Coagulation factor Xa (recombinant), inactivated-zhzo lyophilized powder for solution for intravenous injection (Andexxa®) HCPCS code J3590: Billing Guidelines

Monday, July 1, 2019

Effective with date of service April 4, 2019, the North Carolina Medicaid and NC Health Choice programs cover coagulation factor Xa (recombinant), inactivated-zhzo lyophilized powder for solution for intravenous injection (Andexxa) for use in the Physician Administered Drug Program when billed with HCPCS code J3590 - Unclassified biologics.

Strength/Package Size: Lyophilized powder in single-use vials of 100 mg or 200 mg

Indicated for patients treated with rivaroxaban and apixaban, when reversal of anticoagulation is needed due to life-threatening or uncontrolled bleeding.

Recommended Dose: The recommended dosing of Andexxa is based on the specific FXa inhibitor, dose of FXa inhibitor, and time since the patient’s last dose of FXa inhibitor.

Low Dose:

Initial IV Bolus - 400 mg at a target rate of 30 mg/min

Follow-On IV Infusion - 4 mg/min for up to 120 minutes

High Dose:

Initial IV Bolus - 800 mg at a target rate of 30 mg/min

Follow-On IV Infusion - 8 mg/min for up to 120 minutes

The safety and effectiveness of more than one dose have not been evaluated.  See package insert for full dosage and administration guidelines and further detail.

For Medicaid and NC Health Choice Billing:       

  • The ICD-10-CM diagnosis codes required for billing are:  D68.4 - Acquired coagulation factor deficiency; T45.511A  - Poisoning by anticoagulants, accidental (unintentional), initial encounter; T45.511D - Poisoning by anticoagulants, accidental (unintentional), subsequent encounter; T45.511S - Poisoning by anticoagulants, accidental (unintentional), sequela; T45.512A - Poisoning by anticoagulants, intentional self-harm, initial encounter;  T45.512D - Poisoning by anticoagulants, intentional self-harm, subsequent encounter; T45.512S - Poisoning by anticoagulants, intentional self-harm, sequela; T45.513A - Poisoning by anticoagulants, assault, initial encounter; T45.513D - Poisoning by anticoagulants, assault, subsequent encounter; T45.513S - Poisoning by anticoagulants, assault, sequela; T45.514A - Poisoning by anticoagulants, undetermined, initial encounter; T45.514D - Poisoning by anticoagulants, undetermined, subsequent encounter; T45.514S - Poisoning by anticoagulants, undetermined, sequela;  T45.515A - Adverse effect of anticoagulants, initial encounter;  T45.515D - Adverse effect of anticoagulants, subsequent encounter; T45.515S - Adverse effect of anticoagulants, sequela
  • Providers must bill with HCPCS code:  J3590 - Unclassified biologics
  • One Medicaid and NC Health Choice unit of coverage is:  1 mg
  • The maximum reimbursement rate per unit is:  $29.70
  • Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units: 69853-0101-01, 69853-0102-01
  • 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 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.

Author: 
GDIT, (800) 688-6696