Effective with date of service July 8, 2021, the Medicaid and NC Health Choice programs cover oritavancin for injection, for intravenous use (Kimyrsa™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs. It is available as 1,200 mg of lyophilized powder in a single-dose vial for reconstitution.
Kimyrsa™ is indicated for the treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible isolates of the following Gram-positive microorganisms: Staphylococcus aureus (including methicillin-susceptible and methicillin-resistant isolates), Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus dysgalactiae, Streptococcus anginosus group (includes S. anginosus, S. intermedius, and S. constellatus), and Enterococcus faecalis (vancomycin-susceptible isolates only). To reduce the development of drug-resistant bacteria and maintain the effectiveness of Kimyrsa™ and other antibacterial drugs, Kimyrsa™ should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.
Recommended Dose: 1,200 mg of Kimyrsa™ as a single dose by intravenous infusion over 1 hour. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code(s) required for billing is/are:
A46 - Erysipelas;
A49.01 - Methicillin susceptible Staphylococcus aureus infection, unspecified site;
A49.02 - Methicillin resistant Staphylococcus aureus infection, unspecified site;
A49.1 - Streptococcal infection, unspecified site;
H00.031 - Abscess of right upper eyelid;
H00.032 - Abscess of right lower eyelid;
H00.033 - Abscess of eyelid right eye, unspecified eyelid;
H00.034 - Abscess of left upper eyelid;
H00.035 - Abscess of left lower eyelid;
H00.036 - Abscess of eyelid left eye, unspecified eyelid;
H00.039 - Abscess of eyelid unspecified eye, unspecified eyelid;
H05.011 - Cellulitis of right orbit;
H05.012 - Cellulitis of left orbit;
H05.013 - Cellulitis of bilateral orbits;
H05.019 - Cellulitis of unspecified orbit;
H60.00 - Abscess of external ear, unspecified ear;
H60.01 - Abscess of right external ear;
H60.02 - Abscess of left external ear;
H60.03 - Abscess of external ear, bilateral;
H60.10 - Cellulitis of external ear, unspecified ear;
H60.11 - Cellulitis of right external ear;
H60.12 - Cellulitis of left external ear;
H60.13 - Cellulitis of external ear, bilateral;
J34.0 - Abscess, furuncle and carbuncle of nose;
J36 - Peritonsillar abscess;
K11.3 - Abscess of salivary gland;
K12.2 - Cellulitis and abscess of mouth;
K61.0 - Anal abscess;
K61.1 - Rectal abscess;
K61.2 - Anorectal abscess;
K61.31 - Horseshoe abscess;
K61.39 - Other ischiorectal abscess;
K61.4 - Intrasphincteric abscess;
K61.5 - Supralevator abscess;
L00 - Staphylococcal scalded skin syndrome;
L01.00 - Impetigo, unspecified;
L01.01 - Non-bullous impetigo;
L01.02 - Bockhart's impetigo;
L01.03 - Bullous impetigo;
L01.09 - Other impetigo;
L01.1 - Impetiginization of other dermatoses;
L02.01 - Cutaneous abscess of face;
L02.02 - Furuncle of face;
L02.03 - Carbuncle of face;
L02.11 - Cutaneous abscess of neck;
L02.12 - Furuncle of neck;
L02.13 - Carbuncle of neck;
L02.211 - Cutaneous abscess of abdominal wall;
L02.212 - Cutaneous abscess of back [any part, except buttock];
L02.213 - Cutaneous abscess of chest wall;
L02.214 - Cutaneous abscess of groin;
L02.215 - Cutaneous abscess of perineum;
L02.216 - Cutaneous abscess of umbilicus;
L02.219 - Cutaneous abscess of trunk, unspecified;
L02.221 - Furuncle of abdominal wall;
L02.222 - Furuncle of back [any part, except buttock];
L02.223 - Furuncle of chest wall;
L02.224 - Furuncle of groin;
L02.225 - Furuncle of perineum;
L02.226 - Furuncle of umbilicus;
L02.229 - Furuncle of trunk, unspecified;
L02.231 - Carbuncle of abdominal wall;
L02.232 - Carbuncle of back [any part, except buttock];
L02.233 - Carbuncle of chest wall;
