Author: GDIT (800) 688-6696
Effective with date of service Nov. 18, 2019, the NC Medicaid and NC Health Choice programs cover immune globulin intravenous, human – slra 10% liquid (Asceniv) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J1599 - Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified, 500 mg.
Strength/Package Size(s): Liquid solution containing 10% IgG (100 mg/mL) for intravenous infusion; (5g in 50 mL solution).
Indicated for the treatment of primary humoral immunodeficiency (PI) in adults and adolescents (12 to 17 years of age).
Recommended Dose: 300 to 800 mg/kg body weight administered every 3 to 4 weeks. 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:
- D80.0 - Hereditary hypogammaglobulinemia;
- D80.1 - Nonfamilial hypogammaglobulinemia;
- D80.2 - Selective deficiency of immunoglobulin A [IgA];
- D80.3 - Selective deficiency of immunoglobulin G [IgG] subclasses;
- D80.4 - Selective deficiency of immunoglobulin M [IgM];
- D80.5 - Immunodeficiency with increased immunoglobulin M [IgM];
- D80.6 - Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia;
- D80.8 - Other immunodeficiencies with predominantly antibody defects;
- D80.9 - Immunodeficiency with predominantly antibody defects, unspecified;
- D81.0 - Severe combined immunodeficiency [SCID] with reticular dysgenesis;
- D81.1 - Severe combined immunodeficiency [SCID] with low T- and B-cell numbers;
- D81.2 - Severe combined immunodeficiency [SCID] with low or normal B-cell numbers;
- D81.4 - Nezelof's syndrome; D81.6 - Major histocompatibility complex class I deficiency;
- D81.7 - Major histocompatibility complex class II deficiency;
- D81.89 - Other combined immunodeficiencies;
- D81.9 - Combined immunodeficiency, unspecified;
- D82.0 - Wiskott-Aldrich syndrome;
- D82.1 - Di George's syndrome;
- D82.2 - Immunodeficiency with short-limbed stature;
- D82.3 - Immunodeficiency following hereditary defective response to Epstein-Barr virus;
- D82.4 - Hyperimmunoglobulin E [IgE] syndrome;
- D82.8 - Immunodeficiency associated with other specified major defects;
- D82.9 - Immunodeficiency associated with major defect, unspecified;
- D83.0 - Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function;
- D83.1 - Common variable immunodeficiency with predominant immunoregulatory T-cell disorders;
- D83.2 - Common variable immunodeficiency with autoantibodies to B- or T-cells;
- D83.8 - Other common variable immunodeficiencies; D83.9 - Common variable immunodeficiency, unspecified;
- D84.8 - Other specified immunodeficiencies
- Providers must bill with HCPCS code: J1599 - Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified, 500 mg
- One Medicaid and NC Health Choice unit of coverage is: 500 mg
- The maximum reimbursement rate per unit is: $490.86
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 69800-0250-01
- The NDC units should be reported as “UN1.”
- For additional information, refer to the January 2012 Medicaid 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 Medicaid'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 PADP is available on Medicaid's PADP web page.