Specialty Drug Reimbursement – Newsletter – October 2019 – Volume 19, Issue 10

INSIDE THIS ISSUE

CMS News

  • 2019-2020 Influenza Vaccine Season NDCs Now Available
  • New HCPCS Code J0642-Injection, levoleucovorin (khapzory), 0.5 mg and Revised Code Description for J0641-levoleucovorin, 0.5mg Coming Soon
  • 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
  • 2020 ICD-10 CM File Containing New, Revised, and Deleted ICD-10 CM Codes Effective October 1, 2019 Now Available

Drug Reimbursement Code Price Updates

  • 60 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 60 AWP Drug Code Price changes this month, 17 (29%) 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:

  • S0088 Imatinib, 100 mg 11%
  • J1453 Injection, fosaprepitant, 1 mg 10%
  • J0290 Injection, ampicillin sodium, 500 mg 9%

Price Increases:

  • J7665 Mannitol, administered through an inhaler, 5 mg (Code reused by CMS) 56%
  • S0106 Bupropion HCl sustained release tablet, 150 mg, per bottle of 60 tablets 38%
  • J9245 Injection, melphalan hydrochloride, per 50 mg 18%

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 Code J0642-Injection, levoleucovorin (khapzory), 0.5 mg and Revised Code Description for J0641-levoleucovorin, 0.5mg Coming Soon

CMS (Centers for Medicare & Medicaid Services) released a new HCPCS® Code J0642-Injection, levoleucovorin (khapzory), 0.5 mg effective for billing on October 1, 2019. CMS also revised the description for J0641- Injection, levoleucovorin, not otherwise specified, 0.5 mg. These updates came after RJ Health released the October update.  This new code will be available on ReimbursementCodes.com on November 1, 2019.

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

 

2020 ICD-10 CM File Containing New, Revised, and Deleted ICD-10 CM Codes Effective October 1, 2019 Now Available:

The 2020 ICD-10 CM file released by CMS contains new, revised, and deleted ICD-10 codes effective for patient encounters from October 1, 2019 through September 30, 2020. Please refer to ReimbursementCodes.com to view these changes for specific HCPCS® codes.

 


DRUG REIMBURSEMENT CODE PRICE UPDATES

This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 60 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:

 

90650 C9043 J0641 J3260 J3260
90687 C9044 J0878 J3475 J9260
A4216 C9045 J1327 J7040 J9269
A4614 C9048 J1453 J7131 J9395
A6025 C9049 J1556 J7300 L8605
B4158 C9050 J1580 J7311 Q0161
C9035 C9051 J1726 J7517 Q4208
C9036 C9052 J1942 J7614 S0032
C9037 C9447 J2060 J7665 S0088
C9038 E0607 J2270 J9017 S0106
C9039 J0153 J2590 J9036 S1090
C9040 J0290 J2786 J9245 S4991

 


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. Our review of existing drugs in our database with clinical and billing information already assigned identified twenty-five drugs that required updating.

New:

GVOKE™ (glucagon) injection, for subcutaneous use – by Xeris Pharmaceuticals, Inc.

ROZLYTREK™ (entrectinib) capsules, for oral use – by Genentech, Inc.

 

Updated:

BYETTA® (exenatide) injection, for subcutaneous use – by AstraZeneca

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

COMETRIQ® (cabozantinib) capsules, for oral use – by Exelixis, Inc.

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

ERLEADA® (apalutamide) tablets, for oral use – by Janssen Products, LP

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

GILOTRIF® (afatinib) tablets, for oral use – by Boehringer Ingelheim Pharmaceuticals Inc.

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

GRASTEK® (Timothy Grass Pollen Allergen Extract) Tablet for Sublingual Use – by Catalent Pharma Solutions Limited

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

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

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

JAKAFI® (ruxolitinib) tablets, for oral use – by Incyte Corporation

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

LENVIMA® (lenvatinib) capsules, for oral use – by Eisai Inc.

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

LUPANETA PACK (leuprolide acetate for depot suspension; norethindrone acetate tablets) – by AbbVie Inc.

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

LYNPARZA® (olaparib) capsules, for oral use – by AstraZeneca Pharmaceuticals LP

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

ODOMZO® (sonidegib) capsules, for oral use – by Sun Pharma Global FZE

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

ORALAIR® (sweet vernal, orchard, perennial rye, timothy, and Kentucky blue grass mixed pollens allergen extract) tablet, for sublingual use – by Stallergenes S.A.

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

PIQRAY® (alpelisib) tablets, for oral use – by Novartis

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

PLEGRIDY™ (peginterferon beta-1a) injection, for subcutaneous injection – by Biogen Inc.

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

PURIXAN® (mercaptopurine) oral suspension – by Rare Disease Therapeutics

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

RAGWITEK® (short ragweed pollen allergen extract) tablet, for sublingual use – by Catalent Pharma Solutions Limited

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

RYANODEX® (dantrolene sodium) for injectable suspension, for intravenous use – by Eagle Pharmaceuticals, Inc.

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

SANCUSO® (Granisetron Transdermal System) – by Kyowa Kirin, Inc.

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

SOVALDI® (sofosbuvir) tablets and oral pellets, for oral use – by Gilead Sciences, Inc.

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

SPRYCEL® (dasatinib) tablets, for oral use – by Bristol-Myers Squibb

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

TALTZ®- ixekizumab injection, solution – by Eli Lilly and Company

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

TANZEUM (albiglutide) for injection, for subcutaneous use – by GlaxoSmithKline LLC

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

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

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

TYKERB® (lapatinib) tablets, for oral use – by Novartis

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

ZOLINZA® (vorinostat capsules, for oral use) – by Merck & Co., Inc.

  • 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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