L02.234 - Carbuncle of groin;
L02.235 - Carbuncle of perineum;
L02.236 - Carbuncle of umbilicus;
L02.239 - Carbuncle of trunk, unspecified;
L02.31 - Cutaneous abscess of buttock;
L02.32 - Furuncle of buttock;
L02.33 - Carbuncle of buttock;
L02.411 - Cutaneous abscess of right axilla;
L02.412 - Cutaneous abscess of left axilla;
L02.413 - Cutaneous abscess of right upper limb;
L02.414 - Cutaneous abscess of left upper limb;
L02.415 - Cutaneous abscess of right lower limb;
L02.416 - Cutaneous abscess of left lower limb;
L02.419 - Cutaneous abscess of limb, unspecified;
L02.421 - Furuncle of right axilla;
L02.422 - Furuncle of left axilla;
L02.423 - Furuncle of right upper limb;
L02.424 - Furuncle of left upper limb;
L02.425 - Furuncle of right lower limb;
L02.426 - Furuncle of left lower limb;
L02.429 - Furuncle of limb, unspecified;
L02.431 - Carbuncle of right axilla;
L02.432 - Carbuncle of left axilla;
L02.433 - Carbuncle of right upper limb;
L02.434 - Carbuncle of left upper limb;
L02.435 - Carbuncle of right lower limb;
L02.436 - Carbuncle of left lower limb;
L02.439 - Carbuncle of limb, unspecified;
L02.511 - Cutaneous abscess of right hand;
L02.512 - Cutaneous abscess of left hand;
L02.519 - Cutaneous abscess of unspecified hand;
L02.521 - Furuncle right hand;
L02.522 - Furuncle left hand;
L02.529 - Furuncle unspecified hand;
L02.531 - Carbuncle of right hand;
L02.532 - Carbuncle of left hand;
L02.539 - Carbuncle of unspecified hand;
L02.611 - Cutaneous abscess of right foot;
L02.612 - Cutaneous abscess of left foot;
L02.619 - Cutaneous abscess of unspecified foot;
L02.621 - Furuncle of right foot;
L02.622 - Furuncle of left foot;
L02.629 - Furuncle of unspecified foot;
L02.631 - Carbuncle of right foot;
L02.632 - Carbuncle of left foot;
L02.639 - Carbuncle of unspecified foot;
L02.811 - Cutaneous abscess of head [any part, except face];
L02.818 - Cutaneous abscess of other sites;
L02.821 - Furuncle of head [any part, except face];
L02.828 - Furuncle of other sites;
L02.831 - Carbuncle of head [any part, except face];
L02.838 - Carbuncle of other sites;
L02.91 - Cutaneous abscess, unspecified;
L02.92 - Furuncle, unspecified;
L02.93 - Carbuncle, unspecified;
L03.011 - Cellulitis of right finger;
L03.012 - Cellulitis of left finger;
L03.019 - Cellulitis of unspecified finger;
L03.021 - Acute lymphangitis of right finger;
L03.022 - Acute lymphangitis of left finger;
L03.029 - Acute lymphangitis of unspecified finger;
L03.031 - Cellulitis of right toe;
L03.032 - Cellulitis of left toe;
L03.039 - Cellulitis of unspecified toe;
L03.041 - Acute lymphangitis of right toe;
L03.042 - Acute lymphangitis of left toe;
L03.049 - Acute lymphangitis of unspecified toe;
L03.111 - Cellulitis of right axilla;
L03.112 - Cellulitis of left axilla;
L03.113 - Cellulitis of right upper limb;
L03.114 - Cellulitis of left upper limb;
L03.115 - Cellulitis of right lower limb;
L03.116 - Cellulitis of left lower limb;
L03.119 - Cellulitis of unspecified part of limb;
L03.121 - Acute lymphangitis of right axilla;
L03.122 - Acute lymphangitis of left axilla;
L03.123 - Acute lymphangitis of right upper limb;
L03.124 - Acute lymphangitis of left upper limb;
L03.125 - Acute lymphangitis of right lower limb;
L03.126 - Acute lymphangitis of left lower limb;
L03.129 - Acute lymphangitis of unspecified part of limb;
L03.211 - Cellulitis of face;
L03.212 - Acute lymphangitis of face;
L03.213 - Periorbital cellulitis;
L03.221 - Cellulitis of neck;
L03.222 - Acute lymphangitis of neck;
L03.311 - Cellulitis of abdominal wall;
L03.312 - Cellulitis of back [any part except buttock];
L03.313 - Cellulitis of chest wall;
L03.314 - Cellulitis of groin;
L03.315 - Cellulitis of perineum;
L03.316 - Cellulitis of umbilicus;
