Famotidine Injection (Pepcid®) HCPCS Code J3490: Billing Guidelines

Tuesday, December 15, 2020

Effective with date of service Jan. 1, 2020, the Medicaid and NC Health Choice programs cover famotidine injection (Pepcid®) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.

Strength/Package Size(s): Famotidine injection, 20 mg piggyback, 20 mg/2 mL single-dose vials, 40 mg/4 mL multi-dose vials, 200 mg/20 mL multi-dose vials, 500 mg/50 mL multi-dose vials

Indicated in some patients with pathological hypersecretory conditions or intractable ulcers, or as an alternative to the oral dosage forms for short term use in patients who are unable to take oral medication for the following conditions:

  1. Short term treatment of active duodenal ulcer. Most adult patients heal within four weeks; there is rarely reason to use famotidine at full dosage for longer than six to eight weeks. Studies have not assessed the safety of famotidine in uncomplicated active duodenal ulcer for periods of more than eight weeks.
  2. Maintenance therapy for duodenal ulcer patients at reduced dosage after healing of an active ulcer. Controlled studies in adults have not extended beyond one year.
  3. Short term treatment of active benign gastric ulcer. Most adult patients heal within 6 weeks. Studies have not assessed the safety or efficacy of famotidine in uncomplicated active benign gastric ulcer for periods of more than eight weeks.
  4. Short term treatment of gastroesophageal reflux disease (GERD). Famotidine is indicated for short term treatment of patients with symptoms of GERD.  
  5. Famotidine is also indicated for the short-term treatment of esophagitis due to GERD including erosive or ulcerative disease diagnosed by endoscopy.
  6. Treatment of pathological hypersecretory conditions (e.g., Zollinger-Ellison Syndrome, multiple endocrine adenomas).

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

  • The recommended dosage in adult patients is 20 mg intravenously q 12 h.
  • Pediatric Patients 1-16 years of age suggest that the starting dose in pediatric patients 1-16 years of age is 0.25 mg/kg intravenously (injected over a period of not less than two minutes or as a 15-minute infusion) q 12 h up to 40 mg/day.

For Medicaid and NC Health Choice Billing

  • The ICD-10-CM diagnosis code(s) required for billing is/are:  
    • E16.4 Increased secretion of gastrin;
    • K21.00 - Gastro-esophageal reflux disease with esophagitis, without bleeding;
    • K21.01 - Gastro-esophageal reflux disease with esophagitis, with bleeding;
    • K21.9 - Gastro-esophageal reflux disease without esophagitis;
    • K25.0 - Acute gastric ulcer with hemorrhage;
    • K25.1 - Acute gastric ulcer with perforation;
    • K25.2 - Acute gastric ulcer with both hemorrhage and perforation;
    • K25.3-  Acute gastric ulcer without hemorrhage or perforation;
    • K25.4 - Chronic or unspecified gastric ulcer with hemorrhage;
    • K25.5 - Chronic or unspecified gastric ulcer with perforation;
    • K25.6 - Chronic or unspecified gastric ulcer with both hemorrhage and perforation;
    • K25.7 - Chronic gastric ulcer without hemorrhage or perforation;
    • K25.9 - Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation;
    • K26.0 - Acute duodenal ulcer with hemorrhage;
    • K26.1 - Acute duodenal ulcer with perforation;
    • K26.2 - Acute duodenal ulcer with both hemorrhage and perforation;
    • K26.3 - Acute duodenal ulcer without hemorrhage or perforation;
    • K26.4 - Chronic or unspecified duodenal ulcer with hemorrhage;
    • K26.5 - Chronic or unspecified duodenal ulcer with perforation;
    • K26.6 - Chronic or unspecified duodenal ulcer with both hemorrhage and perforation;
    • K26.7 - Chronic duodenal ulcer without hemorrhage or perforation;
    • K26.9 - Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
  • Providers must bill with HCPCS code: J3490 - Unclassified drugs
  • One Medicaid and Health Choice unit of coverage is: 1 mg 
  • The maximum reimbursement rate per unit is: $0.04
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is/are: 
    • 00338-5197-41
    • 00641-6021-01
    • 00641-6021-10
    • 00641-6022-01
    • 00641-6022-25
    • 00641-6023-01
    • 00641-6023-25
    • 63323-0738-03
    • 63323-0738-09
    • 63323-0738-20
    • 63323-0739-11 
    • 63323-0739-12
    • 63323-0739-16
    • 67457-0433-00
    • 67457-0433-22
    • 67457-0448-00
    • 67457-0448-43
    • 67457-0457-00
    • 67457-0457-20
  • 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