Specialty Drug Reimbursement – Newsletter – July 2018 – Volume 18, Issue 07

INSIDE THIS ISSUE

Code Updates:

  • Large Price Changes
  • HCPCS Code Update for Makena Subcutaneous Auto-Injector
  • NDC Crosswalk update for HCPCS Code(s) J7060 and J7070 (Dextrose)
  • NDC Crosswalk update for HCPCS Code J0461
  • Reminder – NEW HCPCS Q-Codes effective July 1, 2018
  • NEW HCPCS C-Codes for Hospital OPPS Billing effective July 1, 2018
  • Deleted HCPCS Code C9469 effective June 30, 2018

 CMS NEWS:

  • July 1, 2018 NOC Pricing File Available
  • July 1, 2018 ASP and APC Pricing Files Available

Drug Reimbursement Code Price Updates

 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 47 AWP Drug Code Price changes this month, 19 (60%) 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.
 

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Price Decreases:

A9180   Pediculosis (lice infestation) treatment, topical for administration by patient/caretaker

  • Decrease of 38% due to decrease for lowest brand NDC

J9245   Injection, melphalan hydrochloride, 50 mg

  • Decrease of 30% due to decrease for 2 generic NDCs shifting median down

J2800   Injection, methocarbamol, up to 10 mL

  • Decrease of 25% due to 1 new generic NDC entering market shifting median down

Price Increases:

J0744   Injection, ciprofloxacin for intravenous infusion, 200 mg

  • Increase of 98% due to in-activation of 1 generic NDC shifting median up

J0698   Cefotaxime sodium, per gram

  • Increase of 64% due to re-activation of 2 generic NDCs shifting median up

J2060   Injection, lorazepam, 2 mg

  • Increase of 31% due to increase for 8 generic NDCs shifting median up

HCPCS Code Update for Makena Subcutaneous Auto-Injector:

Effective with our August 1st update, RJ Health will be moving the Makena 275mg/1.1mL Subcutaneous Auto-Injector (NDC 64011-0301-03) out of J3490Unclassified drugs and into permanent HCPCS Code J1726 – Injection, hydroxyprogesterone caproate, (Makena), 10mg.

NDC Crosswalk update for HCPCS Code(s) J7060 and J7070 (Dextrose):

During this past month RJ Health made changes to the NDC crosswalks for HCPCS codes J7060 5% Dextrose/water (500 mL = 1 unit) and J7070 Infusion, D5W, 1,000 cc.

NDC Crosswalk update for HCPCS Code J0461:

During this past month RJ Health made changes to the NDC crosswalk for HCPCS code J0461Injection, atropine sulfate.

Since these crosswalk updates only effect RJ Health customers details have been removed from this public newsletter, but are retained in the newsletters supplied directly to clients and on ReimbursementCodes.com.

Reminder- New HCPCS Drug Q-Codes effective July 1, 2018:

CMS has created 6 new drug Q-codes that are now payable by Medicare effective for claims with dates of service on or after July 1, 2018. Please note: Brand names are noted in parenthesis and italic if not already noted in the code description.

Q5105 Injection, epoetin alfa, biosimilar, (Retacrit) (for ESRD on dialysis), 100 units

Q5106 Injection, epoetin alfa, biosimilar, (Retacrit) (for non-ESRD use), 1000 units

Q9991 Injection, buprenorphine extended-release (Sublocade), less than or equal to 100 mg

Q9992 Injection, buprenorphine extended-release (Sublocade), greater than 100 mg

Q9993 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg (Zilretta)

Q9995 Injection, emicizumab-kxwh, 0.5 mg (Hemlibra)

CMS has also created 1 new Q-code effective July1, 2018 that is not payable by Medicare.