L03.317 - Cellulitis of buttock;
L03.319 - Cellulitis of trunk, unspecified;
L03.321 - Acute lymphangitis of abdominal wall;
L03.322 - Acute lymphangitis of back [any part except buttock];
L03.323 - Acute lymphangitis of chest wall;
L03.324 - Acute lymphangitis of groin;
L03.325 - Acute lymphangitis of perineum;
L03.326 - Acute lymphangitis of umbilicus;
L03.327 - Acute lymphangitis of buttock;
L03.329 - Acute lymphangitis of trunk, unspecified;
L03.811 - Cellulitis of head [any part, except face];
L03.818 - Cellulitis of other sites;
L03.891 - Acute lymphangitis of head [any part, except face];
L03.898 - Acute lymphangitis of other sites;
L03.90 - Cellulitis, unspecified;
L03.91 - Acute lymphangitis, unspecified;
L04.0 - Acute lymphadenitis of face, head and neck;
L04.1 - Acute lymphadenitis of trunk;
L04.2 - Acute lymphadenitis of upper limb;
L04.3 - Acute lymphadenitis of lower limb;
L04.8 - Acute lymphadenitis of other sites;
L04.9 - Acute lymphadenitis, unspecified;
L05.01 - Pilonidal cyst with abscess;
L05.02 - Pilonidal sinus with abscess;
L05.91 - Pilonidal cyst without abscess;
L05.92 - Pilonidal sinus without abscess;
L08.0 - Pyoderma;
L08.1 - Erythrasma;
L08.81 - Pyoderma vegetans;
L08.82 - Omphalitis not of newborn;
L08.89 - Other specified local infections of the skin and subcutaneous tissue;
L08.9 - Local infection of the skin and subcutaneous tissue, unspecified;
L88 - Pyoderma gangrenosum;
L98.0 - Pyogenic granuloma;
N48.21 - Abscess of corpus cavernosum and penis;
N48.22 - Cellulitis of corpus cavernosum and penis;
N61.0 - Mastitis without abscess;
N61.1 - Abscess of the breast and nipple;
N76.4 - Abscess of vulva;
O91.011 - Infection of nipple associated with pregnancy, first trimester;
O91.012 - Infection of nipple associated with pregnancy, second trimester;
O91.013 - Infection of nipple associated with pregnancy, third trimester;
O91.019 - Infection of nipple associated with pregnancy, unspecified trimester;
O91.111 - Abscess of breast associated with pregnancy, first trimester;
O91.112 - Abscess of breast associated with pregnancy, second trimester;
O91.113 - Abscess of breast associated with pregnancy, third trimester;
O91.119 - Abscess of breast associated with pregnancy, unspecified trimester;
O91.12 - Abscess of breast associated with the puerperium;
O91.13 - Abscess of breast associated with lactation;
O91.211 - Nonpurulent mastitis associated with pregnancy, first trimester;
O91.212 - Nonpurulent mastitis associated with pregnancy, second trimester;
O91.213 - Nonpurulent mastitis associated with pregnancy, third trimester;
O91.219 - Nonpurulent mastitis associated with pregnancy, unspecified trimester;
O91.22 - Nonpurulent mastitis associated with the puerperium;
O91.23 - Nonpurulent mastitis associated with lactation;
B95.0 - Streptococcus, group A, as the cause of diseases classified elsewhere;
B95.1 - Streptococcus, group B, as the cause of diseases classified elsewhere;
B95.2 - Enterococcus as the cause of diseases classified elsewhere;
B95.4 - Other streptococcus as the cause of diseases classified elsewhere;
B95.5 - Unspecified streptococcus as the cause of diseases classified elsewhere;
B95.61 - Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere;
B95.62 - Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere;
B95.7 - Other staphylococcus as the cause of diseases classified elsewhere;
B95.8 - Unspecified staphylococcus as the cause of diseases classified elsewhere
- Providers must bill with HCPCS code: J3490 - Unclassified drugs
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $4.40
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is:70842-0225-01
- 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