Fosnetupitant and palonosetron for injection, for intravenous use (Akynzeo) HCPCS code J3490: Billing Guidelines

<p>Effective with date of service May 1, 2018, the North Carolina Medicaid and N.C. Health Choice programs covers fosnetupitant and palonosetron for injection, for intravenous use (Akynzeo) for use in the Physician&rsquo;s Drug Program when billed with HCPCS code J3490 - Unclassified drugs.</p>

Author: CSRA

Effective with date of service May 1, 2018, the North Carolina Medicaid and N.C. Health Choice (NCHC) programs covers fosnetupitant and palonosetron for injection, for intravenous use (Akynzeo) for use in the Physician’s Drug Program (PDP) when billed with HCPCS code J3490 - Unclassified drugs.

Akynzeo is available as 235 mg fosnetupitant/0.25 mg palonosetron lyophilized powder in a single-dose vial for reconstitution. U.S. Food and Drug Administration (FDA) approved indication(s) include use in combination with dexamethasone in adults for the prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of highly emetogenic cancer chemotherapy.

Akynzeo for injection has not been studied for the prevention of nausea and vomiting associated with anthracycline plus cyclophosphamide chemotherapy.

The recommended dose is one vial of Akynzeo (235 mg fosnetupitant/0.25 mg palonosetron) infused intravenously over 30 minutes starting 30 minutes before chemotherapy. See full prescribing information for further detail.

For Medicaid and NCHC Billing

  • The ICD-10-CM diagnosis codes required for billing are:
    • T45.1X5A - Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter
    • T45.1X5D - Adverse effect of antineoplastic and immunosuppressive drugs, subsequent encounter
    • T45.1X5S - Adverse effect of antineoplastic and immunosuppressive drugs, sequela
    • Z51.11 - Encounter for antineoplastic chemotherapy required in addition to cancer diagnosis
  • Accompanied by one or more of the following:
    • R11.0 - Nausea; R11.10 - Vomiting, unspecified
    • R11.11 - Vomiting without nausea
    • R11.12 - Projectile vomiting
    • R11.13 - Vomiting of fecal matter
    • R11.14 - Bilious vomiting
    • R11.2 - Nausea with vomiting, unspecified
  • Providers must bill with HCPCS code J3490 - Unclassified drugs.
  • One Medicaid unit of coverage is 1 vial. NCHC bills according to Medicaid units.
  • The maximum reimbursement rate per unit is $550.80.
  • Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDC is 69639-0102-01.
  • 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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