Specialty Drug Reimbursement – Newsletter – January 2020 – Volume 20, Issue 1


CMS News

    • REMINDER – New HCPCS® Codes are Now Effective
    • Quarterly ASP (Average Sales Price) Pricing File Revised for January 2020
    • Hospital OPPS (Outpatient Prospective Payment System) Update
    • January 2020 NOC (Not Otherwise Classified) Pricing File

Drug Reimbursement Code Price Updates

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


    • 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 65 AWP Drug Code Price changes this month, 20 (31%) 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.


Price Decreases:

  • A9575Injection, gadoterate meglumine, 0.1 mL, 46%
  • J7626 Budesonide, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, up to 0.5 mg, 44%
  • Q0180 Dolasetron mesylate, 100 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 24-hour dosage regimen 37%

Price Increases:

  • S0017 Injection, aminocaproic acid, 5 g, 37%
  • J1642 Injection, heparin sodium (heparin lock flush), per 10 units, 25%
  • J2265 Injection, minocycline hydrochloride, 1 mg (For billing prior to 1/1/12 use J3490), 19%

CMS News:

REMINDER- New HCPCS® Codes are Now Effective

CMS (Centers for Medicare & Medicaid Services) released their annual Alpha-Numeric HCPCS File for 2020.  All new codes have been added to ReimbursementCodes.com and are now effective. These drug codes became effective for Medicare billing for dates of service on and after January 1, 2020.  HCPCS drug code description changes, and deleted HCPCS drug codes are also now effective and can be reviewed on ReimbursementCodes.com.

For a complete list regarding these HCPCS® Code updates please refer to our November and December newsletters.

Quarterly ASP (Average Sales Price) Pricing File Revised for January 2020:

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.

January 2019 ASP Pricing File (Codes: J7518)

April 2019 ASP Pricing File (Codes: J1602, J1745)

July 2019 ASP Pricing File (Codes: J1602, J1745)

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.

Hospital OPPS (Outpatient Prospective Payment System) Update:

If billing under the Hospital OPPS (Outpatient Prospective Payment System) the January 1, 2020 – March 31, 2020 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.

January 2020 NOC (Not Otherwise Classified) Pricing File 

CMS released the January 1, 2020 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.

Clinical News

Each month the RJ Health Clinical Committee meets to review newly approved drugs, dosing, ICD-10 assignments, coding assignments and billable units. Additionally, we discuss questions and concerns our customers raise to ensure we are providing the most accurate and current information in our data and on our website.

Addition of Home Infusion Therapy (HIT) Administration Codes

We have enhanced our data with the cross-walking of drug-related Home Infusion Therapy (HIT) administration codes. These can now be found in RJ Health’s data and cross-walked to codes by accessing the Administration Codes module on ReimbursementCodes.com.

Drug Reimbursement Code Price Updates:

This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 65 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.

S0017 90378 J2010 A4213 S0119
J1642 90389 J2590 J0735 J9065
J2265 J1560 J7209 J9313 J3030
A4216 J1670 90698 J2675 Q0162
A4217 90281 C9132 J3010 S0106
A4245 J1460 90375 A6248 J0894
J0692 J8670 J9206 E0607 J1817
J2440 90734 J1627 J0780 S0156
J7190 90713 90714 A4253 J2250
J2425 90702 90738 J1453 S0174
86580 J0285 J1644 S5566 Q0180
90691 J2550 J1559 S5571 J7626
90376 J7183 J7503 J2545 A9575


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 two new drugs which needed to be added to our database.


ASCENIV™ (immune globulin intravenous, human – slra) 10% Liquid – By ADMA Biologics

ADAKVEO® (crizanlizumab-tmca) injection, for intravenous use – by Novartis Pharmaceuticals Corporation

 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

View last month’s newsletter.

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