Levalbuterol Hydrochloride Inhalation Solution (Xopenex®) HCPCS Code J7614: Billing Guidelines

Effective Oct. 1, 2022, Medicaid and NC Health Choice cover Levalbuterol Hydrochloride inhalation solution (Xopenex)

Effective with date of service Oct. 1, 2022, the Medicaid and NC Health Choice programs cover Levalbuterol Hydrochloride inhalation solution (Xopenex) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J7614 - Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg.

Strength/Package Sizes: Inhalation solution (unit-dose vial for nebulization): 0.31 mg/3 mL, 0.63 mg/3 mL and 1.25 mg/3 mL

Indicated for the treatment or prevention of bronchospasm in adults, adolescents, and children 6 years of age and older with reversible obstructive airway disease

Recommended Dose: 

  • Children 6 to 11 years old: 0.31 mg administered three times a day, by nebulization. Routine dosing should not exceed 0.63 mg three times a day.
  • Adults and Adolescents ≥12 years old: 0.63 mg administered three times a day, every six to eight hours, by nebulization. The maximum recommended dose is 1.25 mg three times a day.

If a previously effective dosage regimen fails to provide the usual response this may be a marker of destabilization of asthma and requires reevaluation of the patient and the treatment regimen, giving special consideration to the possible need for anti-inflammatory treatment, e.g., corticosteroids.

See full prescribing information for further detail.

For Medicaid and NC Health Choice Billing

  • The ICD-10-CM diagnosis codes required for billing are: 
    • 45.20 - Mild intermittent asthma, uncomplicated;
    • J45.21 - Mild intermittent asthma with (acute) exacerbation;
    • J45.22 - Mild intermittent asthma with status asthmaticus;
    • J45.30 - Mild persistent asthma, uncomplicated;
    • J45.31 - Mild persistent asthma with (acute) exacerbation;
    • J45.32 - Mild persistent asthma with status asthmaticus;
    • J45.40 - Moderate persistent asthma, uncomplicated;
    • J45.41 - Moderate persistent asthma with (acute) exacerbation;
    • J45.42 - Moderate persistent asthma with status asthmaticus;
    • J45.50 - Severe persistent asthma, uncomplicated;
    • J45.51 - Severe persistent asthma with (acute) exacerbation;
    • J45.52 - Severe persistent asthma with status asthmaticus;
    • J45.901 - Unspecified asthma with (acute) exacerbation;
    • J45.902 - Unspecified asthma with status asthmaticus;
    • J45.909 - Unspecified asthma, uncomplicated;
    • J45.990 - Exercise induced bronchospasm;
    • J45.991 - Cough variant asthma;
    • J45.998 - Other asthma;
    • J98.01 - Acute bronchospasm
  • Providers must bill with HCPCS code: J7614 - Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg
  • One Medicaid and NC Health Choice unit of coverage is: 0.5 mg 
  • The maximum reimbursement rate per unit is: $0.05
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 
    • Xopenex: 17478-0172-12, 17478-0172-24, 17478-0173-12, 17478-0173-24, 17478-0174-12, 17478-0174-24
    • Generic: 00093-4145-45, 00093-4145-56, 00093-4146-45, 00093-4146-56, 00093-4148-45, 00093-4148-56, 00115-9930-76, 00115-9930-78, 00115-9931-76, 00115-9931-78, 00115-9932-76, 00115-9932-78, 00378-9690-52, 00378-9690-62, 00378-9691-52, 00378-9691-62, 00378-9692-52, 00378-9692-62, 16714-0094-05, 16714-0094-25, 16714-0094-30, 16714-0095-05, 16714-0095-25, 16714-0096-05, 16714-0096-25, 35573-0443-25, 35573-0444-25, 35573-0445-25, 47335-0743-49, 47335-0746-49, 47335-0753-49, 65862-0943-12, 65862-0943-24, 65862-0944-12, 65862-0944-24, 65862-0945-12, 65862-0945-24, 66993-0022-27, 66993-0022-35, 66993-0023-27, 66993-0023-35, 76204-0700-01, 76204-0700-11, 76204-0700-15, 76204-0700-25, 76204-0800-01, 76204-0800-11, 76204-0800-15, 76204-0800-25, 76204-0900-01, 76204-0900-11, 76204-0900-15, 76204-0900-25.
  • 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

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