HCPCS replacement codes, effective April 1, 2023, established

Q5127 replaces C9399, J3490, J3590 and J9999 when billing for Stimufend (pegfilgrastim-fpgk), a biosimilar

The Centers for Medicare & Medicaid Services has established a permanent procedure code for specialty medical drug Stimufend (pegfilgrastim-fpgk), a biosimilar.

All services through March 31, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after April 1, 2023, must be reported with Q5127.       

Prior authorization is required through the Medical Benefit Drug program for Q5127 for all groups unless they’re opted out of the program.

For groups that have opted out of the prior authorization program, this code is covered for its FDA-approved indications.

Q5128 replaces C9399, J3490, J3590 and J9999 when billing for Cimerli (ranibizumab-eqrn), a biosimilar

CMS has established a permanent procedure code for specialty medical drug Cimerli (ranibizumab-eqrn), a biosimilar.

All services through March 31, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after April 1, 2023, must be reported with Q5128.       

Prior authorization is required through the Medical Benefit Drug program for Q5128 for all groups unless they’re opted out of the program.

For groups that have opted out of the prior authorization program, this code is covered for its FDA-approved indications.

Q5129 replaces C9399, J3490, J3590 and J9999 when billing for Vegzelma (bevacizumab-adcd), a biosimilar

CMS has established a permanent procedure code for specialty medical drug Vegzelma (bevacizumab-adcd), a biosimilar.

All services through March 31, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after April 1, 2023, must be reported with Q5129.       

Prior authorization is required through the Medical Benefit Drug program for Q5129 for all groups unless they’re opted out of the program.

For groups that have opted out of the prior authorization program, this code is covered for its FDA-approved indications.

Q5130 replaces C9399, J3490, J3590 and J9999 when billing for Fylnetra (pegfilgrastim-pbbk), a biosimilar

CMS has established a permanent procedure code for specialty medical drug Fylnetra (pegfilgrastim-pbbk), a biosimilar.

All services through March 31, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after April 1, 2023, must be reported with Q5130.

Prior authorization is required through the Medical Benefit Drug program for Q5130 for all groups unless they’re opted out of the program.

For groups that have opted out of the prior authorization program, this code is covered for its FDA-approved indications.

C9145 replaces J3490, J3590 when billing for Aponvie (aprepitant) for facility services only

CMS has established a permanent procedure code for specialty medical drug Aponvie (aprepitant).
All services through March 31, 2023, will continue to be reported with code J3490 and J3590. All facility services performed on and after April 1, 2023, must be reported with C9145, while all professional services will continue to be reported with J3490 and J3590.

C9146 replaces J9999 when billing for Elahere (mirvetuximab soravtansine-gynx) for facility services only

CMS has established a permanent procedure code for specialty medical drug Elahere.

All services through March 31, 2023, will continue to be reported with J9999.  All facility services performed on and after April 1, 2023, must be reported with C9146, while all professional services will continue to be reported with J9999.

C9147 replaces J9999 when billing for Imjudo (tremelimumab-actl) for facility services only

CMS has established a permanent procedure code for specialty medical drug Imjudo.

All services through March 31, 2023, will continue to be reported with J9999. All facility services performed on and after April 1, 2023, must be reported with C9147, while all professional services will continue to be reported with J9999.

C9148 replaces J3590 when billing for Tzield (teplizumab-mzwv) for facility services only

CMS has established a permanent procedure code for specialty medical drug Tzield.

All services through March 31, 2023, will continue to be reported with J3590. All facility services performed on and after April 1, 2023, must be reported with C9148, while all professional services will continue to be reported with J3590.

C9149 replaces C9399, J3490 and J3590, and when billing for Tzield (teplizumab-mzwv) for facility services only

CMS has established a permanent procedure code for specialty medical drug Tzield.

All services through March 31, 2023, will continue to be reported with J3590. All facility services performed on and after April 1, 2023, must be reported with C9149, while all professional services will continue to be reported with J3590.  

J0208 replaces J3490 when billing for Pedmark (sodium thiosulfate)

CMS has established a permanent procedure code for specialty medical drug Pedmark.

All services through March 31, 2023, will continue to be reported with J3490. All services performed on and after April 1, 2023, must be reported with J0208.

J0218 replaces J3490, J3590 and C9399 when billing for Xenpozyme (olipudase alfa-rpcp)

CMS has established a permanent procedure code for specialty medical drug Xenpozyme.

All services through March 31, 2023, will continue to be reported with J3490, J3590 and C9399. All services performed on and after April 1, 2023, must be reported with J0218.

Site-of-care prior authorization is required through the Medical Benefit Drug program for J0218 for all groups unless they’re opted out of the program.

For groups that have opted out of the Medical Benefit Drug program, this code is covered for its FDA-approved indications and requires manual review.

J1411 replaces C9399, J3490, J3590 and J9999 when billing for Hemgenix (etranacogene dezaparvovec-drlb)

CMS has established a permanent procedure code for specialty medical drug Hemgenix (etranacogene dezaparvovec-drlb), a gene/cellular therapy.

All services through March 31, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after April 1, 2023, must be reported with J1411.

Prior authorization is required through the Medical Benefit Drug program for J1411 for all groups unless they’re opted out of the program.

For groups that have opted out of the Medical Benefit Drug program, this code is covered for its FDA-approved indications and requires manual review.

J1449 replaces J3490, J3590, C9399 and J9999 when billing for Rolvedon (eflapegrastim-xnst)

CMS has established a permanent procedure code for specialty medical drug Rolvedon (eflapegrastim-xnst).

All services through March 31, 2023, will continue to be reported with codes J3490, J3590, C9399 and J9999.  All services performed on and after April 1, 2023, must be reported with J1449.

Prior authorization is required through the Medical Benefit Drug program for J1449 for all groups unless they’re opted out of the program.

For groups that have opted out of the prior authorization program, this code is covered for its FDA-approved indications.

J1747 replaces J3490, J3590, C9399 and J9999 when billing for Spevigo (spesolimab-sbzo)

CMS has established a permanent procedure code for specialty medical drug Spevigo (spesolimab-sbzo).
All services through March 31, 2023, will continue to be reported with codes J3490, J3590, C9399 and J9999. All services performed on and after April 1, 2023, must be reported with J1747.

Site-of-care prior authorization is required through the Medical Benefit Drug program for J1747 for all groups unless they’re opted out of the program.

For groups that have opted out of the Medical Benefit Drug program, this code is covered for its FDA-approved indications and requires manual review.