Author: GDIT, (800) 688-6696
Effective March 1, 2019, the North Carolina Medicaid and NC Health Choice programs cover dexamethasone intraocular suspension 9%, for intraocular administration (Dexycu) for use in the Physician Administered Drug Program when billed with HCPCS code J1095 - Injection, dexamethasone 9%, intraocular, 1 microgram.
Dexycu is available as an intraocular suspension: 9% equivalent to dexamethasone 103.4 mg/mL in a single-dose vial provided in a kit. It is indicated for the treatment of postoperative inflammation.
Administer 0.005 mL of Dexycu into the posterior chamber inferiorly behind the iris at the end of ocular surgery.
See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code(s) required for billing is/are: H20.041 - Secondary noninfectious iridocyclitis, right eye; H20.042 - Secondary noninfectious iridocyclitis, left eye; H20.043 - Secondary noninfectious iridocyclitis, bilateral; H20.049 - Secondary noninfectious iridocyclitis, unspecified eye; H44.001 - Unspecified purulent endophthalmitis, right eye; H44.002 - Unspecified purulent endophthalmitis, left eye; H44.003 - Unspecified purulent endophthalmitis, bilateral; H44.009 - Unspecified purulent endophthalmitis, unspecified eye; H44.131 - Sympathetic uveitis, right eye; H44.132 - Sympathetic uveitis, left eye; H44.133 - Sympathetic uveitis, bilateral; H44.139 - Sympathetic uveitis, unspecified eye; H44.19 - Other endophthalmitis; H59.091 - Other disorders of the right eye following cataract surgery; H59.092 - Other disorders of the left eye following cataract surgery; H59.093 - Other disorders of the eye following cataract surgery, bilateral; H59.099 - Other disorders of unspecified eye following cataract surgery
- Providers must bill with HCPCS code: J1095 - Injection, dexamethasone 9%, intraocular, 1 microgram
- One Medicaid and NC Health Choice unit of coverage is: 1 microgram
- The maximum reimbursement rate per unit is: $1.24
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDC is: 71879-0001-01
- 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 PADP, refer to the PADP Clinical Coverage Policy 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.