INSIDE THIS ISSUE
-New Clinical and Billing Information
-New and Deleted HCPCS® Codes Effective July 1, 2021, Now Available
-New CPT® Codes Now Available
-Quarterly ASP (Average Sales Price) File Released
-Hospital OPPS (Outpatient Prospective Payment System) Update
-July 2021 NOC (Not Otherwise Classified) Pricing File Released
-HCPCS® Quarterly File Revision
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 57 AWP Drug Code Price changes this month, 25 (44%) 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.
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- A7005 Administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable
(Code Price is based on median pricing methodology), 66%
- Q0175 Perphenazine, 4 mg, oral, FDA-approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at time of chemotherapy threatment, not to exceed a 48-hour dosage regimen, 48%
- J7626 Budesonide, inhalation solution, FDA-approved final product, non-compounded,
administered through DME, unit dose form, up to 0.5 mg, 31%
- Q4239 Amnio-maxx or amnio-maxx lite, per square centimeter (Code Price is based on median pricing methodology), 122%
- Q4238 Derm-maxx, per square centimeter (Code Price is based on median pricing methodology), 105%
- Q4217 Woundfix, BioWound, Woundfix Plus, BioWound Plus, Woundfix Xplus or BioWound Xplus, per square centimeter (Code Price is based on Median Pricing Methodology), 100%
New and Deleted HCPCS® Codes Effective July 1, 2021 Now Available
CMS (Centers for Medicare & Medicaid Services) released their annual HCPCS® File for July 2021 which includes all New and Deleted HCPCS® Codes. New codes and codes that have been deleted by CMS have been added to www.ReimbursementCodes.com The new codes became effective for Medicare billing for dates of service on and after July 1, 2021. CMS did not include any revisions to HCPCS® codes in the July file. We have provided a list of the new HCPCS® codes RJ Health maintains in their database below as well as the codes which have been deleted:
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
J9348 Injection, naxitamab-gqgk, 1 mg
J9353 Injection, margetuximab-cmkb, 5 mg
M0201 Covid-19 vaccine administration inside a patient’s home; reported only once per individual home per date of service when only covid-19 vaccine administration is performed at the patient’s home
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
M0247 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring
M0248 Intravenous infusion, sotrovimab, 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
Q0247 Injection, sotrovimab, 500 mg
Q5123 Injection, rituximab-arrx, biosimilar, (riabni), 10 mg
Deleted HCPCS® Codes
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
Quarterly ASP (Average Sales Price) File Released:
Another quarter has passed, and this means CMS has released the July 2021 ASP pricing and revisions files. These rates are effective July 1, 2021 through September 30, 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 2021 ASP Pricing File (Codes: J1756, J2820, J9035, J9311, J9312, J9355, Q5114, Q5116)
April 2021 ASP Pricing File (Codes: J1557, J3315, Q2050)
October 2020 ASP Pricing File (Codes: J2820)
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.
July 2021 NOC (Not Otherwise Classified) Pricing File
CMS released the July 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 July 1, 2021 – September 30, 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.
HCPCS® Quarterly File Revision
Center for Medicare and Medicaid Services (CMS) made an update to their quarterly HCPCS® file regarding the effectiveness of code J9314: Injection, romidepsin, non-lyophilized (e.g. liquid), 0.1 mg. CMS has since removed J9314 from their data and has reinstated C9065: Injection, romidepsin, non-lypohilized (e.g. liquid), 1mg.
We were unfortunately not notified of this update to coding with enough time to make the appropriate changes for July. We are however making the required changes to remove J9314 from our data and reinstate C9065 for our August update.
Sorry for any inconvenience.
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.
Check back next month for any pertinent clinical updates
Drug Reimbursement Code Price Updates:
This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 57 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.
A4259 B4158 J2278 J7605 J9371 Q4232 A4614 E0570 J2430 J7626 Q0161 Q4237 A4627 J0583 J2543 J7674 Q0175 Q4238 A7003 J0641 J2800 J9025 Q4162 Q4239 A7005 J0642 J2820 J9032 Q4173 Q4254 A7015 J0780 J3095 J9202 Q4180 S0187 A9155 J1453 J7131 J9207 Q4203 S5571 A9543 J1631 J7300 J9245 Q4213 B4150 J1817 J7315 J9246 Q4217 B4152 J2020 J7507 J9307 Q4231
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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 five 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.
ADUHELM™ (aducanumab-avwa) injection, for intravenous use-By Biogen Inc.
LUMAKRAS™ (sotorasib) tablets, for oral use-By Amgen Inc.
RYBREVANT™ (amivantamab-vmjw) injection, for intravenous use-By Janssen Biotech, Inc.
TRUSELTIQ™ (infigratinib) capsules, for oral use-By QED Therapeutics, Inc.
WEGOVY™ (semaglutide) injection, for subcutaneous use-By Novo Nordisk Inc.
BOSULIF® (bosutinib) tablets, for oral use-By Pfizer Labs
COSENTYX® (secukinumab) injection, for subcutaneous use-By Novartis Pharmaceuticals Corporation
XATMEP® (methotrexate) oral solution-By Azurity Pharmaceuticals
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