Infliximab-axxq for Injection, for Intravenous use (Avsola™) HCPCS code Q5121: Billing Guidelines

Tuesday, October 13, 2020

Effective with date of service Sept. 11, 2020, the Medicaid and NC Health Choice programs cover infliximab-axxq for injection, for intravenous use (Avsola) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code Q5121 - Injection, infliximab-axxq, biosimilar, (avsola), 10 mg.

Strength/Package Size:  For injection: 100 mg of lyophilized infliximab-axxq in a 20 mL single-dose vial for intravenous infusion.

Indicated for:
 

Crohn’s Disease:

  • reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy.
  • reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing disease.

Pediatric Crohn’s Disease:

  • reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients with moderately to severely active disease who have had an inadequate response to conventional therapy.

Ulcerative Colitis:

  • reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy.

Pediatric Ulcerative Colitis:

  • reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients with moderately to severely active disease who have had an inadequate response to conventional therapy.

Rheumatoid Arthritis in combination with methotrexate:

  • reducing signs and symptoms, inhibiting the progression of structural damage, and improving physical function in patients with moderately to severely active disease.

Ankylosing Spondylitis:

  • reducing signs and symptoms in patients with active disease.

Psoriatic Arthritis:

  • reducing signs and symptoms of active arthritis, inhibiting the progression of structural damage, and improving physical function.

Plaque Psoriasis:

  • treatment of adult patients with chronic severe (i.e., extensive and/or disabling) plaque psoriasis who are candidates for systemic therapy and when other systemic therapies are medically less appropriate.

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

Crohn’s Disease:

  • 5 mg/kg at 0, 2 and 6 weeks, then every 8 weeks. Some adult patients who initially respond to treatment may benefit from increasing the dose to 10 mg/kg if they later lose their response.

Rheumatoid Arthritis:

  • In conjunction with methotrexate, 3 mg/kg at 0, 2 and 6 weeks, then every 8 weeks. Some patients may benefit from increasing the dose up to 10 mg/kg or treating as often as every 4 weeks.

Ankylosing Spondylitis:

  • 5 mg/kg at 0, 2 and 6 weeks, then every 6 weeks.

Pediatric Crohn’s Disease, Ulcerative Colitis, Pediatric Ulcerative Colitis, Psoriatic Arthritis and Plaque Psoriasis:

  • 5 mg/kg at 0, 2 and 6 weeks, then every 8 weeks.
     

For Medicaid and NC Health Choice Billing

The ICD-10-CM diagnosis codes required for billing are: 

Crohn's Disease:
K50.00 - Crohn's disease of small intestine without complications; K50.011 - Crohn's disease of small intestine with rectal bleeding;
K50.012 - Crohn's disease of small intestine with intestinal obstruction; K50.013 - Crohn's disease of small intestine with fistula; K50.014 - Crohn's disease of small intestine with abscess; K50.018 - Crohn's disease of small intestine with other complication; K50.019 - Crohn's disease of small intestine with unspecified complications; K50.10 - Crohn's disease of large intestine without complications; K50.111 - Crohn's disease of large intestine with rectal bleeding; K50.112 - Crohn's disease of large intestine with intestinal obstruction; K50.113 - Crohn's disease of large intestine with fistula; K50.114 - Crohn's disease of large intestine with abscess; K50.118 - Crohn's disease of large intestine with other complication; K50.119 - Crohn's disease of large intestine with unspecified complications; K50.80 - Crohn's disease of both small and large intestine without complications; K50.811 - Crohn's disease of both small and large intestine with rectal bleeding; K50.812 - Crohn's disease of both small and large intestine with intestinal obstruction; K50.813 - Crohn's disease of both small and large intestine with fistula; K50.814 - Crohn's disease of both small and large intestine with abscess; K50.818 - Crohn's disease of both small and large intestine with other complication; K50.819 - Crohn's disease of both small and large intestine with unspecified complications; K50.90 - Crohn's disease, unspecified, without complications; K50.911 - Crohn's disease, unspecified, with rectal bleeding; K50.912 - Crohn's disease, unspecified, with intestinal obstruction; K50.913 - Crohn's disease, unspecified, with fistula; K50.914 - Crohn's disease, unspecified, with abscess; K50.918 - Crohn's disease, unspecified, with other complication; K50.919 - Crohn's disease, unspecified, with unspecified complications; Can be used in addition to code for Crohn's disease:  K60.3 - Anal fistula; K60.4 - Rectal fistula

Ulcerative Colitis:

