CMS issued a unique HCPCS J-code for hylenex recombinant

	HCPCS Descriptor
	J3473 Injection, hyaluronidase, recombinant, 1 USP Unit

• Although hylenex recombinant (hyaluronidase human injection) is supplied in 150 USP Unit single-use vials, providers should report one Unit of code J3473 for each USP Unit of hylenex recombinant administered, per the code descriptor.
• For coding clarity, for each 150 USP Unit vial of hylenex recombinant, 150 Units of code J3473 should be reported.
• Healthcare Common Procedure Coding System (HCPCS) code J3473 must be reported with revenue code 0636 (Drugs Requiring Detailed Coding) on Medicare hospital outpatient claims.
• Effective for services on or after January 1, 2007.

Medicare provides separate payment for hylenex recombinant in the physician office and hospital outpatient setting at ASP plus 6%

	HCPCS Descriptor Q1 2008 Medicare Payment
	J3473 1 USP $0.412 (ASP + 6%)

• CMS calculates an Average Sales Price (ASP)–based payment amount for most separately payable drugs based on manufacturer-submitted sales data.
• Payment amounts under the ASP methodology are updated quarterly and may differ from one quarter to the next based on sales, discounts, and rebates that are reported to CMS.
• Q1 2008 Medicare payment for a 150 USP Unit single-use vial is $61.80.
• Find the latest Medicare payment amounts for drugs and biologicals on the CMS Web site: http://www.cms.hhs.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage.

hylenex reimbursement by private insurers & Medicaid

• Many private insurers and state Medicaid programs use HCPCS codes in the physician office and hospital outpatient settings.
• Private insurers and state Medicaid programs should accept HCPCS code J3473 for dates of service on or after January 1, 2007.
• Private insurers and state Medicaid programs use a variety of reimbursement methods for drugs and biologicals, including Average Wholesale Price (AWP), ASP, invoice, or percentage of charges.
• Please check with your specific payors to determine their coding and payment policies for hylenex recombinant.

Current Procedural Terminology (CPT®^†) codes for administration of hylenex recombinant

• Relevant CPT codes might include, but are not limited to, the following:

	CPT Descriptor
	67500 Retrobulbar injection; medication (separate procedure, does not include supply of medication)
	67515   Injection of medication or other substance into Tenon’s capsule
	90769 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to one hour, including pump set-up and establishment of subcutaneous infusion site(s)
	90770 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)
	90771 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure)
	90772 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

• Medicare generally provides separate payment for the above CPT codes in the physician office and hospital outpatient settings. However, payment for the injection may be restricted by Correct Coding Initiative (CCI) edits when these codes are billed together with certain other procedures, such as cataract surgery.
• CCI edits are available for download at http://www.cms.hhs.gov/nationalcorrectcodinited
• Separate payment for hylenex should not be affected by the CCI edits.
• CPT codes 67500/67515 and 90772 are examples of administration codes that may apply when hylenex is used for ophthalmic and non-opthalmic indications, respectively. However, these codes may not always be appropriate.
• Providers should consult a current CPT manual and always select the CPT code that accurately identifies the service provided.

Click here to see full Prescribing Information.

† Current Procedural Terminology (CPT) is copyright ©2008 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

If you have additional product inquiries or reimbursement questions about hylenex recombinant, please contact these Baxter resources for assistance:

	Product Inquiries 1-800-262-3784 (1-800-ANA-DRUG)
	Orders & Returns 1-800-667-0959
	Reimbursement 1-888-338-0001

Click here to see full Prescribing Information.

The information contained in the Reimbursement section is provided for informational purposes only. Every reasonable effort has been made to verify the accuracy of the information; however, this section is not intended to provide specific guidance on how to utilize, code, bill, or charge for any product or service. Healthcare providers should make the ultimate determination as to when to use a specific product based on clinical appropriateness for a particular patient. Third-party payment for medical products and services is affected by numerous factors, and Baxter Healthcare Corporation cannot guarantee success in obtaining insurance payments.