Pegfilgrastim-bmez Injection, for Subcutaneous Use (Ziextenzo™) HCPCS Code J3590: Billing Guidelines

Tuesday, January 28, 2020

Effective with date of service Nov. 8, 2019, the NC Medicaid and NC Health Choice programs cover pegfilgrastim-bmez injection, for subcutaneous use (Ziextenzo) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.

Strength/Package Size(s): Injection: 6 mg/0.6 mL solution in a single-dose prefilled syringe for manual use only.

Indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia.

Limitations of Use: Ziextenzo is not indicated for the mobilization of peripheral blood progenitor cells for hematopoietic stem cell transplantation.

Recommended Dose (see full prescribing information for further detail):  

  • The recommended dosage of Ziextenzo is a single subcutaneous injection of 6 mg administered once per chemotherapy cycle. 
  • Dosing in pediatric patients weighing less than 45 kg:
    - Body weight 10-20 kg: 1.5 mg
    - Body weight 21-30 kg: 2.5 mg
    - Body weight 31-44 kg: 4 mg
    * For pediatric patients weighing less than 10 kg, administer 0.1 mg/kg.

For Medicaid and NC Health Choice Billing

  • The ICD-10-CM diagnosis code(s) required for billing is/are: 
    • D70.1 - Agranulocytosis secondary to cancer chemotherapy; 
    • T45.1X5A - Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter; 
    • T45.1X5D - Adverse effect of antineoplastic and immunosuppressive drugs, subsequent encounter; 
    • T45.1X5S - Adverse effect of antineoplastic and immunosuppressive drugs, sequela
  • Providers must bill with HCPCS code: J3590 - Unclassified biologics
  • One Medicaid and NC Health Choice unit of coverage is: 0.5 mg 
  • The maximum reimbursement rate per unit is: $353.30
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 61314-0866-01The 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.
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