Specialty Drug Reimbursement – Newsletter – December 2019 – Volume 19, Issue 12

INSIDE THIS ISSUE

CMS News

    • New HCPCS® Codes Effective January 1, 2020 Now Available
    • Deleted and Revised HCPCS® Codes Effective January 1, 2020 Coming Soon

    Drug Reimbursement Code Price Updates

    • 39 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 39 AWP Drug Code Price changes this month, 13 (33%) 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:

  • J1595 Injection, glatiramer acetate, 20 mg 52%
  • J9050 Injection, carmustine, 100 mg 29%
  • J7518 Mycophenolic acid, oral, 180 mg 23%

Price Increases:

  • J0743 Injection, cilastatin sodium; imipenem, per 250 mg 65%
  • J1265 Injection, dopamine HCl, 40 mg 56%
  • C9046 Cocaine hydrochloride nasal solution for topical administration, 1 mg) 37%

CMS News:

New HCPCS® Codes Effective January 1, 2020 Now Available

Centers for Medicare and Medicaid (CMS) have released New HCPCS® Codes effective January 1, 2020. We have updated our data with the new codes in order to allow customers time to update their systems accordingly before such codes go into effect. Below is a list of the new codes:

New Codes:

A4226 Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week

A9590 Iodine i-131, iobenguane, 1 millicurie

B4187  Omegaven, 10 grams lipids

C1734 Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable)

C1824 Generator, cardiac contractility modulation (implantable)

C1839 Iris prosthesis

C1982 Catheter, pressure-generating, one-way valve, intermittently occlusive

C2596 Probe, image-guided, robotic, waterjet ablation

C9054 Injection, lefamulin (xenleta), 1 mg

C9055 Injection, brexanolone, 1mg

C9757 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and excision of herniated intervertebral disc, and repair of annular defect with implantation of bone anchored annular closure device, including annular defect  measurement, alignment and sizing assessment, and image guidance; 1 interspace, lumbar

C9758 Blinded procedure for nyha class iii/iv heart failure; transcatheter implantation of interatrial shunt or placebo control, including right heart catheterization, trans-esophageal echocardiography (tee)/intracardiac echocardiography (ice), and all imaging with or without guidance (e.g., ultrasound, fluoroscopy), performed in an approved investigational device exemption (ide) study

E0787  External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing

G2067 Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a medicare-enrolled opioid treatment program)

G2068 Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)

G2069 Medication assisted treatment, buprenorphine (injectable); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)

G2070 Medication assisted treatment, buprenorphine (implant insertion); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)

G2071 Medication assisted treatment, buprenorphine (implant removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)

G2072 Medication assisted treatment, buprenorphine (implant insertion and removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)

G2073 Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)

G2078 Take-home supply of methadone; up to 7 additional day supply (provision of the services by a medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure

G2079 Take-home supply of buprenorphine (oral); up to 7 additional day supply (provision of the services by a medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure

G2082 Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation

G2083 Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of  greater than 56 mg esketamine nasal self-administration, includes 2 hours post-administration observation

J0179  Injection, brolucizumab-dbll, 1 mg

J9199  Injection, gemcitabine hydrochloride (infugem), 200 mg

J9309  Injection, polatuzumab vedotin-piiq, 1 mg

P9099  Blood component or product not otherwise classified

Deleted and Revised HCPCS® Codes Effective January 1, 2020 Coming Soon

CMS has released Deleted and Revised HCPCS® Codes effective January 1, 2020. We will be updating our system this month with the following changes:

Deletions:

C9043 Injection, levoleucovorin, 1 mg

C9407 Iodine i-131 iobenguane, diagnostic, 1 millicurie

C9408 Iodine i-131 iobenguane, therapeutic, 1 millicurie

G9017 Amantadine hydrochloride, oral, per 100 mg (for use in a medicare-approved demonstration project)

G9018 Zanamivir, inhalation powder, administered through inhaler, per 10 mg (for use in a medicare-approved demonstration project)

G9019 Oseltamivir phosphate, oral, per 75 mg (for use in a medicare-approved demonstration project)

G9020 Rimantadine hydrochloride, oral, per 100 mg (for use in a medicare-approved demonstration project)

G9033 Amantadine hydrochloride, oral brand, per 100 mg (for use in a medicare-approved demonstration project)

G9034 Zanamivir, inhalation powder, administered through inhaler, brand, per 10 mg (for use in a medicare-approved demonstration project)

G9035 Oseltamivir phosphate, oral, brand, per 75 mg (for use in a medicare-approved demonstration project)

G9036 Rimantadine hydrochloride, oral, brand, per 100 mg (for use in a medicare-approved demonstration project)

G9158 Motor speech functional limitation, discharge status, at discharge from therapy or to end reporting

 

Revisions:

B4185  Parenteral nutrition solution, per 10 grams lipids (Effective 2/1/07 Code Price is per 10 gm lipids and is based on median pricing methodology – previously Code Price was based on 1 mL and average pricing methodology)

Revision: B4185 Parenteral nutrition solution, not otherwise specified, 10 grams lipids

J9201  Injection, gemcitabine hydrochloride, 200 mg

Revision: J9201 Injection, gemcitabine hydrochloride, not otherwise specified, 200 mg

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

Revision: Q5105 Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units

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

Revision: Q5106 Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units


DRUG REIMBURSEMENT CODE PRICE UPDATES

This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 39 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:

 

A9572 J0500 J2820 J9293
A9590 J0571 J3095 J9309
B4152 J0743 J7518 Q2004
B4155 J1100 J7520 Q5114
B4187 J1265 J7620 Q5115
C9046 J1453 J8520 Q9961
C9054 J1557 J8521 S0088
C9055 J1595 J9050 S0106
G9017 J2185 J9199 S4991
J0179 J2326 J9201

 


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 three drugs that required updating.

New:

REBLOZYL® (luspatercept-aamt) for injection, for subcutaneous use – by Celgene Corporation

ZIEXTENZO™ (pegfilgrastim-bmez) injection, for subcutaneous use – by Sandoz Inc

Updated:

OLUMIANT® (baricitinib) tablets, for oral use – by Eli Lilly and Company

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

    BAXDELA® (delafloxacin) for injection, for intravenous use – by Melinta Therapeutics, Inc

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

    EVZIO® naloxone hydrochloride injection, solution – by Kaleo, 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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