HCPCS 2020: Don’t Miss These 5 C Code Changes for Drugs

HCPCS Level II coding for drugs

If you report HCPCS Level II C codes for drugs, there are a handful of changes coming Jan. 1, 2020, that you’ll want to know. Here’s what’s being added and deleted for lefamulin, brexanolone, levoleucovorin, and iodine I-131 iobenguane.

Reminder: HCPCS Level II C codes, meaning codes that start with the letter C, were originally developed by Medicare for use by Outpatient Prospective Payment System (OPPS) hospitals. A short list of non-OPPS hospitals may also use C codes. But physician and other pro-fee claims should not use these codes. Instead, pro-fee claims may need to use an unclassified drug code, such as J3490 (Unclassified drugs), instead of using a C code. C codes are temporary codes that often get replaced with more permanent codes (like A codes and J codes), which are appropriate for pro-fee claims.

Start Using These C Codes for Lefamulin and Brexanolone

Lefamulin: The first new C code you should have on your radar is C9054 (Injection, lefamulin (Xenleta), 1 mg). XenletaTM is an antibacterial used to treat adults with community-acquired bacterial pneumonia (CABP). You should report 1 billing unit per 1 mg, and a typical dose is 150 mg every 12 hours, infused over 60 minutes, for five to seven days.

Brexanolone: If you code for the treatment of postpartum depression, you may be interested in C9055 (Injection, brexanolone, 1 mg). Sold under the brand name ZulressoTM, this antidepressant is administered intravenously over 60 hours, meaning two and half days.

When the manufacturer requested a code for brexanolone, the preliminary decision was that the drug was not suitable for a HCPCS Level II code, according to the May 15, 2019, “Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS) Application Summaries for Drugs, Biologicals and Radiopharmaceuticals.”

But the primary speaker requesting the code argued that new data supports using the drug in places other than hospital inpatient and outpatient settings.

CMS agreed to create a code, but the decision has some important side notes reflecting the initial decision to have no code: “Zulresso is not suitable for coding in Level II HCPCS outside of CMS’ pass-through coding process due to setting of use. For hospital inpatient use the product is included in the bundled payment. Newly established pass-through code C9055 ‘Injection, brexanolone, 1mg’ is available for assignment by insurers, if they deem appropriate to identify hospital outpatient use.”

Stop Using These C Codes for Levoleucovorin and Iobenguane

Levoleucovorin: CMS made some last-minute changes to levoleucovorin codes effective Oct. 1, 2019. The changes added new code J0642 (Injection, levoleucovorin (Khapzory), 0.5 mg) and added “not otherwise specified” to the descriptor for existing code J0641 (Injection, levoleucovorin, not otherwise specified, 0.5 mg). CMS also opted not to delete C9043 (Injection, levoleucovorin, 1 mg) for the Oct. 1 HCPCS Level II updates. But effective Jan. 1, 2020, C9043 will be discontinued, meaning it will no longer be a valid code. Levoleucovorin is used to reduce toxic effects of chemotherapy.

Iodine i-131 iobenguane: The January update to the HCPCS Level II codes will also discontinue these two codes:

  • C9407 (Iodine I-131 iobenguane, diagnostic, 1 millicurie)
  • C9408 (Iodine I-131 iobenguane, therapeutic, 1 millicurie)

Iobenguane I-131, sold under the name Azedra® is used to treat patients who are 12 and older “with iobenguane scan positive, unresectable, locally advanced or metastatic pheochromocytoma or paraganglioma who require systemic anticancer therapy,” according to the May 14, 2019, CMS HCPCS public meeting agenda. Paragangliomas are rare tumors that develop from cells from embryonic nervous tissue (paraganglia). Pheochromocytomas are paraganglia that form in the adrenal glands that are on top of the kidneys. (By the way, oncology coders have some 2020 HCPCS Level II J and Q code updates, they should know, too.)

Starting Jan. 1, 2020, HCPCS Level II will include A9590 (Iodine I-131, iobenguane, 1 millicurie). Don’t confuse this new code with existing codes A9508 (Iodine I-131 iobenguane sulfate, diagnostic, per 0.5 millicurie) and A9582 (Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 millicuries).

What About You?

Are you an outpatient coder who uses C codes? If you’re a physician coder, do you wish you could report C codes when they provide more specific options than A and J codes?

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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