K51.00 - Ulcerative (chronic) pancolitis without complications; K51.011 - Ulcerative (chronic) pancolitis with rectal bleeding;
K51.012 - Ulcerative (chronic) pancolitis with intestinal obstruction; K51.013 - Ulcerative (chronic) pancolitis with fistula; K51.014 - Ulcerative (chronic) pancolitis with abscess; K51.018 - Ulcerative (chronic) pancolitis with other complication; K51.019 - Ulcerative (chronic) pancolitis with unspecified complications; K51.20 - Ulcerative (chronic) proctitis without complications; K51.211 - Ulcerative (chronic) proctitis with rectal bleeding; K51.212 - Ulcerative (chronic) proctitis with intestinal obstruction; K51.213 - Ulcerative (chronic) proctitis with fistula; K51.214 - Ulcerative (chronic) proctitis with abscess; K51.218 - Ulcerative (chronic) proctitis with other complication; K51.219 - Ulcerative (chronic) proctitis with unspecified complications; K51.30 - Ulcerative (chronic) rectosigmoiditis without complications; K51.311 - Ulcerative (chronic) rectosigmoiditis with rectal bleeding; K51.312 - Ulcerative (chronic) rectosigmoiditis with intestinal obstruction; K51.313 - Ulcerative (chronic) rectosigmoiditis with fistula; K51.314 - Ulcerative (chronic) rectosigmoiditis with abscess; K51.318 - Ulcerative (chronic) rectosigmoiditis with other complication; K51.319 - Ulcerative (chronic) rectosigmoiditis with unspecified complications; K51.50 - Left sided colitis without complications; K51.511 - Left sided colitis with rectal bleeding; K51.512 - Left sided colitis with intestinal obstruction; K51.513 - Left sided colitis with fistula; K51.514 - Left sided colitis with abscess; K51.518 - Left sided colitis with other complication; K51.519 - Left sided colitis with unspecified complications; K51.80 - Other ulcerative colitis without complications; K51.811 - Other ulcerative colitis with rectal bleeding; K51.812 - Other ulcerative colitis with intestinal obstruction; K51.813 - Other ulcerative colitis with fistula; K51.814 - Other ulcerative colitis with abscess; K51.818 - Other ulcerative colitis with other complication; K51.819 - Other ulcerative colitis with unspecified complications; K51.90 - Ulcerative colitis, unspecified without complications; K51.911 - Ulcerative colitis, unspecified with rectal bleeding; K51.912 - Ulcerative colitis, unspecified with intestinal obstruction; K51.913 - Ulcerative colitis, unspecified with fistula; K51.914 - Ulcerative colitis, unspecified with abscess; K51.918 - Ulcerative colitis, unspecified with other complication; K51.919 - Ulcerative colitis, unspecified with unspecified complications

