Retroactive code pricing updates may require claims lookback.
The Centers for Medicare & Medicaid Services (CMS) has posted a retroactive update to the April Average Sales Price (ASP) pricing file for three Medicare Part B drugs. Also now available are the July ASP and Not Otherwise Classified (NOC) pricing files and the ASP NDC HCPCS crosswalk.
April ASP Update
On June 1, CMS retroactively updated the ASP for three HCPCS Level II codes. The updated payment limits are affective April 1, 2021, through June 30, 2021.
| Code | Short Description | Dosage | Payment Limit |
| J1557 | Gammaplex injection | 500 mg | $49.45 |
| J3315 | Triptorelin pamoate injection | 3.75 mg | $515.49 |
| Q2050 | Doxorubicin injection | 10 mg | $308.82 |
The ASP for these codes change again in third quarter.
July ASP Update
The following table shows updated payment limits for five HCPCS Level II codes, effective July 1, 2021, through Sept. 30, 2021:
| Code | Short Description | Dosage | Payment Limit |
| J1437 | Ferric derisomaltose injection | 10 mg | $25.815 |
| J1951 | Fensolvi injection | 0.25 mg | $127.748 |
| J3032 | Eptinezumab-jjmr injection | 1 mg | $15.603 |
| J7212 | Factor viia (recomb sevenfact) | 1 mcg | $2.185 |
| Q5123 | Riabni injection | 10 mg | $73.83 |
Take Note
Payment allowance limits subject to the ASP methodology are based on first quarter 2021 (1Q21) ASP data. The absence or presence of a HCPCS Level II code and the payment allowance limits in the pricing files does not indicate whether Medicare covers a drug. Determinations are made by the local Medicare Administrative Contractor processing the claim.
Where applicable, the payment amounts in the quarterly ASP files are 106 percent of the ASP calculated from data submitted by drug manufacturers. The quarter-to-quarter price changes are generally the result of updated data from the manufacturers of these drugs.
According to CMS, comparing the third quarter 2021 payment amounts with the prior quarter reveals that, on average, payment amounts for the top 50 Part B drugs decreased by 0.8 percent. For most of the higher volume drugs (26 out of the top 50), the prices changed 2 percent or less. Overall, the prices for 21 of the top 50 drugs decreased.
HCPCS Quarterly Update Correction
CMS updated on June 9 the July 2021 Alpha-Numeric HCPCS File to make several corrections, as shown below:
| HCPCS/MOD Code | Action | Short Description | Long Description | Effective Date | TOS | BETOS | Cov | Pricing |
| C9065 | Do not terminate | |||||||
| G0327 | Revise TOS | 7/1/2021 | 5 | |||||
| J9314 | Remove code | |||||||
| M0201 | Add | COVID-19 vaccine home admin | COVID-19 vaccine administration inside a patient’s home; reported only once per individual home per date of service when only COVID-19 vaccine administration is performed at the patient’s home | 6/8/2021 | V | O1G | C | 54 |
| M0247 | Add | Sotrovimab infusion | Intravenous infusion, sotrovimab, includes infusion and post administration monitoring | 5/26/2021 | V | O1G | C | 54 |
| M0248 | Add | Sotrovimab inf, home admin | Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency | 5/26/2021 | V | O1G | C | 54 |
| Q0247 | Add | Sotrovimab | Injection, sotrovimab, 500 mg | 5/26/2021 | V | O1G | C | 54 |
For More Information: https://www.aapc.com/blog/75566-cms-updates-medicare-part-b-drug-prices/