Specialty Drug Reimbursement – Newsletter – October 2020 – Volume 20, Issue 10


Drug Reimbursement Code Price Updates


      • New Clinical and Billing Information

    CMS News

      • New HCPCS® Codes Effective 10/1/2020 Now Available
      • Deleted and Revised HCPCS® Now Available
      • Quarterly ASP (Average Sales Price) Pricing File Released
      • October 2020 NOC (Not Otherwise Classified) Pricing File
      • Hospital OPPS (Outpatient Prospective Payment System) Update

    Clinical News

      • Crosswalk Update for J7401


    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 49 AWP Drug Code Price changes this month, 25 (51%) 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:

    • J0330 Injection, succinylcholine chloride, up to 20mg, 33%
    • J0594 Injection, busulfan, 1 mg, 23%
    • J0878 Injection, daptomycin, 1 mg, 21%

    Price Increases:

    • Q4169 Artacent wound, per square centimeter (Code Price is based on Median Pricing Methodology), 56%
    • J3475 Injection, magnesium sulfate, per 500 mg, 50%
    • Q0177 Hydroxyzine pamoate, 25 mg, oral, FDA-approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at time of chemotherapy treatment, not to exceed a 48-hour dosage regimen (Indication not FDA-approved at this time), 25%

    CMS News:

    New HCPCS® Codes Effective October 1, 2020 Now Available

    CMS (Centers for Medicare & Medicaid Services) released their quarterly Alpha-Numeric HCPCS® File for October 2020. All new codes have been added to www.ReimbursementCodes.com  These codes become effective for Medicare billing for dates of service on and after October 1, 2020. Our system has been updated with the new codes one month in advance to allow for our customers to update their systems ahead of time. Below is the complete list of new codes:

    C9060 Fluoroestradiol f18, diagnostic, 1 mci

    C9062 Injection, daratumumab 10 mg and hyaluronidase-fihj

    C9064 Mitomycin pyelocalyceal instillation, 1 mg

    C9065 Injection, romidepsin, non-lypohilized (e.g. liquid), 1mg

    C9066 Injection, sacituzumab govitecan-hziy, 2.5 mg

    C9067 Gallium ga-68, dotatoc, diagnostic, 0.01 mci

    J1437 Injection, ferric derisomaltose, 10 mg

    J1632 Injection, brexanolone, 1 mg

    J1738 Injection, meloxicam, 1 mg

    J3032 Injection, eptinezumab-jjmr, 1 mg

    J3241 Injection, teprotumumab-trbw, 10 mg

    J7351 Injection, bimatoprost, intracameral implant, 1 microgram

    J9227 Injection, isatuximab-irfc, 10 mg

    J9304 Injection, pemetrexed (pemfexy), 10 mg

    Q4249 Amniply, for topical use only, per square centimeter

    Q4250 Amnioamp-mp, per square centimeter

    Q4254 Novafix dl, per square centimeter

    Q4255 Reguard, for topical use only, per square centimeter


    Deleted and Revised HCPCS® Coming Soon

    CMS released their quarterly Alpha-Numeric HCPCS® File for October 2020 which contains deleted and revised HCPCS® code changes effective October 1, 2020. These changes will be made for our October release. See below for a complete list of deleted and revised HCPCS® codes:

    Deleted HCPCS® Codes:

    C9055 Injection, brexanolone, 1mg

    C9059 Injection, meloxicam, 1 mg

    C9061 Injection, teprotumumab-trbw, 10 mg

    C9063 Injection, eptinezumab-jjmr, 1 mg

    Revised HCPCS® Codes:

    J9305 Current Description: Injection, pemetrexed, 10 mg

    J9305 Revised Description: Injection, pemetrexed, not otherwise specified, 10 mg

Quarterly ASP (Average Sales Price) File Released:

Another quarter has passed, and this means CMS has released the 2020 ASP pricing and revisions file. These rates are effective October 1, 2020 through December 31, 2020. 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.

April 2020 ASP Pricing File (Codes: J1557)

July 2020 ASP Pricing File (Codes: J1557)

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.


October 2020 NOC (Not Otherwise Classified) Pricing File 

CMS released the October 1, 2020 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 October 1, 2020 – December 31, 2020 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.


Code Strength Change Issued for C9066

CMS issued an updated code strength for new code, C9066: Injection, sacituzumab govitecan-hziy, 2.5 mg. The code strength was changed from 10mg to 2.5mg.  This update became effective prior to the code effective date. However, since we publish all new codes one month prior to their effective date, our website and file will show a price decrease between the months of September and October which corresponds with the code unit change. We have decided to leave this price change to increase visibility of this code strength update to our clients if only price changes are loaded month over month.  The previous price dating back to September should not be used for reimbursement and will be removed with our November update.

  • Clinical News

    Crosswalk Update for J7401

    Our clinical team met this past month to discuss the crosswalk of J7401: Mometasone furoate sinus implant, 10 micrograms (Effective 10/1/20 use NDC level pricing for appropriate reimbursement based on NDC submitted). Upon creation of the specific code C9122 for billing of Sinuva in July, that product was moved out of the crosswalk for J7401.  After further review, we have determined that this is a unique scenario where C9122 can be used for billing Sinuva under OPPS while maintaining Sinuva in J7401 for physician billing.  Since Sinuva has been added back to J7401, we are again suggesting NDC level reimbursement due to the differences in per-unit pricing of the two products aligned to the HCPCS code.  Please ensure your systems are updated accordingly.

    Drug Reimbursement Code Price Updates:

    This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 49 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.

    90284 A6248 J0360 J9206
    A4213 B4100 J0583 J9207
    A4215 B4103 J0594 J9315
    A4245 B4150 J0604 Q0177
    A4259 B4158 J0878 Q4169
    A4349 B4161 J0883 Q4180
    A4414 E0570 J0884 S0017
    A4415 E0607 J1100 S4991
    A4614 E2100 J1453 S5553
    J0330 J1561 S8490


    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 and one drug that required updating.


    KESIMPTA®(ofatumumab) injection, for subcutaneous use By Novartis Pharmaceuticals Corporation

    TRULICITY® (dulaglutide) injection, for subcutaneous use By Eli Lilly and Company


    ERLEADA® (apalutamide) tablets, for oral use By: Janssen Products, LP

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

    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

    View last month’s newsletter.

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