Specialty Drug Reimbursement – Newsletter – July 2021 – Volume 21, Issue 7

INSIDE THIS ISSUE

Drug Reimbursement Code Price Updates

Drugs/Devices

-New Clinical and Billing Information

CMS News

-New and Deleted HCPCS® Codes Effective July 1, 2021, Now Available
-New CPT® Codes Now Available
-Quarterly ASP (Average Sales Price) File Released
-Hospital OPPS (Outpatient Prospective Payment System) Update
-July 2021 NOC (Not Otherwise Classified) Pricing File Released
-HCPCS® Quarterly File Revision


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 57 AWP Drug Code Price changes this month, 25 (44%) 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:

  • A7005 Administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable
    (Code Price is based on median pricing methodology), 66%
  • Q0175  Perphenazine, 4 mg, oral, FDA-approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at time of chemotherapy threatment, not to exceed a 48-hour dosage regimen, 48%
  • J7626  Budesonide, inhalation solution, FDA-approved final product, non-compounded,
    administered through DME, unit dose form, up to 0.5 mg, 31%

Price Increases:

  • Q4239  Amnio-maxx or amnio-maxx lite, per square centimeter (Code Price is based on median pricing methodology), 122%
  • Q4238  Derm-maxx, per square centimeter (Code Price is based on median pricing methodology), 105%
  • Q4217 Woundfix, BioWound, Woundfix Plus, BioWound Plus, Woundfix Xplus or BioWound Xplus, per square centimeter (Code Price is based on Median Pricing Methodology), 100%

CMS News

New and Deleted HCPCS® Codes Effective July 1, 2021 Now Available

CMS (Centers for Medicare & Medicaid Services) released their annual HCPCS® File for July 2021 which includes all New and Deleted HCPCS® Codes. New codes and codes that have been deleted by CMS have been added to www.ReimbursementCodes.com  The new codes became effective for Medicare billing for dates of service on and after July 1, 2021. CMS did not include any revisions to HCPCS® codes in the July file. We have provided a list of the new HCPCS® codes RJ Health maintains in their database below as well as the codes which have been deleted:

 

New HCPCS® Codes

A9593 Gallium ga-68 psma-11, diagnostic, (ucsf), 1 millicurie

A9594 Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie

C9075  Injection, casimersen, 10 mg

C9076  Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose

C9077  Injection, cabotegravir and rilpivirine, 2mg/3mg

C9078  Injection, trilaciclib, 1 mg

C9079  Injection, evinacumab-dgnb, 5 mg

C9080  Injection, melphalan flufenamide hydrochloride, 1 mg

C9778  Colpopexy, vaginal; minimally invasive extra-peritoneal approach (sacrospinous)

J0224   Injection, lumasiran, 0.5 mg

J1951   Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg

J7168   Prothrombin complex concentrate (human), kcentra, per i.u. of factor ix activity

J9348   Injection, naxitamab-gqgk, 1 mg

J9353   Injection, margetuximab-cmkb, 5 mg

M0201 Covid-19 vaccine administration inside a patient’s home; reported only once per individual home per date of service when only covid-19 vaccine administration is performed at the patient’s home

M0244 Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring the home or residence; this includes a beneficiary’s home that has been made provider based to the hospital during the covid 19 public health emergency

M0246 Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider based to the hospital during the covid 19 public health emergency

M0247 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring

M0248 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary?s home that has been made provider-based to the hospital during the covid-19 public health emergency

Q0247 Injection, sotrovimab, 500 mg

Q5123 Injection, rituximab-arrx, biosimilar, (riabni), 10 mg

 

Deleted HCPCS® Codes

C9074  Injection, lumasiran, 0.5 mg

C9132  Prothrombin complex concentrate (human), kcentra, per i.u. of factor ix activity

M0239 Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring

Q0239 Injection, bamlanivimab-xxxx, 700 mg

 

New CPT® Codes Now Available

The American Medical Association (AMA) released five new CPT® codes effective for billing on or after July 1, 2021.  These codes have been added to www.ReimbursementCodes.com  and are listed below:

90626 Tick-borne encephalitis virus vaccine, inactivated; 0.25 mL dosage, for intramuscular use

90627 0.5 mL dosage, for intramuscular use

90671 Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use

90677 Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use

90758 Zaire ebolavirus vaccine, live, for intramuscular use

See previous updates.

 

Quarterly ASP (Average Sales Price) File Released:

Another quarter has passed, and this means CMS has released the July 2021 ASP pricing and revisions files. These rates are effective July 1, 2021 through September 30, 2021. This new ASP pricing file is incorporated in our own data and website. To view the most recent revised rates simply click on the Medicare Allowable tab on the pricing screen.  Please note: Code(s) with revisions are noted in parenthesis.

 

January 2021 ASP Pricing File (Codes: J1756, J2820, J9035, J9311, J9312, J9355, Q5114, Q5116)

April 2021 ASP Pricing File (Codes: J1557, J3315, Q2050)

October 2020 ASP Pricing File (Codes: J2820)

 

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.

 

July 2021 NOC (Not Otherwise Classified) Pricing File

CMS released the July 1, 2021 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 July 1, 2021 – September 30, 2021 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.

 

HCPCS® Quarterly File Revision

Center for Medicare and Medicaid Services (CMS) made an update to their quarterly HCPCS® file regarding the effectiveness of code J9314: Injection, romidepsin, non-lyophilized (e.g. liquid), 0.1 mg. CMS has since removed J9314 from their data and has reinstated C9065: Injection, romidepsin, non-lypohilized (e.g. liquid), 1mg.

We were unfortunately not notified of this update to coding with enough time to make the appropriate changes for July.  We are however making the required changes to remove J9314 from our data and reinstate C9065 for our August update.

Sorry for any inconvenience.


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.

Check back next month for any pertinent clinical updates

See news from previous months.

 


  • Drug Reimbursement Code Price Updates:

    This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 57 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.

    A4259 B4158 J2278 J7605 J9371 Q4232
    A4614 E0570 J2430 J7626 Q0161 Q4237
    A4627 J0583 J2543 J7674 Q0175 Q4238
    A7003 J0641 J2800 J9025 Q4162 Q4239
    A7005 J0642 J2820 J9032 Q4173 Q4254
    A7015 J0780 J3095 J9202 Q4180 S0187
    A9155 J1453 J7131 J9207 Q4203 S5571
    A9543 J1631 J7300 J9245 Q4213
    B4150 J1817 J7315 J9246 Q4217
    B4152 J2020 J7507 J9307 Q4231


LOOK UP PRICES NOW:
 


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:

ADUHELM™ (aducanumab-avwa) injection, for intravenous use-By Biogen Inc.

LUMAKRAS™ (sotorasib) tablets, for oral use-By Amgen Inc. 

RYBREVANT™ (amivantamab-vmjw) injection, for intravenous use-By Janssen Biotech, Inc. 

TRUSELTIQ™ (infigratinib) capsules, for oral use-By QED Therapeutics, Inc. 

WEGOVY™ (semaglutide) injection, for subcutaneous use-By Novo Nordisk Inc.

Updated:

BOSULIF® (bosutinib) tablets, for oral use-By Pfizer Labs 

COSENTYX® (secukinumab) injection, for subcutaneous use-By Novartis Pharmaceuticals Corporation

XATMEP® (methotrexate) oral solution-By Azurity Pharmaceuticals

 


Our Resources

Learn more – RJ Health Resources


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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