Effective Sept. 1, 2021: Non-Risk Based Payment for Amondys 45 – Texas Medicaid

What’s changing?

Effective Sept. 1, 2021, the implementation of the clinical criteria for Amondys 45 procedure code C9075 for Texas Medicaid non-risk-based payment will begin. Amondys 45 is indicated to treat a Duchenne muscular dystrophy (DMD).

Payment Information:

The following applies:

• Payments are limited to the actual amount paid to providers for the cost of ingredients of the drugs, up to the fee-for-service reimbursement amount.
• Drug administration is included in the capitation rate and is not included in the non-risk-based payment.
• The correct HCPCS code and NDC code must be billed to be eligible for non-risk-based payment.
• Dates of services as of June 1, 2021 and after, payments will apply to medical encounters.
• HCPCS Code C9075 is the temporary code as of July 1, 2021.

Questions

You can contact our BCBSTX Medicaid Provider Service Center at 1-877-560-8055 or contact your BCBSTX Medicaid Provider Network Representative at 1-855-212-1615.

Clinical payment and coding policies are based on using healthcare professionals and industry standard guidelines. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.