Author: GDIT Call Center, (800) 688-6696
Effective with date of service of Feb. 4, 2019, the North Carolina Medicaid and NC Health Choice programs cover fluocinolone acetonide intravitreal implant (Yutiq) for use in the Physician Administered Drug Program when billed with HCPCS code J7313 Injection, fluocinolone acetonide, intravitreal implant, 0.01 mg.
Yutiq is available as a non-bioerodible intravitreal implant containing 0.18 mg fluocinolone acetonide in a drug delivery system and is indicated for the treatment of chronic non-infectious uveitis affecting the posterior segment of the eye.
Recommended Dose: For opthalmic intravitreal injection. Each intravitreal implant contains 0.18 mg of fluocinolone acetonide in a drug delivery system designed to release fluocinolone acetonide at an initial rate of 0.25 mcg/day and lasting 36 months.
See full prescribing information for further detail.
For North Carolina Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code(s) required for billing is/are: H30.001 - Unspecified focal chorioretinal inflammation, right eye; H30.002 - Unspecified focal chorioretinal inflammation, left eye; H30.003 - Unspecified focal chorioretinal inflammation, bilateral; H30.009 - Unspecified focal chorioretinal inflammation, unspecified eye; H30.013 - Focal chorioretinal inflammation, juxtapapillary, bilateral; H30.011 - Focal chorioretinal inflammation, juxtapapillary, right eye; H30.012 - Focal chorioretinal inflammation, juxtapapillary, left eye; H30.019 - Focal chorioretinal inflammation, juxtapapillary, unspecified eye; H30.021 - Focal chorioretinal inflammation of posterior pole, right eye; H30.022 - Focal chorioretinal inflammation of posterior pole, left eye; H30.023 - Focal chorioretinal inflammation of posterior pole, bilateral; H30.029 - Focal chorioretinal inflammation of posterior pole, unspecified eye; H30.033 - Focal chorioretinal inflammation, peripheral, bilateral; H30.031 - Focal chorioretinal inflammation, peripheral, right eye; H30.032 - Focal chorioretinal inflammation, peripheral, left eye; H30.039 - Focal chorioretinal inflammation, peripheral, unspecified eye; H30.041 - Focal chorioretinal inflammation, macular or paramacular, right eye; H30.042 - Focal chorioretinal inflammation, macular or paramacular, left eye; H30.043 - Focal chorioretinal inflammation, macular or paramacular, bilateral; H30.049 - Focal chorioretinal inflammation, macular or paramacular, unspecified eye; H30.101 - Unspecified disseminated chorioretinal inflammation, right eye; H30.102 - Unspecified disseminated chorioretinal inflammation, left eye; H30.103 - Unspecified disseminated chorioretinal inflammation, bilateral; H30.109 - Unspecified disseminated chorioretinal inflammation, unspecified eye; H30.111 - Disseminated chorioretinal inflammation of posterior pole, right eye; H30.112 - Disseminated chorioretinal inflammation of posterior pole, left eye; H30.113 - Disseminated chorioretinal inflammation of posterior pole, bilateral; H30.119 - Disseminated chorioretinal inflammation of posterior pole, unspecified eye; H30.123 - Disseminated chorioretinal inflammation, peripheral, bilateral; H30.121 - Disseminated chorioretinal inflammation, peripheral, right eye; H30.122 - Disseminated chorioretinal inflammation, peripheral, left eye; H30.129 - Disseminated chorioretinal inflammation, peripheral, unspecified eye; H30.133 - Disseminated chorioretinal inflammation, generalized, bilateral; H30.139 - Disseminated chorioretinal inflammation, generalized, unspecified eye; H30.131 - Disseminated chorioretinal inflammation, generalized, right eye; H30.132- Disseminated chorioretinal inflammation, generalized, left eye; H30.141 - Acute posterior multifocal placoid pigment epitheliopathy, right eye; H30.142 - Acute posterior multifocal placoid pigment epitheliopathy, left eye; H30.143 - Acute posterior multifocal placoid pigment epitheliopathy, bilateral; H30.149 - Acute posterior multifocal placoid pigment epitheliopathy, unspecified eye; H30.90 - Unspecified chorioretinal inflammation, unspecified eye; H30.91 - Unspecified chorioretinal inflammation, right eye; H30.92 - Unspecified chorioretinal inflammation, left eye; H30.93 - Unspecified chorioretinal inflammation, bilateral
- Providers must bill with HCPCS code: J7313 Injection, fluocinolone acetonide, intravitreal implant, 0.01 mg
- One North Carolina Medicaid and NC Health Choice unit of coverage is: 0.01 mg
- The maximum reimbursement rate per unit is: $490.95
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDC is: 71879-0136-01
- 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 PADP, refer to the PADP Clinical Coverage Policy No. 1B, Attachment A, H.7 on DHB's website.
- Providers shall bill their usual and customary charge for non-340B drugs.
- PADP reimburses for drugs billed for Medicaid and NC Health Choice 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 Physician Administered Drug Program is available on DHB's PADP web page.