Effective with date of service Jan. 27, 2022, the Medicaid and NC Health Choice programs cover triamcinolone acetonide injectable suspension, for suprachoroidal use (Xipere™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.
Strength/Package Sizes: Injectable suspension: triamcinolone acetonide 40 mg/mL in a single-dose vial
Indicated for the treatment of macular edema associated with uveitis.
Recommended Dose: 4 mg (0.1 mL) administered as a suprachoroidal injection. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
- H20.011 - Primary iridocyclitis, right eye;
- H20.012 - Primary iridocyclitis, left eye;
- H20.013 - Primary iridocyclitis, bilateral;
- H20.021 - Recurrent acute iridocyclitis, right eye;
- H20.022 - Recurrent acute iridocyclitis, left eye;
- H20.023 - Recurrent acute iridocyclitis, bilateral;
- H20.031 - Secondary infectious iridocyclitis, right eye;
- H20.032 - Secondary infectious iridocyclitis, left eye;
- H20.033 - Secondary infectious iridocyclitis, bilateral;
- H20.041 - Secondary noninfectious iridocyclitis, right eye;
- H20.042 - Secondary noninfectious iridocyclitis, left eye;
- H20.043 - Secondary noninfectious iridocyclitis, bilateral;
- H20.11 - Chronic iridocyclitis, right eye;
- H20.12 - Chronic iridocyclitis, left eye;
- H20.13 - Chronic iridocyclitis, bilateral;
- H20.21 - Lens-induced iridocyclitis, right eye;
- H20.22 - Lens-induced iridocyclitis, left eye;
- H20.23 - Lens-induced iridocyclitis, bilateral;
- H20.821 - Vogt-Koyanagi syndrome, right eye;
- H20.822 - Vogt-Koyanagi syndrome, left eye;
- H20.823 - Vogt-Koyanagi syndrome, bilateral;
- H30.001 - Unspecified focal chorioretinal inflammation, right eye;
- H30.002 - Unspecified focal chorioretinal inflammation, left eye;
- H30.003 - Unspecified focal chorioretinal inflammation, bilateral;
- H30.011 - Focal chorioretinal inflammation, juxtapapillary, right eye;
- H30.012 - Focal chorioretinal inflammation, juxtapapillary, left eye;
- H30.013 - Focal chorioretinal inflammation, juxtapapillary, bilateral;
- H30.021 - Focal chorioretinal inflammation of posterior pole, right eye;
- H30.022 - Focal chorioretinal inflammation of posterior pole, left eye;
- H30.023 - Focal chorioretinal inflammation of posterior pole, bilateral;
- H30.031 - Focal chorioretinal inflammation, peripheral, right eye;
- H30.032 - Focal chorioretinal inflammation, peripheral, left eye;
- H30.033 - Focal chorioretinal inflammation, peripheral, bilateral;
- H30.041 - Focal chorioretinal inflammation, macular or paramacular, right eye;
- H30.042 - Focal chorioretinal inflammation, macular or paramacular, left eye;
- H30.043 - Focal chorioretinal inflammation, macular or paramacular, bilateral;
- H30.101 - Unspecified disseminated chorioretinal inflammation, right eye;
- H30.102 - Unspecified disseminated chorioretinal inflammation, left eye;
- H30.103 - Unspecified disseminated chorioretinal inflammation, bilateral;
- H30.111 - Disseminated chorioretinal inflammation of posterior pole, right eye;
- H30.112 - Disseminated chorioretinal inflammation of posterior pole, left eye;
- H30.113 - Disseminated chorioretinal inflammation of posterior pole, bilateral;
- H30.121 - Disseminated chorioretinal inflammation, peripheral right eye;
- H30.122 - Disseminated chorioretinal inflammation, peripheral, left eye;
- H30.123 - Disseminated chorioretinal inflammation, peripheral, bilateral;
- H30.131 - Disseminated chorioretinal inflammation, generalized, right eye;
- H30.132 - Disseminated chorioretinal inflammation, generalized, left eye;
- H30.133 - Disseminated chorioretinal inflammation, generalized, bilateral;
- H30.21 - Posterior cyclitis, right eye;
- H30.22 - Posterior cyclitis, left eye;
- H30.23 - Posterior cyclitis, bilateral;
- H30.811 - Harada's disease, right eye;
- H30.812 - Harada's disease, left eye;
- H30.813 - Harada's disease, bilateral;
- H30.891 - Other chorioretinal inflammations, right eye;
- H30.892 - Other chorioretinal inflammations, left eye;
- H30.893 - Other chorioretinal inflammations, bilateral;
- H30.91 - Unspecified chorioretinal inflammation, right eye;
- H30.92 - Unspecified chorioretinal inflammation, left eye;
- H30.93 - Unspecified chorioretinal inflammation, bilateral;
- H35.021 - Exudative retinopathy, right eye;
- H35.022 - Exudative retinopathy, left eye;
- H35.023 - Exudative retinopathy, bilateral;
- H35.061 - Retinal vasculitis, right eye;
- H35.062 - Retinal vasculitis, left eye;
- H35.063 - Retinal vasculitis, bilateral;
- H43.89 - Other disorders of vitreous body;
- H44.001 - Unspecified purulent endophthalmitis, right eye;
- H44.002 - Unspecified purulent endophthalmitis, left eye;
- H44.003 - Unspecified purulent endophthalmitis, bilateral;
- H44.011 - Panophthalmitis (acute), right eye;
- H44.012 - Panophthalmitis (acute), left eye;
- H44.013 - Panophthalmitis (acute), bilateral;
- H44.021 - Vitreous abscess (chronic), right eye;
- H44.022 - Vitreous abscess (chronic), left eye;
- H44.023 - Vitreous abscess (chronic), bilateral;
- H44.111 - Panuveitis, right eye;
- H44.112 - Panuveitis, left eye;
- H44.113 - Panuveitis, bilateral
- Providers must bill with HCPCS code: J3490 - Unclassified drugs
- One Medicaid and NC Health Choice unit of coverage is: 1 single-dose vial
- The maximum reimbursement rate per unit is: $1,782.00
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 71565-0040-01, 71565-0040-25
- 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 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 Medicaid's PADP web page.
Contact
NCTracks Call Center: 800-688-6696