September 29, 2017

Texas HHS has revised the policy for Spinraza and Exondys 51 to allow use of the unlisted or not otherwise classified Healthcare Common Procedure Coding System (HCPCS) code by non-hospital providers. This change allows coverage of these drugs through the medical benefit in two ways:

  1. Hospitals can submit a medical claim for the cost of the drug, the administration, and any other authorized services rendered; or
  2. The prescriber can send the prescription to the specialty pharmacy. The specialty pharmacy can ship the drug directly to the prescriber and subsequently submit a medical claim to TMHP or the MCO for the cost of the drug using J3490 and the National Drug Code (NDC). Then, the provider can submit a medical claim to TMHP or the MCO for the administration of the drug and any other authorized services rendered. 

Texas HHS has updated the NDC-to-HCPCS Crosswalk to include the NDCs for Spinraza and Exondys 51 under J3490. Below is a summary of the policy:

Requirements for Clinician-Administered Drugs:

  • All claims for Spinraza and Exondys 51 must include the correct HCPCS code and NDC to be eligible for payment. If a claim is missing the NDC information, or the NDC is not valid for the corresponding HCPCS code, then the drug is not considered a covered Medicaid benefit.

Spinraza

  1. The NDC for Spinraza is  64406-0058-01.
  2. Hospitals billing for the cost of Spinraza must use Procedure Code C9489. 
  3. Non-hospitals billing for the cost of Spinraza must utilize Procedure Code J3490 until CMS issues a permanent J-code. 
  4. The fee-for-service rate for C9489 and J3490 is $1,118.75 per 0.1 milligrams. Providers should contact MCOs for information about reimbursement rates in managed care.

Exondys 51

  1. The NDCs for Exondys 51 are 60923-0284-10 and 60923-0284-10.
  2. Hospitals billing for the cost of Exondys 51 must use Procedure Code C9484.
  3. Non-hospitals billing for the cost of Exondys 51must utilize Procedure Code J3490 until CMS issues a permanent J-code. 
  4. The fee-for-service rate for C9484 and J3490 is $171.84 per ten milligrams. Providers should contact MCOs for information about reimbursement rates in managed care.