Specialty Drug Reimbursement – Newsletter – June 2019 – Volume 19, Issue 6


CMS News

  • New, Revised, and Deleted HCPCS® Effective July 1, 2019

Drug Reimbursement Code Price Updates


  • New Clinical and Billing Information

Software Updates

  • Data Enhancements Coming Soon


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 37 AWP Drug Code Price changes this month, 14 (38%) 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:

  • J9171 Injection, docetaxel, 1 mg 31%
  • J1953 Injection, levetiracetam, 10 mg 7%
  • J9025 Injection, azacitidine, 1 mg 6%

Price Increases:

  • Q4149 Excellagen, 0.1 cc 383%
  • Q4184 Cellesta, per square centimeter 240%
  • J0694 Injection, cefoxitin sodium, 1 g 47%

CMS News:

New, Revised, and Deleted HCPCS® Effective July 1, 2019

CMS (Centers for Medicare & Medicaid Services) have released a set of new, revised, and deleted HCPCS® codes effective July 1, 2019.  The new codes are now appropriately crosswalked in our data for customers to update their systems ahead of time and prepare for the changes.  These codes will become billable on July 1st.

The American Medical Association (AMA) has also released recent changes to the CPT® Vaccine Codes, shown below. All new codes are currently available in our system. Any changes or deletions to CPT® or HCPCS® codes will be available in the July release.

The following is a list of codes which will be available and/or revised:

New HCPCS® Codes:

J9030-BCG live intravesical instillation, 1 mg

J9036- Injection, bendamustine hydrochloride, (Belrapzo/bendamustine), 1 mg

J1444-Injection, ferric pyrophosphate citrate powder, 0.1 mg of iron

J7208-Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u.

J7677-Revefenacin inhalation solution, fda-approved final product, non-compounded, administered through DME, 1 microgram

J9356-Injection, trastuzumab, 10 mg and Hyaluronidase-oysk

Q5112-Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg

Q5113-Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg

Q5114-Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mg

Q5115-Injection, rituximab-abbs, biosimilar, (Truxima), 10 mg

New CPT® Codes:

90619-Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier (MenACWY-TT), for intramuscular use

Revised HCPCS® Codes:


                Old Description: Injection, trastuzumab, 10 mg

                New Description: Injection, trastuzumab, excludes biosimilar, 10 mg

Revised CPT® Codes:


                Old Description: Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent (MCV4 or MenACWY), for intramuscular use

                New Description: Meningococcal conjugate vaccine, serogroups A, C, W, Y,
quadrivalent, diphtheria toxoid carrier (MenACWY-D) or CRM197 carrier (MenACWY-CRM), for intramuscular use

Deleted HCPCS® Codes:

J9031-bCG (intravesical), per installation

There has been an update of the Hospital Outpatient Prospective Payment System (OPPS) through the addition and deletion of new HCPCS® Codes. These codes will be effective July 1st.

The following is a list of codes which will be available and/or revised for the July update:

New HCPCS® Codes:

C9047-Injection, caplacizumab-yhdp, 1 mg

C9048-Dexamethasone, lacrimal ophthalmic insert, 0.1 mg

C9049-Injection, tagraxofusp-erzs, 10 mcg

C9050-Injection, emapalumab-lzsg, 1 mg

C9051-Injection, omadacycline, 1 mg

C9052-Injection, ravulizumab-cwvz, 10 mg

C9756-Intraoperative near-infrared fluorescence lymphatic mapping for lymph node(s) (sentinel or tumor draining) with administration of indocyanine green (ICG) (List separately in addition to code for primary procedure)

Deleted HCPCS® Codes:

C9042-Injection, bendamustine hcl (belrapzo), 1 mg

C9141-Injection factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi), 1 i.u.

C9746-Transperineal implantation of permanent adjustable balloon continence device, with cystourethroscopy, when performed and/or fluoroscopy, when performed


This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 37 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:

J9171 J9025 J0604 J3010 J0592 J2469 Q4149
A9155 J9206 S0088 J0887 J1568 B4105  
B4185 J9357 J2675 J0888 J1212 J1443  
A4247 S0190 J3420 J3095 E0570 J0694
J1953 J0641 J1726 S0122 S0109 C9250  
A6257 A4259 E0607 B4103 Q4156 Q4184  



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 drug 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.


CUTAQUIG® (Immune Globulin Subcutaneous (Human) – hipp)by Octapharma USA Inc.

SKYRIZI™ (risankizumab-rzaa) injection, for subcutaneous useby AbbVie Inc.



PRALUENT® (alirocumab) injection, for subcutaneous use-by Sanofi-Aventis U.S. LLC and Regeneron Pharmaceuticals, Inc.

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

SIMPONI® (golimumab) Injection, for subcutaneous use- by Janssen Biotech Inc.

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

SUTENT® (sunitinib malate) capsules, for oral useby Pfizer Labs

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


Expect to see new enhancements to your data coming soon!  This will include more NDCs crosswalked, updated pricing methodology, and the addition of CMS’ Medically Unlikely Edit (MUE) values.

For more detailed information regarding the update Click Here.

View last month’s Newsletter


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