Specialty Drug Reimbursement – Newsletter – January 2021 – Volume 21, Issue 1

INSIDE THIS ISSUE

Drug Reimbursement Code Price Updates

Drugs/Devices

-New Clinical and Billing Information

CMS News

-New, Revised, and Deleted HCPCS® Codes Now Available

-New CPT® Codes Now Available

-Quarterly ASP (Average Sales Price) Pricing File Released

-January 2021 NOC (Not Otherwise Classified) Pricing File

-Hospital OPPS (Outpatient Prospective Payment System) Update

Clinical News


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 112 AWP Drug Code Price changes this month, 29 (26%) 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:

  • J9395  Injection, fulvestrant, 25 mg, 5%
  • J2405  Ondansetron hydrochloride, per 1 mg, 5%
  • A4456  Adhesive remover, wipes, any type, each (Code Price is based on median pricing
    methodology), 4%

Price Increases:

  • J9209   Injection, mesna, 200 mg, 61%
  • S0109   Methadone, oral, 5 mg, 20%
  • E0570   Nebulizer, with compressor (Code Price based on median pricing methodology), 42%

CMS News:

New, Revised, and Deleted HCPCS® Codes Now Available

CMS (Centers for Medicare & Medicaid Services) released their annual HCPCS® File for January 2021 which includes all New, Deleted, and Revised HCPCS® Codes. New codes have been added to www.ReimbursementCodes.com  These codes became effective for Medicare billing for dates of service on and after January 1, 2021. Below is the list of new, deleted, and revised HCPCS® codes that RJ Health maintains in their database:

New HCPCS® Codes

A9591  Fluoroestradiol f 18, diagnostic, 1 millicurie

C1052  Hemostatic agent, gastrointestinal, topical

C9068  Copper cu-64, dotatate, diagnostic, 1 millicurie

C9069  Injection, belantamab mafodontin-blmf, 0.5 mg

C9070  Injection, tafasitamab-cxix, 2 mg

C9071  Injection, viltolarsen, 10 mg

C9072  Injection, immune globulin (asceniv), 500 mg

C9073  Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose

G0088 Professional services, initial visit, for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual’s home, each 15 minutes

G0089 Professional services, initial visit, for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual’s home, each 15 minutes

G0090 Professional services, initial visit, for the administration of intravenous chemotherapy or other highly complex infusion drug or biological for each infusion drug administration calendar day in the individual’s home, each 15 minutes

J0693   Injection, cefiderocol, 5 mg

J1823   Injection, inebilizumab-cdon, 1 mg

J7212   Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 microgram

J7352   Afamelanotide implant, 1 mg

J9144   Injection, daratumumab, 10 mg and hyaluronidase-fihj

J9223   Injection, lurbinectedin, 0.1 mg

J9281   Mitomycin pyelocalyceal instillation, 1 mg

J9316   Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg

J9317   Injection, sacituzumab govitecan-hziy, 2.5 mg

M0239 Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring

M0243 Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring

Q0239 Injection, bamlanivimab-xxxx, 700 mg

Q0243 Injection, casirivimab and imdevimab, 2400 mg

Q5122 Injection, pegfilgrastim-apgf, biosimilar, (nyvepria), 0.5 mg

S0013  Esketamine, nasal spray, 1 mg

U0005 Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, cdc or non-cdc, making use of high throughput technologies, completed within 2 calendar days from date of specimen collection (list separately in addition to either hcpcs code u0003 or u0004) as described by cms-2020-01-r2

 

Deleted HCPCS® Codes

C9060  Fluoroestradiol f18, diagnostic, 1 mci

C9062  Injection, daratumumab 10 mg and hyaluronidase-fihj

C9064  Mitomycin pyelocalyceal instillation, 1 mg

C9066  Injection, sacituzumab govitecan-hziy, 2.5 mg

C9745  Nasal endoscopy, surgical; balloon dilation of eustachian tube

C9747  Ablation of prostate, transrectal, high intensity focused ultrasound (hifu), including imaging guidance

C9749  Repair of nasal vestibular lateral wall stenosis with implant(s)

 

Revised HCPCS® Codes

J7189

Previous Description: Factor VIIa (antihemophilic factor, recombinant), per 1 microgram

Revised Description: Factor viia (antihemophilic factor, recombinant), (novoseven rt), 1 microgram

 

New CPT® Codes Now Available

The American Medical Association (AMA) released two new CPT® codes effective for billing on or after January 1, 2021.  Both codes have been added to www.ReimbursementCodes.com  and are listed below:

90377  Rabies immune globulin, heat- and solvent/detergent-treated (RIg-HT S/D), human, for intramuscular and/or subcutaneous use (Code Price is per 150 IU) (Uses median pricing methodology)

90697  Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use

 

Quarterly ASP (Average Sales Price) File Released:

Another quarter has passed, and this means CMS has released the January 2021 ASP pricing and revisions files. These rates are effective January 1, 2021 through March 31, 2021. 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.

January 2020 ASP Pricing File (Codes: J7682)

April 2020 ASP Pricing File (Codes: J7682)

October 2020 ASP Pricing File (Codes: J0642, J9055, J9305, Q4133)                       

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.

 

January 2021 NOC (Not Otherwise Classified) Pricing File 

CMS released the January 1, 2021 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 January 1, 2021 – March 31, 2021 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.


  • Clinical News

    Each month the RJ Health Clinical Committee meets to review newly approved drugs, dosing, ICD-10 assignments, coding assignments and billable units. Additionally, we discuss questions and concerns our customers raise to ensure we are providing the most accurate and current information in our data and on our website.

See news from previous months.


  • Drug Reimbursement Code Price Updates:

    This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 112 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.

    86580 A4259 J0153 J1000 J1720 J2700 J7314 J9201 Q4213 S0157
    90376 A4371 J0171 J1020 J1940 J2770 J7345 J9209 Q4231 S0164
    90619 A4394 J0256 J1071 J2020 J2787 J7503 J9211 Q4232 S0171
    90691 A4456 J0280 J1170 J2150 J2800 J7504 J9266 S0017 S0187
    90698 A6248 J0295 J1250 J2260 J3245 J7507 J9268 S0020
    90702 A9513 J0348 J1335 J2274 J3315 J8515 J9370 S0028
    90713 A9588 J0461 J1364 J2278 J3430 J8540 J9395 S0030
    90715 B4103 J0583 J1450 J2300 J3465 J9036 Q0161 S0032
    90734 C9113 J0595 J1455 J2405 J7030 J9040 Q0162 S0077
    A4245 C9122 J0604 J1572 J2510 J7100 J9118 Q0163 S0093
    A4250 E0570 J0670 J1580 J2540 J7175 J9171 Q0169 S0109
    A4256 J0131 J0713 J1645 J2690 J7189 J9178 Q4180 S0119


    LOOK UP PRICES NOW:
     


    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 one new drugs which needed to be added to our database and zero drugs that required updating.

    New:

    DANYELZA® (naxitamab-gqgk) injection, for intravenous use-By Y-mAbs Therapeutics, Inc (NOC Codes: J9999, C9399)

    Updated:

    Check back next month for updates.


Our Resources

Learn more – RJ Health Resources


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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