RA:
M05.00 - Felty's syndrome, unspecified site; M05.011 - Felty's syndrome, right shoulder; M05.012 - Felty's syndrome, left shoulder; M05.019 - Felty's syndrome, unspecified shoulder; M05.021 - Felty's syndrome, right elbow; M05.022 - Felty's syndrome, left elbow; M05.029 - Felty's syndrome, unspecified elbow; M05.031 - Felty's syndrome, right wrist; M05.032 - Felty's syndrome, left wrist; M05.039 - Felty's syndrome, unspecified wrist; M05.041 - Felty's syndrome, right hand; M05.042 - Felty's syndrome, left hand; M05.049 - Felty's syndrome, unspecified hand; M05.051 - Felty's syndrome, right hip; M05.052 - Felty's syndrome, left hip; M05.059 - Felty's syndrome, unspecified hip; M05.061 Felty's syndrome, right knee; M05.062 - Felty's syndrome, left knee; M05.069 - Felty's syndrome, unspecified knee; M05.071 - Felty's syndrome, right ankle and foot; M05.072 - Felty's syndrome, left ankle and foot; M05.079 - Felty's syndrome, unspecified ankle and foot; M05.09 - Felty's syndrome, multiple sites; M05.60 - Rheumatoid arthritis of unspecified site with involvement of other organs and systems; M05.611 - Rheumatoid arthritis of right shoulder with involvement of other organs and systems; M05.612 - Rheumatoid arthritis of left shoulder with involvement of other organs and systems; M05.619 - Rheumatoid arthritis of unspecified shoulder with involvement of other organs/systems; M05.621 - Rheumatoid arthritis of right elbow with involvement of other organs and systems; M05.622 - Rheumatoid arthritis of left elbow with involvement of other organs and systems; M05.629 - Rheumatoid arthritis of unspecified elbow with involvement of other organs/systems; M05.631 - Rheumatoid arthritis of right wrist with involvement of other organs and systems; M05.632 - Rheumatoid arthritis of left wrist with involvement of other organs and systems; M05.639 - Rheumatoid arthritis of unspecified wrist with involvement of other organs and systems; M05.641 - Rheumatoid arthritis of right hand with involvement of other organs and systems; M05.642 - Rheumatoid arthritis of left hand with involvement of other organs and systems; M05.649 - Rheumatoid arthritis of unspecified hand with involvement of other organs and systems; M05.651 - Rheumatoid arthritis of right hip with involvement of other organs and systems; M05.652 - Rheumatoid arthritis of left hip with involvement of other organs and systems; M05.659 - Rheumatoid arthritis of unspecified hip with involvement of other organs and systems; M05.661 - Rheumatoid arthritis of right knee with involvement of other organs and systems; M05.662 - Rheumatoid arthritis of left knee with involvement of other organs and systems; M05.669 - Rheumatoid arthritis of unspecified knee with involvement of other organs and systems; M05.671 - Rheumatoid arthritis of right ankle and foot with involvement of other organs/systems; M05.672 - Rheumatoid arthritis of left ankle and foot with involvement of other organs/systems; M05.679 - Rheumatoid arthritis of unspecified ankle/foot with involvement of other organs/systems; M05.69 - Rheumatoid arthritis of multiple sites with involvement of other organs and systems; M05.70 - Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or systems involvement; M05.711 - Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement; M05.712 - Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement; M05.719 - Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or systems involvement; M05.721 - Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement; M05.722 - Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement;   M05.729 - Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or systems involvement; M05.731 - Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement; M05.732 - Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement; M05.739 - - Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems involvement; M05.741 - Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement; M05.742 - Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement; M05.749 - Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems involvement; M05.751 - Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement; M05.752 - Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement; M05.759 - Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems involvement; M05.761-  Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement; M05.762 - Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement; M05.769 - Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement; M05.771 - Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement; M05.772 - Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement; M05.779 - Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement; M05.79 - Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement; M05.80 - Other rheumatoid arthritis with rheumatoid factor of unspecified site; M05.811 - Other rheumatoid arthritis with rheumatoid factor of right shoulder; M05.812 - Other rheumatoid arthritis with rheumatoid factor of left shoulder; M05.819 - Other rheumatoid arthritis with rheumatoid factor of unspecified shoulder; M05.821 - Other rheumatoid arthritis with rheumatoid factor of right elbow; M05.822 - Other rheumatoid arthritis with rheumatoid factor of left elbow; M05.829 - Other rheumatoid arthritis with rheumatoid factor of unspecified elbow; M05.831 - Other rheumatoid arthritis with rheumatoid factor of right wrist; M05.832 - Other rheumatoid arthritis with rheumatoid factor of left wrist; M05.839 - Other rheumatoid arthritis with rheumatoid factor of unspecified wrist; M05.841 - Other rheumatoid arthritis with rheumatoid factor of right hand; M05.842 - Other rheumatoid arthritis with rheumatoid factor of left hand; M05.849 - Other rheumatoid arthritis with rheumatoid factor of unspecified hand; M05.851 - Other rheumatoid arthritis with rheumatoid factor of right hip; M05.852 - Other rheumatoid arthritis with rheumatoid factor of left hip; M05.859 - Other rheumatoid arthritis with rheumatoid factor of unspecified hip; M05.861 - Other rheumatoid arthritis with rheumatoid factor of right knee; M05.862 - Other rheumatoid arthritis with rheumatoid factor of left knee; M05.869 - Other rheumatoid arthritis with rheumatoid factor of unspecified knee; M05.871 - Other rheumatoid arthritis with rheumatoid factor of right ankle and foot; M05.872 - Other rheumatoid arthritis with rheumatoid factor of left ankle and foot; M05.879 - Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot; M05.89 - Other rheumatoid arthritis with rheumatoid factor of multiple sites; M05.9 - Rheumatoid arthritis with rheumatoid factor, unspecified; M06.00 - Rheumatoid arthritis without rheumatoid factor, unspecified site; M06.011 - Rheumatoid arthritis without rheumatoid factor, right shoulder; M06.012 - Rheumatoid arthritis without rheumatoid factor, left shoulder; M06.019 - Rheumatoid arthritis without rheumatoid factor, unspecified shoulder; M06.021 - Rheumatoid arthritis without rheumatoid factor, right elbow; M06.022 - Rheumatoid arthritis without rheumatoid factor, left elbow; M06.029 - Rheumatoid arthritis without rheumatoid factor, unspecified elbow; M06.031 - Rheumatoid arthritis without rheumatoid factor, right wrist; M06.032 - Rheumatoid arthritis without rheumatoid factor, left wrist; M06.039 - Rheumatoid arthritis without rheumatoid factor, unspecified wrist; M06.041 - Rheumatoid arthritis without rheumatoid factor, right hand; M06.042 - Rheumatoid arthritis without rheumatoid factor, left hand; M06.049 - Rheumatoid arthritis without rheumatoid factor, unspecified hand; M06.051 - Rheumatoid arthritis without rheumatoid factor, right hip; M06.052 - Rheumatoid arthritis without rheumatoid factor, left hip; M06.059 - Rheumatoid arthritis without rheumatoid factor, unspecified hip; M06.061 - Rheumatoid arthritis without rheumatoid factor, right knee; M06.062 - Rheumatoid arthritis without rheumatoid factor, left knee; M06.069 - Rheumatoid arthritis without rheumatoid factor, unspecified knee; M06.071 - Rheumatoid arthritis without rheumatoid factor, right ankle and foot; M06.072 - Rheumatoid arthritis without rheumatoid factor, left ankle and foot; M06.079 - Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot; M06.08 - Rheumatoid arthritis without rheumatoid factor, vertebrae; M06.09 - Rheumatoid arthritis without rheumatoid factor, multiple sites; M06.80 - Other specified rheumatoid arthritis unspecified site; M06.811 - Other specified rheumatoid arthritis, right shoulder; M06.812 - Other specified rheumatoid arthritis, left shoulder; M06.819 - Other specified rheumatoid arthritis, unspecified shoulder; M06.821 - Other specified rheumatoid arthritis, right elbow; M06.822 - Other specified rheumatoid arthritis, left elbow; M06.829 - Other specified rheumatoid arthritis, unspecified elbow; M06.831 - Other specified rheumatoid arthritis, right wrist; M06.832 - Other specified rheumatoid arthritis, left wrist; M06.839 - Other specified rheumatoid arthritis, unspecified wrist; M06.841 - Other specified rheumatoid arthritis, right hand; M06.842 - Other specified rheumatoid arthritis, left hand; M06.849 - Other specified rheumatoid arthritis, unspecified hand; M06.851 - Other specified rheumatoid arthritis, right hip; M06.852 - Other specified rheumatoid arthritis, left hip; M06.859 - Other specified rheumatoid arthritis, unspecified hip; M06.861 - Other specified rheumatoid arthritis, right knee; M06.862 - Other specified rheumatoid arthritis, left knee; M06.869 - Other specified rheumatoid arthritis, unspecified knee; M06.871 - Other specified rheumatoid arthritis, right ankle and foot; M06.872 - Other specified rheumatoid arthritis, left ankle and foot; M06.879 - Other specified rheumatoid arthritis, unspecified ankle and foot; M06.88 - Other specified rheumatoid arthritis, vertebrae; M06.89 - Other specified rheumatoid arthritis, multiple sites; M06.9 Rheumatoid arthritis, unspecified