Q9994 In-line cartridge containing digestive enzyme(s) for enteral feeding, each (Relizorb)

Additional information from CMS for Q9994 can be found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4063CP.pdf

Please note: CMS has updated the Transmittal regarding these new HCPCS Q-Codes to include Q5105 and Q5106 https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4083CP.pdf

New HCPCS Drug C-Codes Effective July 1, 2018:

CMS created 3 new HCPCS drug C-codes effective July 1, 2018 for Medicare’s Hospital OPPS (Outpatient Prospective Payment System) billing. Please note:  Brand names, if applicable, are noted in parenthesis and italics if not already noted in the code description.

C9030 Injection, copanlisib, 1 mg (Aliqopa)

C9031 Lutetium Lu 177, dotatate, therapeutic, 1 mCi (Lutathera)

C9032 Injection, voretigene neparvovec-rzyl, 1 billion vector genome (Luxturna)

Deleted HCPCS C-Code effective June 30, 2018:

CMS has deleted 1 C-Code C9469 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg effective June 30, 2018 and replaced it with

Q9993 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg (see above for Q9993).


CMS NEWS:

July 1, 2018 NOC Pricing File is now available:

CMS has released the July 1, 2018 NOC Pricing File. There were NO new drugs added this quarter but please note that Hemlibra has been removed and replaced with new Q-Code, Q9995 Injection, emicizumab-kxwh, 0.5 mg effective July 1, 2018.

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.

July 1, 2018 ASP (Average Sales Price) and APC (Ambulatory Payment Classification) Rates are now available:

CMS has released the July 1, 2018 ASP (Average Sales Price) file for dates of service July 1, 2018 – September 30,2018. These rates, if established can be found on the Pricing tab under Medicare Allowable. Please note: The Medicare Allowable (ASP) rate for 2018 is ASP+6%.

If billing under the Hospital OPPS (Outpatient Prospective Payment System) the July 1, 2018 – September 30, 2018 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. Please note: For 2018 non-pass through (SI K) and pass-through (SI G) are both ASP +6%.

Please note: There were NO revisions to previous ASP or APC quarters effective July 1, 2018.


DRUG REIMBURSEMENT CODE PRICE UPDATES

This month, during our review of the 2986 Reimbursement HCPCS/CPT® Codes in our system, we identified 47 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 J0515 J1170 J1940 J2800 J7050 J9070 J9267
A9180 J0583 J1451 J2060 J3240 J7186 J9150 P9045
E0607 J0694 J1630 J2270 J3380 J7674 J9171 P9047
J0180 J0698 J1786 J2405 J3475 J8530 J9206 Q4180
J0221 J0744 J1885 J2469 J3489 J8540 J9245 S0092
J0360 J1071 J1931 J2680 J7030 J9025 J9260

 

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.

New:

AIMOVIG™ (erenumab-aooe) injection, for subcutaneous use – by Amgen Inc.  (NOC Codes: C9399, J3490)

DEXYCU™ (dexamethasone intraocular suspension) 9%, for intraocular administration – by Icon Bioscience, Inc.  (NOC Codes: C9399, J3490)

DOPTELET® (avatrombopag) tablets, for oral use – by Dova Pharmaceuticals, Inc (NOC Codes: C9399, J8499)

OLUMIANT® (baricitinib) tablets, for oral useby Lilly USA. (NOC Codes: C9399, J8499)

PALYNZIQ™ (pegvaliase-pqpz) injection, for subcutaneous useby BioMarin Pharmaceuticals, Inc. (NOC Codes: C9399, J3590)

RETACRIT™ (epoetin alfa-epbx) injection, for intravenous or subcutaneous use – by Hospira (Codes: Q5105, Q5106 effective 7/1/18)

YONSA® (abiraterone acetate) tablets, for oral use – by Sun Pharmaceuticals (NOC Codes: C9399, J8999)

Updated:

XELJANZ® (tofacitinib) tablets and XELJANZ® XR (tofacitinib) extended-release tablets for oral use – by Pfizer U.S.  (NOC Code: J8499)

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

Previous Newsletter:

Specialty Drug Reimbursement – Newsletter – June 2018 – Volume 18, Issue 06

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