 PF* pre-filled syringe||For specific pricing please log into ReimbursementCodes.com|
|00069-0291-10||300 mcg/0.5 mL||10 PF* pre-filled syringes|
|00069-0292-01||480 mcg/0.8 mL||1 PF* pre-filled syringe|
|00069-0292-10||480 mcg/0.8 mL||10 PF* pre-filled syringes|
New HCPCS Drug C-Codes Effective October 1, 2018:
CMS has created 2 new HCPCS drug C-codes effective October 1, 2018 for Medicare’s Hospital OPPS (Outpatient Prospective Payment System) billing. These new codes appear with our September 1, 2018 release. Please note: Brand names, if applicable, are noted in parenthesis and italics.
- C9033 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg (Akynzeo)
- C9034 Injection, dexamethasone 9%, intraocular, 1 mcg (Dexycu)
Medicare Influenza Vaccine Pricing for 2018-2019 Season:
CMS has released the Medicare Part B payment allowance limits for the seasonal influenza vaccines for the 2018-2019 season. These payment limits are effective for Dates of Service 8/1/18 – 7/31/19. The Medicare Part B payment limits for seasonal influenza are 95% of the Average Wholesale Price (AWP).
These rates will be available on the website and files with our October 1, 2018 release. Since these rates became effective 8/1/18 we are providing them ahead of the October 1st release.
|HCPCS/CPT® Code||Payment Limit|
|90653||For specific pricing please log into ReimbursementCodes.com|
According to the CMS website, payment limits for certain codes are pending payment allowances. We will monitor CMS for any updates to these pending rates and provide updates.
NEW Influenza CPT® Code 90689 Effective January 1, 2019:
The AMA (American Medical Association) has created one new influenza virus vaccine code effective on or after January 1, 2019.
Effective for claims processed with Dates of Service (DOS) on or after January 1, 2019, 90689 Influenza virus vaccine quadrivalent (IIV4), inactivated, adjuvanted, preservative free, 0.25 mL dosage, for intramuscular use will be payable by Medicare. Please note: The product for this code is still pending FDA approval.
CMS has released the following information regarding this code. ”The new influenza virus vaccine code 90689 is not retroactive to August 1, 2018. No claims should be accepted for influenza virus vaccine code 90689 between the DOS August 1, 2018 and December 31, 2018. If claims are received in January 2019 with code 90689 for DOS between August 1, 2018 and December 31, 2018, contractors should follow their normal course of action for codes billed prior to their effective date.”
To view the CMS transmittal regarding this and January 2019 Influenza Virus Vaccine information please see https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4127CP.pdf
Please note: 90689 will be available in our data with our December 1, 2018 release to provide customers with the time needed to update systems, if applicable.
Medicare Coverage Indicator Change for Q9994:
Effective for dates of service on or after July 13, 2018, the Medicare coverage indicator changed for code Q9994 In-line cartridge containing digestive enzyme(s) for enteral feeding, each from “I” that means “not payable by Medicare” to “D” which means “special coverage instructions apply”. This change is effective for dates of service on or after July 13, 2018. This will be updated in our files for our October 1, 2018 update.
DRUG REIMBURSEMENT CODE PRICE UPDATES
This month, during our review of the 2990 Reimbursement HCPCS/CPT® Codes in our system, we identified 48 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 seven 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 one drug that required updating. For specific coding assignments please log into ReimbursementCodes.com
- GALAFOLD™ (migalastat) capsules, for oral use – by Amicus Therapeutics
- ILUMYA™ (tildrakizumab-asmn) injection, for subcutaneous use – by Sun Pharmaceuticals
- MULPLETA® (lusutrombopag) tablets for oral use – by Shionogi
- ONPATTRO™ (patisiran) lipid complex injection, for intravenous use – by Alnylam Pharmaceuticals
- PERSERIS™ (risperidone) for extended-release injectable suspension, for subcutaneous use – by Indivior
- POTELIGEO® (mogamulizumab-kpkc) injection, for intravenous use – by Kyowa Kirin, Inc
- TIBSOVO® (ivosidenib) tablets, for oral use – by Agios Pharmaceuticals
- LENVIMA® (lenvatinib) capsules, for oral use – by Eisai: Indications & Usage, Dosage & Administration, ICD-10-CM codes
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.
© 2018 RJ Health Systems International, LLC. All rights reserved. This newsletter and its contents are copyright protected. No part of this newsletter may be reproduced in any manner by any means without written permission of RJ Health Systems International, LLC.
CPT copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.