Understanding Diagnosis Codes for Abilify Asimtufii: A Comprehensive Guide for Healthcare Providers

Effective from May 30, 2023, North Carolina Medicaid has included aripiprazole extended-release injectable suspension, specifically Abilify Asimtufii, under its Physician Administered Drug Program (PADP). This medication, administered intramuscularly, is crucial for managing serious mental health conditions. This guide aims to provide healthcare providers with a clear understanding of the necessary diagnosis codes for billing Abilify Asimtufii, ensuring accurate claims and reimbursements.

Abilify Asimtufii is available in extended-release injectable suspension, with two package sizes: 960 mg/3.2 mL and 720 mg/2.4 mL, both in single-dose pre-filled syringes. It is indicated for:

• The treatment of schizophrenia in adults.
• Maintenance monotherapy treatment of bipolar I disorder in adults.

ICD-10-CM Diagnosis Codes for Abilify Asimtufii Billing

For Medicaid billing purposes, specific ICD-10-CM diagnosis codes are mandatory. These codes must accurately reflect the patient’s condition for which Abilify Asimtufii is being administered. Below are the detailed diagnosis codes categorized by condition:

Schizophrenia Diagnosis Codes:

The following ICD-10-CM codes are recognized for diagnoses of schizophrenia when billing for Abilify Asimtufii:

• F20.0 – Paranoid schizophrenia
• F20.1 – Disorganized schizophrenia
• F20.2 – Catatonic schizophrenia
• F20.3 – Undifferentiated schizophrenia
• F20.5 – Residual schizophrenia
• F20.89 – Other schizophrenia

Bipolar I Disorder Diagnosis Codes:

For patients diagnosed with Bipolar I Disorder, the following ICD-10-CM codes are applicable for billing Abilify Asimtufii:

• F31.0 – Bipolar disorder, current episode hypomanic
• F31.11 – Bipolar disorder, current episode manic without psychotic features, mild
• F31.12 – Bipolar disorder, current episode manic without psychotic features, moderate
• F31.13 – Bipolar disorder, current episode manic without psychotic features, severe
• F31.2 – Bipolar disorder, current episode manic severe with psychotic features
• F31.31 – Bipolar disorder, current episode depressed, mild
• F31.32 – Bipolar disorder, current episode depressed, moderate
• F31.4 – Bipolar disorder, current episode depressed, severe, without psychotic features
• F31.5 – Bipolar disorder, current episode depressed, severe, with psychotic features
• F31.61 – Bipolar disorder, current episode mixed, mild
• F31.62 – Bipolar disorder, current episode mixed, moderate
• F31.63 – Bipolar disorder, current episode mixed, severe, without psychotic features
• F31.64 – Bipolar disorder, current episode mixed, severe, with psychotic features
• F31.71 – Bipolar disorder, in partial remission, most recent episode hypomanic
• F31.72 – Bipolar disorder, in full remission, most recent episode hypomanic
• F31.73 – Bipolar disorder, in partial remission, most recent episode manic
• F31.74 – Bipolar disorder, in full remission, most recent episode manic
• F31.75 – Bipolar disorder, in partial remission, most recent episode depressed
• F31.76 – Bipolar disorder, in full remission, most recent episode depressed
• F31.77 – Bipolar disorder, in partial remission, most recent episode mixed
• F31.78 – Bipolar disorder, in full remission, most recent episode mixed
• F31.89 – Other bipolar disorder

Dosage and Administration Guidelines

The standard recommended dosage for Abilify Asimtufii is 960 mg, administered once every 2 months (specifically, 56 days after the preceding injection). There are specific guidelines depending on the patient’s prior medication:

• Patients Switching from Oral Antipsychotics: When initiating Abilify Asimtufii in patients currently on oral aripiprazole, the first dose of Abilify Asimtufii should be given alongside oral aripiprazole (10 mg to 20 mg) for a 14-day period. For patients stable on other oral antipsychotics (and known to tolerate aripiprazole), this co-administration with oral medication for 14 days is also recommended.
• Patients Switching from Abilify Maintena: For those transitioning from Abilify Maintena (monthly dosing), administer Abilify Asimtufii 960 mg (every 2 months) in place of their next scheduled Abilify Maintena injection. The first Abilify Asimtufii injection can replace the second or any subsequent injection of Abilify Maintena.
• Dosage Adjustment: In cases of adverse reactions with the 960 mg dose, a reduced dosage of 720 mg every 2 months may be considered.

For comprehensive details on dosage and administration, always refer to the full prescribing information.

Key Billing Information for NC Medicaid

To ensure successful Medicaid billing for Abilify Asimtufii, providers need to adhere to the following guidelines:

• HCPCS Code: Use HCPCS code J3490 – Unclassified drugs for billing.
• Unit of Coverage: One Medicaid unit of coverage is equivalent to 1 mg.
• Maximum Reimbursement Rate: The maximum reimbursement rate is $6.11826 per unit (1 mg).
• NDC Codes: Providers must bill using 11-digit NDCs and the appropriate NDC units. The specific NDCs are 59148-0102-80 and 59148-0114-80.
• NDC Units: Report NDC units as “UN1.”

For more detailed billing instructions, refer to the January 2012 Special Bulletin on National Drug Code Implementation Update and PADP Clinical Coverage Policy 1B, Attachment A, H.7 on the NC Medicaid website. Links are provided in the resources section below.

Billing for 340B Participating Providers

Providers participating in the 340B program who have registered with the Office of Pharmacy Affairs (OPA) should bill their acquisition cost for 340B drugs. To indicate that a drug was purchased under a 340B agreement, append the “UD” modifier to the drug detail.

Accessing the Fee Schedule

The PADP fee schedule is available on the NC Medicaid Fee Schedule & Covered Code portal, providing up-to-date information on reimbursement rates.

Resources and Contact Information

For further details, please consult the following resources:

• National Drug Code Implementation Update (January 2012 Special Bulletin): https://files.nc.gov/ncdma/documents/Providers/Bulletins/archives/2012/0112-NDCSpecialBulletin.pdf
• PADP Clinical Coverage Policy 1B, Attachment A, H.7: https://medicaid.ncdhhs.gov/providers/program-specific-clinical-coverage-policies
• NC Medicaid Fee Schedule & Covered Code portal: https://ncdhhs.servicenowservices.com/fee_schedules
• Office of Pharmacy Affairs (OPA) Registration: https://340bopais.hrsa.gov/
• NCTracks Call Center: 800-688-6696

For any queries or additional assistance, providers can contact the NCTracks Call Center at 800-688-6696.

By understanding these diagnosis codes and billing procedures, healthcare providers can ensure accurate and efficient processing of claims for Abilify Asimtufii, ultimately benefiting patients requiring this essential medication.