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Medical Injectables Program Update: Coding for STELARA

Based on guidance from the Centers for Medicare & Mediciad Services (CMS), effective July 1, 2017, please use HCPCS code Q9989 when submitting claims for Stelara® for intravenous (IV) (ustekinumab) services provided on and after July 1, 2017.

Stelara (IV) is subject to medical necessity and appropriateness review (MNAR) as part of the Horizon Blue Cross Blue Shield of New Jersey Medical Injectables Program (MIP) administered by Magellan Rx ManagementSM. Magellan Rx Management conducts medical necessity and appropriateness reviews for additional injectable medications that are administered in a freestanding or hospital-based dialysis center, an outpatient facility, a patient’s home or a physician’s office.1

A revised list of injectable medications that require MNAR that shows the various HCPCS codes accepted for this injectable medication in 2017 is available online.

When submitting Stelara (IV) for date of service…

Use HCPCS Code …

January 1, 2017 through March 31, 2017

J3590

April 1, 2017 through June 30, 2017

C9487

July 1, 2017 and after

Q9989

Visit our Medical Injectables Program page for more information.

If you have questions, please contact your Network Specialist.

1 Medical necessity and appropriateness review is not required for injectable medications that are administered during an inpatient stay, or in an Emergency Room setting or Observation Room setting.

For medical injectable services rendered in the patient’s home, call 1-855-243-3321 for participating Horizon Care@Home providers to obtain pre-service determination.

Stelara® is a registered trademark of Janssen Biotech, Inc.

Magellan Rx ManagementSM is a service mark of Magellan Health, Inc

Published on: July 26, 2017, 10:23 a.m. ET
Last updated on: July 26, 2017, 10:42 a.m. ET