Ferumoxytol, for treatment of iron deficiency anemia, injection (Feraheme) HCPCS code Q0138: Billing Guidelines

<p>Effective with the date of service of April 30, 2018, the North Carolina Medicaid and N.C. Health Choice programs will be terminating Clinical Policy 1B-3, Intravenous Iron Therapy, within the Physician Drug Program.</p>

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 ferumoxytol.

Medicaid and NCHC shall cover ferumoxytol only for the following FDA-Approved Indications:

  1. Iron deficiency anemia in adult beneficiaries who are hemodialysis dependent with chronic kidney disease (HDD-CKD)
  2. Iron deficiency anemia in adult beneficiaries who are non-dialysis dependent with chronic kidney disease (NDD-CKD), and
  3. Iron deficiency anemia in adult beneficiaries who are peritoneal dialysis dependent with chronic kidney disease (PDD-CKD).

For Medicaid and NCHC Billing

  • ICD-10 codes for anemia in chronic kidney disease are:

Primary Diagnosis

D63.1

Secondary Diagnosis

N18.1

N18.2

N18.3

N18.4

N18.5

N18.6

N18.9
  • Providers must bill with HCPCS code Q0138: Ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD on dialysis), injection (Feraheme).
  • One Medicaid unit of coverage is1 mg. NCHC bills according to Medicaid units.
  • The maximum reimbursement rate per unit is $0.79.
  • Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs is/are: 59338077501 and 59338077510.
  • 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

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