Specialty Drug Reimbursement – Newsletter – March 2021 – Volume 21, Issue 3

INSIDE THIS ISSUE

Drug Reimbursement Code Price Updates

Drugs/Devices

-New Clinical and Billing Information

CMS News

-New HCPCS® Codes Effective April 1, 2021 Now Available

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 52 AWP Drug Code Price changes this month, 22 (42%) 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:

  • S0194 Dialysis/stress vitamin supplement, oral, 100 capsules, 73%
  • J7510  Predisone, oral, per 5 mg, 69%
  • JJ088  Injection, daptomycin, 1 mg, 35%

Price Increases:

  • J2270  Injection, morphine sulfate, up to 10 mg (Code Price is per 10 mg), 16%
  • J9216  Injection, interferon, gamma-1b, 3 million units, 15%
  • J1270  Injection, doxercalciferol, 1 mcg, 14%

CMS News:

New HCPCS® Codes Effective April 1, 2021 Now Available

CMS (Centers for Medicare and Medicaid) did not release the quarterly file for New, Deleted, and Revised HCPCS® codes in time for RJ Health’s March update. Included in the data this month are the new HCPCS® codes effective for billing April 1, 2021 that were obtained from the Fourth Quarter Application Summary and Coding Decisions meeting minutes. Our system will be updated with any other additions, deletions, or revisions when the quarterly file is released by CMS. The codes that have been added to our data are listed below. Follow this link to view the full meeting minutes: https://www.cms.gov/files/document/2020-hcpcs-application-summary-quarter-4-2020-drugs-and-biologics.pdf

New HCPCS® Codes:

A9592 – Copper Cu-64, dotatate, diagnostic, 1 millicurie

J1427 – Injection, viltolarsen, 10 mg

J1554 – Injection, immune globulin (asceniv), 500 mg

J7402 – Mometasone furoate sinus implant, (sinuva), 10 micrograms

J9037 – Injection, belantamab mafodontin-blmf, 0.5 mg

J9349 – Injection, tafasitamab-cxix, 2 mg

Q2053 – Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose (Code Price is for drug only)

S1091 – Stent, non-coronary, temporary, with delivery system (propel)


  • 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 52 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.

  • 90291 E0607 J1270 J3095 J9047 S0194
    90396 E2100 J1438 J3111 J9119 S8490
    A4213 J0604 J1455 J3411 J9209
    A4253 J0743 J1650 J3415 J9216
    A4259 J0744 J1741 J7050 J9303
    A4627 J0770 J2270 J7507 J9325
    A7015 J0850 J2310 J7510 J9360
    B4160 J0878 J2440 J7517 Q0161
    B4162 J0897 J2507 J9039 Q4174
    C9488 J1100 J2796 J9045 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 six new drugs which needed to be added to our database and three drugs that required updating.

    New:

    BREYANZI® (lisocabtagene maraleucel) suspension for intravenous infusion – By Juno Therapeutics Inc., a Bristol-Myers Squibb Company 

    CABENUVA (cabotegravir extended-release injectable suspension; rilpivirine extended-release injectable suspension), co-packaged for intramuscular use – By ViiV Healthcare 

    COSELA™ (trilaciclib) for injection, for intravenous use – By G1 Therapeutics, Inc

    EVKEEZA™ (evinacumab-dgnb) injection, for intravenous use – By Regeneron Pharmaceuticals, Inc. 

    TEPMETKO® (tepotinib) tablets, for oral use By EMD Serono, Inc.

    UKONIQ™ (umbralisib) tablets, for oral use By TG Therapeutics, Inc.

    Updated:

    AIMOVIG® (erenumab-aooe) injection, for subcutaneous useBy Amgen Inc.

    KEVZARA® (sarilumab) injection, for subcutaneous use By Sanofi-Aventis U.S. LLC

    STIVARGA® (regorafenib) tablets, for oral use By Bayer HealthCare Pharmaceuticals Inc.


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


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