Ankylosing Spondylitis:
M45.0 - Ankylosing spondylitis of multiple sites in spine; M45.1 - Ankylosing spondylitis of occipito-atlanto-axial region; M45.2 - Ankylosing spondylitis of cervical region; M45.3 - Ankylosing spondylitis of cervicothoracic region; M45.4 - Ankylosing spondylitis of thoracic region; M45.5 - Ankylosing spondylitis of thoracolumbar region; M45.6 - Ankylosing spondylitis lumbar region; M45.7 - Ankylosing spondylitis of lumbosacral region; M45.8 - Ankylosing spondylitis sacral and sacrococcygeal region; M45.9 - Ankylosing spondylitis of unspecified sites in spine

Psoriatic Arthritis:

L40.50 - Arthropathic psoriasis, unspecified; L40.51 - Distal interphalangeal psoriatic arthropathy; L40.52 - Psoriatic arthritis mutilans; L40.53 - Psoriatic spondylitis; L40.59 - Other psoriatic arthropathy

Plaque Psoriasis:
L40.0 - Psoriasis vulgaris

  • Providers must bill with HCPCS code: Q5121 - Injection, infliximab-axxq, biosimilar, (avsola), 10 mg
  • One Medicaid and Health Choice unit of coverage is: 10 mg
  • The maximum reimbursement rate per unit is: $51.50
  • Providers must bill 11-digit NDCs and appropriate NDC units.  The NDC(s) is/are: 55513-0670-01
  • 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 NC 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 DHB's PADP web page.

Contact
NCTracks Contact Center: 800-688-6696