Billing Guidelines: Vestronidase alfa-vjbk injection, for intravenous use (Mepsevii) HCPCS code J3590

<p>Effective with date of service December 1, 2017, the North Carolina Medicaid and NC Health Choice (NCHC) programs cover vestronidase alfa-vjbk injection, for intravenous use (Mepsevii) for use in the Physician&rsquo;s Drug Program (PDP) when billed with HCPCS code J3590 &ndash; Unclassified biologics.</p>

Author: CSRA

Effective with date of service December 1, 2017, the North Carolina Medicaid and NC Health Choice (NCHC) programs cover vestronidase alfa-vjbk injection, for intravenous use (Mepsevii) for use in the Physician’s Drug Program (PDP) when billed with HCPCS code J3590 – Unclassified biologics.

Mepsevii is available as 10 mg/5 mL (2 mg/mL) in a single-dose vial for IV injection. Mepsevii is approved by the U.S. Food and Drug Administration (FDA) for the treatment of Mucopolysaccharidosis VII (MPS VII, Sly syndrome) in pediatric and adult patients. The effect of Mepsevii on the central nervous system manifestations of MPS VII has not been determined.

The recommended dose is 4 mg/kg administered every two weeks as an intravenous infusion.

See full prescribing information for further detail.

For Medicaid and NCHC Billing

  • The ICD-10-CM diagnosis code required for billing is E76.29 - Other mucopolysaccharidoses.
  • Providers must bill with HCPCS code J3590 - Unclassified biologics.
  • One Medicaid unit of coverage is 1 mg. NCHC bills according to Medicaid units.
  • The maximum reimbursement rate per unit is $228.42.
  • Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDC is 69794-0001-01.
  • 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, Attachment A, H.7 on North Carolina 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 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 Medicaid’s PDP web page.

CSRA 1-800-688-6696

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