Ephedrine Hydrochloride Injection, for Intravenous use (Rezipres®) HCPCS code J3490: Billing Guidelines
the Medicaid and NC Health Choice programs cover ephedrine hydrochloride injection, for intravenous use

the Medicaid and NC Health Choice programs cover ephedrine hydrochloride injection, for intravenous use

Effective with date of service April 14, 2022, the Medicaid and NC Health Choice programs cover ephedrine hydrochloride injection, for intravenous use (Rezipres®) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.

Strength/Package Size: Injection: 23.5 mg/5 mL (4.7 mg/mL) ephedrine hydrochloride (equivalent to 3.8 mg ephedrine base) in single-dose ampule

Indicated for the treatment of clinically important hypotension occurring in the setting of anesthesia.

Recommended Dose: An initial dose of 4.7 mg to 9.4 mg administered by intravenous bolus.

  • Administer additional boluses as needed, not to exceed a total dosage of 47 mg. 
  • Adjust dosage according to the blood pressure goal (i.e., titrate to effect).

See full prescribing information for further detail.

For Medicaid and NC Health Choice Billing

  • The ICD-10-CM diagnosis codes required for billing are:  
    • I95.0 - Idiopathic hypotension; 
    • I95.2 - Hypotension due to drugs; 
    • I95.81 - Postprocedural hypotension
  • 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: $0.96
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 39822-1410-05, 39822-1410-06
  • 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

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