Author: GDIT, (800) 688-6696
Effective with date of service Nov. 2, 2018, the NC Medicaid and Health Choice (NCHC) programs cover crotalidae immune f(ab’)2 (equine), lyophilized powder for solution for injection for intravenous use (Anavip®) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.
Each vial of Anavip contains a sterile, lyophilized preparation containing not more than 120 milligrams total protein and not less than the indicated number of mouse LD50 neutralizing units:
Bothrops asper (snake species used for standardization): 780 minimum mouse LD50 units per vial
Crotalus durissus (snake species used for standardization): 790 minimum mouse LD50 units per vial
Anavip is indicated for the management of adult and pediatric patients with North American rattlesnake envenomation. The initial dose of Anavip is 10 vials properly diluted (see package insert for instructions) and infused intravenously over 60 minutes.
Additional 10 vial doses can be administered if needed to arrest the progressive symptoms and repeat every hour. There is no known maximum dose. Re-emerging symptoms including coagulopathies may be suppressed with additional four vial doses as needed. See full prescribing information for further detail
For Medicaid and NCHC Billing
- The ICD-10-CM diagnosis code required for billing is/are: T63.011A - Toxic effect of rattlesnake venom, accidental (unintentional), initial encounter; T63.011D - Toxic effect of rattlesnake venom, accidental (unintentional), subsequent encounter; T63.011S - Toxic effect of rattlesnake venom, accidental (unintentional), sequela; T63.012A - Toxic effect of rattlesnake venom, intentional self-harm, initial encounter; T63.012D - Toxic effect of rattlesnake venom, intentional self-harm, subsequent encounter; T63.012S - Toxic effect of rattlesnake venom, intentional self-harm, sequela; T63.013A - Toxic effect of rattlesnake venom, assault, initial encounter; T63.013D - Toxic effect of rattlesnake venom, assault, subsequent encounter; T63.013S - Toxic effect of rattlesnake venom, assault, sequela; T63.014A - Toxic effect of rattlesnake venom, undetermined, initial encounter; T63.014D - Toxic effect of rattlesnake venom, undetermined, subsequent encounter; T63.014S - Toxic effect of rattlesnake venom, undetermined, sequela
- Providers must bill with HCPCS code: J3590 - Unclassified biologics
- One Medicaid and NCHC unit of coverage is: 1 vial
- The maximum reimbursement rate per unit is: $1,317.60
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs is/are: 66621-0790-01, 66621-0790-02
- 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 PADP, refer to the PDP Clinical Coverage Policy No. 1B, Attachment A, H.7 on NC Medicaid's website.
- Providers shall bill their usual and customary charge for non-340B drugs.
- PADP reimburses for drugs billed for Medicaid and NCHC beneficiaries by 340B 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 340B purchasing agreement by appending the "UD" modifier on the drug detail.
- The fee schedule for the PADP is available on NC Medicaid's PADP web page.
ICD-10-CM Manual. American Medical Association, 2018 manual.