Just like their CPT counterparts, HCPCS codes are constantly being studied and reevaluated, and biosimilar biologicals are no exception. Because these products have been proven to be similar to an existing FDA-approved biological (hence the term biosimilar), they shortcut much of the licensing path and are coded differently from many drugs. Starting April 1st, 2018, these items will no longer be grouped into a single billing code even when they have a common reference product.

As outlined below, this update will add three new HCPCS Level II codes to the Medicare Physician Fee Schedule Database:

  • Q5103 Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg
  • Q5104 Injection, infliximab-abda, biosimilar, (renflexis), 10 mg
  • Q2041 Axicabtagene Ciloleucel, up to 200 million autologous Anti-CD19 CAR T Cells, Including leukapheresis and dose preparation procedures, per infusion

These first two codes, Q5103 and Q5104, replaced the newly deleted code Q5102, which denoted simply Injection, infliximab, biosimilar, 10 mg. All three of these new codes will be given the procedure status E, which indicates that the procedures are excluded from the physician fee schedule (PFS) by regulation and that no relative value units (RVUs) are shown.

As far as revisions go, Q5101 will update to read Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram instead of Injection, filgrastim (g-csf), biosimilar, 1 microgram.

This April update also includes a new biosimilar biologicals payment policy that affects the way modifiers are appended to these codes. Modifiers ZC (Merck/Samsung Bioepis) and ZA (Novartis/Sandoz) will no longer be required for Medicare claims containing biosimilars, as the new payment policy makes it unnecessary for coders to differentiate between manufacturers.

If you code or bill for a practice that uses biosimilar biologicals, be sure to review these updates and share them with your coworkers so that when the update goes into effect in April, your practice will be well prepared for the changes.