What is Vabysmo?
According to the manufacturer (Genentech), VABYSMO (faricimab-svoa) is a prescription medicine given by injection into the eye, used to treat adults with Neovascular (Wet) Age-related Macular Degeneration (AMD or nAMD) and Diabetic Macular Edema (DME).[1] AMD and DME are two of the leading causes of vision loss. Genentech announced in January of 2022 that this drug was approved by the FDA.[2]
How is it billed?
CMS (Centers for Medicare & Medicaid Services) announced a new Healthcare Common Procedure Coding System (HCPCS) J-code to represent Vabysmo – J2777 which represents 0.1mg per unit. The code became effective October 1, 2022.[3] There is also an NDC code (50242-0096-01) for when this is billed under a pharmacy benefit.
What is the proper dosage?
For nAMD the recommended dosage is 6mg every 4 weeks for the first 4 doses. After the 4 weeks, patients are to be evaluated to determine if additional doses are needed. For DME the recommended dosage is also 6mg every 4 weeks for 4 doses. After the first 4 doses, patients should be evaluated to determine if additional doses and frequency of those doses are necessary. Ready for a little math today? If HCPCS code J2777 is for .1 mg and the dosage is for 6 mg, how many units should be billed at each service?
What to look for?
1) Always check for double billing on both medical and pharmacy. Analytics should be able to automatically detect any members with claims with HCPCS J2777 on a medical claim and NDC code 50242-0096-01 on a pharmacy claim.
2) Excessive Units that may go above recommended dosages and frequency (60 units), more frequent than every 4 weeks
3) Unnecessary prescribing of this medication based on patient symptoms and history
References:
[3] https://www.vabysmo-hcp.com/content/dam/gene/vabysmo-hcp/pdfs/j-code.pdf
Healthcare Fraud Shield Alerts
As an example, Healthcare Fraud Shield created the following alert to assist our clients in monitoring this behavior:
[5248-01] – SUPPORTING DIAGNOSIS MISSING, VABYSMO: This Alert identifies NDC’s for Vabysmo when billed for a patient without a prior history of Neovascular (Wet) Age-Related Macular Degeneration (nAMD) and/or Diabetic Macular Edema (DME).
[2572-01] – INAPPROPRIATE NUMBER OF UNITS, VABYSMO: This Alert identifies providers billing 61 or more units of J2777 (Vabysmo), per patient, per date of service as the recommended billable units are 60.
[2537-01] – SERVICES NOT RENDERED, BILLING VABYSMO WITHOUT AN ADMINISTRATION CODE: This Alert identifies providers billing an injection of Vabysmo, without a corresponding administration code, as this may be suspect.
[5249-20] – OUTLIER, VABYSMO: This Alert identifies prescribers excessively prescribing Vabysmo when compared to their peers. (PRESCRIBER COMPARISON)
[2547-01] – UNALLOWED PROCEDURE CODE, VABYSMO BILLED BEFORE THE EFFECTIVE DATE: This Alert identifies providers billing J2777, Vabysmo before it’s effective date of October 1, 2022.
If you have any questions or comments, you may email [email protected].