Effective with date of service July 1, 2021, the Medicaid and NC Health Choice programs cover bupivacaine and meloxicam extended-release solution, for soft tissue or periarticular instillation use (Zynrelef™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.
Zynrelef™ is available in two dosage strengths as single-dose glass vials:
- 400 mg bupivacaine and 12 mg meloxicam
- 200 mg bupivacaine and 6 mg meloxicam
Zynrelef™ is indicated in adults for soft tissue or periarticular instillation to produce postsurgical analgesia for up to 72 hours after bunionectomy, open inguinal herniorrhaphy and total knee arthroplasty. Safety and efficacy have not been established in highly vascular surgeries, such as intrathoracic, large multilevel spinal, and head and neck procedures.
Recommended Dose (See full prescribing information for further detail):
- Bunionectomy: up to 2.3 mL to deliver 60 mg/1.8 mg
- Open inguinal herniorrhaphy: up to 10.5 mL to deliver 300 mg/9 mg
- Total knee arthroplasty: up to 14 mL to deliver 400 mg/12 mg
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code(s) required for billing are:
K40.00 - Bilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent;
K40.01 - Bilateral inguinal hernia, with obstruction, without gangrene, recurrent;
K40.10 - Bilateral inguinal hernia, with gangrene, not specified as recurrent;
K40.11 - Bilateral inguinal hernia, with gangrene, recurrent;
K40.20 - Bilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent;
K40.21 - Bilateral inguinal hernia, without obstruction or gangrene, recurrent;
K40.30 - Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent;
K40.31 - Unilateral inguinal hernia, with obstruction, without gangrene, recurrent;
K40.40 - Unilateral inguinal hernia, with gangrene, not specified as recurrent;
K40.41 - Unilateral inguinal hernia, with gangrene, recurrent;
K40.90 - Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent;
K40.91 - Unilateral inguinal hernia, without obstruction or gangrene, recurrent;
M13.861 - Other specified arthritis, right knee;
M13.862 - Other specified arthritis, left knee;
M13.869 - Other specified arthritis, unspecified knee;
M20.10 - Hallux valgus (acquired), unspecified foot;
M20.11 - Hallux valgus (acquired), right foot;
M20.12 - Hallux valgus (acquired), left foot;
M21.611 - Bunion of right foot;
M21.612 - Bunion of left foot;
M21.619 - Bunion of unspecified foot;
- Providers must bill with HCPCS code: J3490 - Unclassified drugs
- One Medicaid and NC Health Choice unit of coverage is: 1 mL
- The maximum reimbursement rate per unit is: $20.64
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are:47426-0301-02, 47426-0303-01
- The NDC units should be reported as “UN1”
- For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update and 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 NC Medicaid's PADP webpage.
Contact
NCTracks Call Center: 800-688-6696