Author: CSRA
Effective with the date of service of April 30, 2018, the North Carolina Medicaid and N.C. Health Choice (NCHC) programs will be terminating Clinical Policy 1B-3, Intravenous Iron Therapy, within the Physician Drug Program (PDP). Requirements, indications, and all other information of the policy are indicated below. From the perspective of the providers, all things associated with the process of submitting claims regarding the IV Iron agents will remain unchanged.
See prescribing information for details.
Below is information regarding Injectafer.
Medicaid and NCHC shall cover ferric carboxymaltose only for the following FDA-Approved Indications:
- Iron deficiency anemia in adults with intolerance to oral iron or unsatisfactory response to oral iron, and
- Iron deficiency anemia in adults with non-dialysis dependent chronic kidney disease (ndd-ckd).
For Medicaid and NCHC Billing
- ICD-10 codes for iron deficiency anemias where oral treatment is not suitable are:
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Primary Diagnosis |
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D50.0
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D50.1
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D50.8 D50.9 |
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Secondary Diagnosis |
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K50.00 K50.011 K50.012 K50.013 K50.014 K50.018 K50.019 K50.10 K50.111 K50.112 K50.113 K50.114 K50.118 K50.119 K50.80 K50.811 K50.812 K50.813 K50.814 K50.818 K50.819 K50.90 K50.911 K50.912 K50.913 K50.914 K50.918 K50.919 K51.00 K51.011 |
K51.012 K51.013 K51.014 K51.018 K51.019 K51.20 K51.211 K51.212 K51.213 K51.214 K51.218 K51.219 K51.30 K51.311 K51.312 K51.313 K51.314 K51.318 K51.319 K51.40 K51.411 K51.412 K51.413 K51.414 K51.418 K51.419 K51.50 K51.511 K51.512 K51.513 |
K51.514 K51.518 K51.519 K51.80 K51.811 K51.812 K51.813 K51.814 K51.818 K51.819 K51.90 K51.911 K51.912 K51.913 K51.914 K51.918 K51.919 K90.0 K90.1 K90.2 K90.3 K90.4 K90.89 K90.9 K91.2 Z87.19 |
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ICD-10 codes for anemia in chronic kidney disease are:
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Primary Diagnosis |
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D63.1 |
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Secondary Diagnosis |
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N18.1 N18.2 N18.3 |
N18.4 N18.5 |
N18.6 N18.9 |
- Providers must bill with HCPCS code J1439: Ferric carboxymaltose (Injectafer).
- One Medicaid unit of coverage is 1 mg. NCHC bills according to Medicaid units.
- The maximum reimbursement rate per unit is $1.11,
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs are: 00517065001 and 00517065002.
- The NDC units should be reported as “UN1.”
- For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update.
- For additional information regarding NDC claim requirements related to the PDP, refer to the PDP Clinical Coverage Policy No. 1B, Physicians Drug Program, Attachment A, H.7 on Medicaid’s website.
- Providers shall bill their usual and customary charge for non-340-B drugs.
- PDP reimburses for drugs billed for Medicaid and NCHC beneficiaries by 340-B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340-B purchasing agreement by appending the “UD” modifier on the drug detail.
- The fee schedule for the PDP is available on the North Carolina Medicaid PDP web page.
CSRA, 1-800-688-6696