Effective with date of service Sept 30, 2022, the Medicaid and NC Health Choice programs cover Indigotindisulfonate sodium injection, for intravenous use (Bludigo) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drug
Strength/Package Size: Injection: 40 mg/5 mL (8 mg/mL) Indigotindisulfonate sodium in a single-dose ampule
Indicated for use as a visualization aid in the cystoscopic assessment of the integrity of the ureters in adults following urological and gynecological open, robotic, or endoscopic surgical procedures
Recommended Dose: 5 mL given intravenously over 1 minute (see full prescribing information for details)
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
N20.0 - Calculus of kidney;
N20.1 - Calculus of ureter;
N20.2 - Calculus of kidney with calculus of ureter;
N21.0 - Calculus in bladder;
N21.1 - Calculus in urethra;
N21.8 - Other lower urinary tract calculus;
N28.89 - Other specified disorders of kidney and ureter;
N99.110 - Postprocedural urethral stricture, male, meatal;
N99.111 - Postprocedural bulbous urethral stricture, male;
N99.112 - Postprocedural membranous urethral stricture, male;
N99.113 - Postprocedural anterior bulbous urethral stricture, male;
N99.115 - Postprocedural fossa navicularis urethral stricture;
N99.116 - Postprocedural urethral stricture, male, overlapping sites;
N99.12 - Postprocedural urethral stricture, female;
S37.13XA - Laceration of ureter, initial encounter;
S37.12XA - Contusion of ureter, initial encounter;
Z41.8 - Encounter for other procedures for purposes other than remedying health state;
Z48.3 - Aftercare following surgery for neoplasm;
Z48.816 - Encounter for surgical aftercare following surgery on the genitourinary system;
Z48.89 - Encounter for other specified surgical aftercare
- Providers must bill with HCPCS code: J3490 - Unclassified drug
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $10.80
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 81284-0315-00, 81284-0315-05.
- 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