Specialty Drug Reimbursement – Newsletter – June 2021 – Volume 21, Issue 6

INSIDE THIS ISSUE

Drug Reimbursement Code Price Updates

Drugs/Devices

-New Clinical and Billing Information

CMS News

-New HCPCS® Codes Now Available

-New CPT® Codes Now Available

Clinical News

-Removal of NOC flag from J1599 and reinstatement of code price coming next month

-Update to A9591 Crosswalk


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 60 AWP Drug Code Price changes this month, 29 (48%) 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:

  • A4247  Betadine or iodine swabs/wipes, per box (Code Price is based on median pricing methodology)(Code Price is per each swab/wipe), 39%
  • S0080   Injection, pentamidine isethionate, 300 mg, 63%
  • J2469   Injection, palonosetron HCl, 25 mcg, 33%

Price Increases:

  • Q4208  Novafix, per square cenitmeter (Code Price is based on median pricing methodology), 78%
  • Q4140  BioDFence, per square centimeter (Code Price based on Median pricing methodology), 43%
  • A6248  Hydrogel dressing, wound filler, gel, per fluid ounce (Code Price is based on median pricing methodology), 25%

CMS News

New, Revised, and Deleted HCPCS® Codes Now Available

CMS (Centers for Medicare & Medicaid Services) released their annual HCPCS® File for July 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 July 1, 2021. All deleted codes will be updated in our data for July 1, 2021. We have provided a list of them to allow clients to prepare. CMS as not provided in revised codes yet in their file. Below is the list of new and deleted HCPCS® codes that RJ Health maintains in their database:

 

New HCPCS® Codes

A9593  Gallium ga-68 psma-11, diagnostic, (ucsf), 1 millicurie

A9594  Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie

C9075  Injection, casimersen, 10 mg

C9076  Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose

C9077  Injection, cabotegravir and rilpivirine, 2mg/3mg

C9078  Injection, trilaciclib, 1 mg

C9079  Injection, evinacumab-dgnb, 5 mg

C9080  Injection, melphalan flufenamide hydrochloride, 1 mg

C9778  Colpopexy, vaginal; minimally invasive extra-peritoneal approach (sacrospinous)

J0224   Injection, lumasiran, 0.5 mg

J1951   Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg

J7168   Prothrombin complex concentrate (human), kcentra, per i.u. of factor ix activity

J9314   Injection, romidepsin, non-lyophilized (e.g. liquid), 0.1 mg

J9348   Injection, naxitamab-gqgk, 1 mg

J9353   Injection, margetuximab-cmkb, 5 mg

M0244 Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring the home or residence; this includes a beneficiary’s home that has been made provider based to the hospital during the covid 19 public health emergency

M0246 Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider based to the hospital during the covid 19 public health emergency

Q5123 Injection, rituximab-arrx, biosimilar, (riabni), 10 mg

 

Deleted HCPCS® Codes

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

C9074  Injection, lumasiran, 0.5 mg

C9132  Prothrombin complex concentrate (human), kcentra, per i.u. of factor ix activity

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

Q0239 Injection, bamlanivimab-xxxx, 700 mg

 

New CPT® Codes Now Available

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

 

90626 Tick-borne encephalitis virus vaccine, inactivated; 0.25 mL dosage, for intramuscular use

90627 0.5 mL dosage, for intramuscular use

90671 Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use

90677 Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use

90758 Zaire ebolavirus vaccine, live, for intramuscular use

See previous updates.


  • 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.

Removal of NOC flag from J1599 and reinstatement of code price

As previously communicated, the committee met internally last month regarding J1599-Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg.  This HCPCS code was flagged as a Not Otherwise Classified (NOC) code in our data, however, now that Panzyga is the only drug cross-walked to this code, it was determined that a code price could be reinstated.  This change was made for our June update. This will also cause this HCPCS to move from the NOC tab to the NDC crosswalk tab in our data files as well.

Update to A9591 Crosswalk

This past month we received clarification from the manufacturer regarding the billable units for Cerianna in code A9591. It was confirmed that the billable units of the product needed to be updated in our data. We have changed the billable units for the Cerianna product from 100 to 6 per package. This update has resulted in a code price change.  This code price is listed in our data as a new 6/1/2021 price, and we have retroactively updated the 1/1/2021 price to reflect this change in units.

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 60 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 A6196 B4150 J1335 J3489 Q4133
    A4216 A6203 B4152 J1453 J7050 Q4208
    A4247 A6219 B4154 J1459 J7500 Q9966
    A4253 A6220 B4155 J1559 J7510 Q9967
    A4256 A6231 B4162 J1630 J8520 S0080
    A4259 A6234 E0607 J1642 J8521 S0122
    A4406 A6248 E2100 J2250 J9250 S0156
    A4455 A6260 J0221 J2469 J9260 S0171
    A4456 A9591 J0282 J2860 J9269 S5010
    A5071 B4103 J0630 J3420 Q4117 S8490

  • 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 three 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 four drugs that required updating.

    New:

    JEMPERLI (dostarlimab-gxly) injection, for intravenous use-By: GlaxoSmithKline LLC 

    ARTESUNATE for injection, for intravenous use- By Amivas LLC

    ZYNLONTA™ (loncastuximab tesirine-lpyl) for injection, for intravenous use- By ADC Therapeutics

    Updated:

    NEXIUM® I.V. (esomeprazole sodium) for injection, for intravenous use- By: AstraZeneca Pharmaceuticals LP 

    PROTONIX® I.V. (pantoprazole sodium) for injection, for intravenous use- By: Pfizer

    SOTRADECOL® (Sodium Tetradecyl Sulfate Injection)-By: Mylan Institutional.

    CUROSURF® (poractant alfa) intratracheal suspension-By Chiesi USA, 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


View last month’s newsletter.


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