Effective with date of service June 26, 2020, the Medicaid and NC Health Choice programs cover bimatoprost implant, for intracameral administration (Durysta™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.
Strength/Package Size: Intracameral implant containing bimatoprost 10 mcg, in the drug delivery system.
Indicated for the reduction of intraocular pressure (IOP) in patients with open angle glaucoma (OAG) or ocular hypertension (OHT).
Recommended Dose: Durysta™ is an ophthalmic drug delivery system containing 10 mcg of bimatoprost for a single intracameral administration. Durysta™ should not be readministered to an eye that received a prior Durysta™. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
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The ICD-10-CM diagnosis codes required for billing is/are:
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H40.051 |
Ocular hypertension, right eye |
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H40.052 |
Ocular hypertension, left eye |
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H40.053 |
Ocular hypertension, bilateral |
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H40.059 |
Ocular hypertension, unspecified eye |
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H40.10X0 |
Unspecified open-angle glaucoma, stage unspecified |
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H40.10X1 |
Unspecified open-angle glaucoma, mild stage |
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H40.10X2 |
Unspecified open-angle glaucoma, moderate stage |
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H40.10X3 |
Unspecified open-angle glaucoma, severe stage |
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H40.10X4 |
Unspecified open-angle glaucoma, indeterminate stage |
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H40.1110 |
Primary open-angle glaucoma, right eye, stage unspecified |
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H40.1111 |
Primary open-angle glaucoma, right eye, mild stage |
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H40.1112 |
Primary open-angle glaucoma, right eye, moderate stage |
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H40.1113 |
Primary open-angle glaucoma, right eye, severe stage |
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H40.1114 |
Primary open-angle glaucoma, right eye, indeterminate stage |
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H40.1120 |
Primary open-angle glaucoma, left eye, stage unspecified |
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H40.1121 |
Primary open-angle glaucoma, left eye, mild stage |
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H40.1122 |
Primary open-angle glaucoma, left eye, moderate stage |
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H40.1123 |
Primary open-angle glaucoma, left eye, severe stage |
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H40.1124 |
Primary open-angle glaucoma, left eye, indeterminate stage |
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H40.1130 |
Primary open-angle glaucoma, bilateral, stage unspecified |
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H40.1131 |
Primary open-angle glaucoma, bilateral, mild stage |
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H40.1132 |
Primary open-angle glaucoma, bilateral, moderate stage |
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H40.1133 |
Primary open-angle glaucoma, bilateral, severe stage |
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H40.1134 |
Primary open-angle glaucoma, bilateral, indeterminate stage |
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H40.1190 |
Primary open-angle glaucoma, unspecified eye, stage unspecified |
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H40.1191 |
Primary open-angle glaucoma, unspecified eye, mild stage |
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H40.1192 |
Primary open-angle glaucoma, unspecified eye, moderate stage |
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H40.1193 |
Primary open-angle glaucoma, unspecified eye, severe stage |
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H40.1194 |
Primary open-angle glaucoma, unspecified eye, indeterminate stage |
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H40.1310 |
Pigmentary glaucoma, right eye, stage unspecified |
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H40.1311 |
Pigmentary glaucoma, right eye, mild stage |
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H40.1312 |
Pigmentary glaucoma, right eye, moderate stage |
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H40.1313 |
Pigmentary glaucoma, right eye, severe stage |
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H40.1314 |
Pigmentary glaucoma, right eye, indeterminate stage |
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H40.1320 |
Pigmentary glaucoma, left eye, stage unspecified |
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H40.1321 |
Pigmentary glaucoma, left eye, mild stage; |
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H40.1322 |
Pigmentary glaucoma, left eye, moderate stage |
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H40.1323 |
Pigmentary glaucoma, left eye, severe stage |
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H40.1324 |
Pigmentary glaucoma, left eye, indeterminate stage |
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H40.1330 |
Pigmentary glaucoma, bilateral, stage unspecified |
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H40.1331 |
Pigmentary glaucoma, bilateral, mild stage |
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H40.1332 |
Pigmentary glaucoma, bilateral, moderate stage |
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H40.1333 |
Pigmentary glaucoma, bilateral, severe stage |
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H40.1334 |
Pigmentary glaucoma, bilateral, indeterminate stage |
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H40.1390 |
Pigmentary glaucoma, unspecified eye, stage unspecified |
|
H40.1391 |
Pigmentary glaucoma, unspecified eye, mild stage |
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H40.1392 |
Pigmentary glaucoma, unspecified eye, moderate stage |
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H40.1393 |
Pigmentary glaucoma, unspecified eye, severe stage |
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H40.1394 |
Pigmentary glaucoma, unspecified eye, indeterminate stage |
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H40.1410 |
Capsular glaucoma with pseudoexfoliation of lens, right eye, stage unspecified |
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H40.1411 |
Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage |
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H40.1412 |
Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage |
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H40.1413 |
Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage |
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H40.1414 |
Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage |
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H40.1420 |
Capsular glaucoma with pseudoexfoliation of lens, left eye, stage unspecified |
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H40.1421 |
Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage |
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H40.1422 |
Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage |
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H40.1423 |
Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage |
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H40.1424 |
Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage |
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H40.1430 |
Capsular glaucoma with pseudoexfoliation of lens, bilateral, stage unspecified |
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H40.1431 |
Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage |
|
H40.1432 |
Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage |
|
H40.1433 |
Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage |
|
H40.1434 |
Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage |
|
H40.1490 |
Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, stage unspecified |
|
H40.1491 |
Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, mild stage |
|
H40.1492 |
Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, moderate stage |
|
H40.1493 |
Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, severe stage |
|
H40.1494 |
Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, indeterminate stage |
- Providers must bill with HCPCS code: J3490 - Unclassified drugs
- One Medicaid and NC Health Choice unit of coverage is: 1 implant (10 mcg)
- The maximum reimbursement rate per unit is: $2,106.00
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 00023-9652-01
- 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