January is always the biggest quarterly update for HCPCS codes and 2022 is no exception. Some changes are routine with new codes replacing temporary codes and new codes for newly marketed products.
One HCPCS code change caught our attention: Pegfilgrastim.
Since January 1, 2004, pegfilgrastim has been billed with HCPCS code J2505-Injection, pegfilgrastim, 6 mg.
It is curious that when the biosimilars for pegfilgrastim were introduced in June 2018, the products were all assigned brand-specific HCPCS codes with a dose description of 0.5 mg.
CMS has now gotten the codes in “sync” so the innovator is now billed with J2506-Injection, pegfilgrastim, excludes biosimilar, 0.5 mg and code J2505 has been deleted.
This doesn’t sound like a big deal unless the HCPCS code is swapped out without a change in the multiplier. Billing J2506 with a quantity of “1” will result in a 12x underpayment since the HCPCS code needs to be multiplied by 12 to make a 6 mg dose.
Payment rates from Addendum B effective January 1, 2022:
SHOUT-OUTS 1. Pharmacy and Chargemaster Managers should ensure that new HCPCS code J2506 is linked to pegfilgrastim and for a 6 mg dose the quantity billed is “12”.
2. Revenue Integrity should review a sample of claims with dates of service on or after January 1, 2022 to ensure that when pegfilgrastim 6 mg dose is administered, the claim reflects HCPCS code J2506 with a quantity of “12”.
Our goal is simple; we’re taking complex information and making it practical.
Until our next edition, this is Maxie Friemel and Agatha Nolen providing you with tips for increasing your Pharmacy Revenue.