Meloxicam Injection, for Intravenous Use (Anjeso™) HCPCS Code J3490: Billing Guidelines

Tuesday, June 16, 2020

Effective with date of service April 7, 2020, the Medicaid and NC Health Choice programs cover meloxicam injection, for intravenous use (Anjeso™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.

Strength/Package Size(s): Injection: 30 mg/mL single-dose vial

Indicated for use in adults for the management of moderate-to-severe pain, alone or in combination with non-NSAID analgesics.

Because of delayed onset of analgesia, Anjeso™ alone is not recommended for use when rapid onset of analgesia is required.

Recommended Dose: 30 mg once daily, administered by intravenous bolus injection over 15 seconds. 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: 

G89.0 - Central pain syndrome

G89.11 - Acute pain due to trauma

G89.12 - Acute post-thoracotomy pain

G89.18 - Other acute postprocedural pain

G89.21 - Chronic pain due to trauma

G89.22 - Chronic post-thoracotomy pain

G89.28 - Other chronic postprocedural pain

G89.29 - Other chronic pain

G89.3 - Neoplasm related pain (acute) (chronic)

G89.4 - Chronic pain syndrome

R52 - Pain, unspecified

G56.40 - Causalgia of unspecified upper limb

G56.41 - Causalgia of right upper limb

G56.42 - Causalgia of left upper limb

G56.43 - Causalgia of bilateral upper limbs

57.70 - Causalgia of unspecified lower limb

G57.71 - Causalgia of right lower limb

G57.72 - Causalgia of left lower limb

G57.73 - Causalgia of bilateral lower limbs

G90.50 - Complex regional pain syndrome I, unspecified

G90.511 - Complex regional pain syndrome I of right upper limb

G90.512 - Complex regional pain syndrome I of left upper limb

G90.513 - Complex regional pain syndrome I of upper limb, bilateral

G90.521 - Complex regional pain syndrome I of right lower limb

G90.522 - Complex regional pain syndrome I of left lower limb

G90.523 - Complex regional pain syndrome I of lower limb, bilateral

G90.529 - Complex regional pain syndrome I of unspecified lower limb

G90.59 - Complex regional pain syndrome I of other specified site

K14.6 - Glossodynia

M25.50 - Pain in unspecified joint

M25.511 - Pain in right shoulder

M25.512 - Pain in left shoulder

M25.519 - Pain in unspecified shoulder

M25.521 - Pain in right elbow

M25.522 - Pain in left elbow

M25.529 - Pain in unspecified elbow

M25.531 - Pain in right wrist

M25.532 - Pain in left wrist

M25.539 - Pain in unspecified wrist

M25.541 - Pain in joints of right hand

M25.542 - Pain in joints of left hand

M25.549 - Pain in joints of unspecified hand

M25.551 - Pain in right hip

M25.552 - Pain in left hip

M25.559 - Pain in unspecified hip

M25.561 - Pain in right knee

M25.562 - Pain in left knee

M25.569 - Pain in unspecified knee

M25.571 - Pain in right ankle and joints of right foot

M25.572 - Pain in left ankle and joints of left foot

M25.579 - Pain in unspecified ankle and joints of unspecified foot

M54.2 - Cervicalgia

M54.30 - Sciatica, unspecified side

M54.31 - Sciatica, right side

M54.32 - Sciatica, left side

M54.40 - Lumbago with sciatica, unspecified side

M54.41 - Lumbago with sciatica, right side

M54.42 - Lumbago with sciatica, left side

M54.5 - Low back pain

M54.6 - Pain in thoracic spine

M54.9 - Dorsalgia, unspecified

M77.40 - Metatarsalgia, unspecified foot

M77.41 - Metatarsalgia, right foot

M77.42 - Metatarsalgia, left foot

M79.601 - Pain in right arm

M79.602 - Pain in left arm

M79.603 - Pain in arm, unspecified

M79.604 - Pain in right leg

M79.605 - Pain in left leg

M79.606 - Pain in leg, unspecified

M79.609 - Pain in unspecified limb

M79.676 - Pain in unspecified toe(s)

M79.621 - Pain in right upper arm

M79.622 - Pain in left upper arm

M79.629 - Pain in unspecified upper arm

M79.631 - Pain in right forearm

M79.632 - Pain in left forearm

M79.639 - Pain in unspecified forearm

M79.641 - Pain in right hand

M79.642 - Pain in left hand

M79.643 - Pain in unspecified hand

M79.644 - Pain in right finger(s)

M79.645 - Pain in left finger(s)

M79.646 - Pain in unspecified finger(s)

M79.651 - Pain in right thigh

M79.652 - Pain in left thigh

M79.659 - Pain in unspecified thigh

M79.661 - Pain in right lower leg

M79.662 - Pain in left lower leg

M79.669 - Pain in unspecified lower leg

M79.671 - Pain in right foot

M79.672 - Pain in left foot

M79.673 - Pain in unspecified foot

M79.674 - Pain in right toe(s)

M79.675 - Pain in left toe(s)

M79.676 - Pain in unspecified toe(s)

  • Providers must bill with HCPCS code: J3490 - Unclassified drugs
  • One Medicaid and NC Health Choice unit of coverage is: 30 mg 
  • The maximum reimbursement rate per unit is: $101.52
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 71518-0001-01 
  • 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 Medicaid's website
  • Providers shall bill their usual and customary charge for non-340B drugs
  • PADP reimburses for drugs billed for Medicaid and 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

Contact

NCTracks Contact Center: 800-688-6696