Billing Guidelines: Methacholine chloride (Provocholine), HCPCS Code J7674

<p>Effective with date of service June 1, 2016, the North Carolina Medicaid and NC Health Choice programs cover methacholine chloride (Provocholine) administered as inhalation solution, for use in the Physician&rsquo;s Drug Program when billed with HCPCS code J7674 (Methacholine chloride, neb, per 1 mg).</p>

Author: CSRA

Effective with date of service June 1, 2016, the North Carolina Medicaid and NC Health Choice (NCHC) programs cover methacholine chloride (Provocholine) administered as inhalation solution, for use in the Physician’s Drug Program (PDP) when billed with HCPCS code J7674 (Methacholine chloride, neb, per 1 mg). Provocholine is available in 20 mL amber vials containing 100 mg of methacholine chloride powder for reconstitution.

Methacholine chloride is a bronchoconstrictor agent indicated for the diagnosis of bronchial airway hyperreactivity in subjects who do not have clinically apparent asthma. There are two different dilution schedules using a 100 mg vial of methacholine depending on the desired protocol for the methacholine challenge test. One is based on a two-minute tidal breathing dosing protocol and the other is a five-breath dosimeter protocol. Both methods use a nebulizer to administer the medication.

Medicaid and NCHC Billing

  • Providers must with HCPCS code J7674 - Methacholine chloride, neb., 1 mg.
  • Providers must indicate the number of HCPCS units (assumption: 1 unit = 1 mg).
  • One Medicaid unit of coverage is 1 mg. NCHC bills according to Medicaid units.
  • The maximum reimbursement rate per unit is $0.52.
  • Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The associated NDCs are 64281-0100-00 (single vial) and 64281-0100-06 (box of six vials).
  • 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 the Clinical Coverage Policy No. 1B, Physician Drug Program, Attachment A, H.7 on the Medicaid 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 340-B 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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