Pegfilgrastim-apgf Injection, for Subcutaneous Use (Nyvepria™) HCPCS Code Q5122: Billing Guidelines

Tuesday, January 5, 2021

Effective with date of service Jan 1, 2021, the Medicaid and NC Health Choice programs cover pegfilgrastim-apgf injection, for subcutaneous use (Nyvepria™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code Q5122 - Injection, pegfilgrastim-apgf, biosimilar, (nyvepria), 0.5 mg.

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 non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia. Nyvepria™ 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): 

  • 6 mg administered subcutaneously once per chemotherapy cycle.
  • Use weight-based dosing for pediatric patients weighing less than 45 kg:
    • Less than 10 kg: 0.1 mg/kg (0.01 mL/kg) of Nyvepria™
    • 10 - 20 kg: 1.5 mg (0.15 mL)
    • 21 - 30 kg: 2.5 mg (0.25 mL)
    • 31 - 44 kg: 4 mg (0.4 mL)

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: Q5122 
  • One Medicaid and NC Health Choice unit of coverage is: 0.5 mg 
  • The maximum reimbursement rate per unit is: $353.25
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is:00069-0324-01 
  • 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