top of page
NDC | HCPCS | HCPCS Description | NDC Label | Route of Administration |
|---|---|---|---|---|
68382-0048-10 | J0133 | INJECTION, ACYCLOVIR, 5 MG | ACYCLOVIR SODIUM (10X10ML;SDV,LATEX-FREE) 50 MG/1 ML | IV |
68382-0049-10 | J0133 | INJECTION, ACYCLOVIR, 5 MG | ACYCLOVIR SODIUM (10X20ML;SDV,LATEX-FREE) 50 MG/1 ML | IV |
68382-0119-01 | J7500 | AZATHIOPRINE, ORAL, 50 MG | AZATHIOPRINE (USP) 75 MG | PO |
68382-0120-01 | J7500 | AZATHIOPRINE, ORAL, 50 MG | AZATHIOPRINE (USP) 100 MG | PO |
68382-0351-01 | J7520 | SIROLIMUS, ORAL, 1 MG | SIROLIMUS (FILM-COATED) 1 MG | PO |
68382-0352-01 | J7520 | SIROLIMUS, ORAL, 1 MG | SIROLIMUS (COATED) 2 MG | PO |
68382-0383-06 | J8999 | PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS | EXEMESTANE (FILM COATED) 25 MG | PO |
68382-0520-01 | J7520 | SIROLIMUS, ORAL, 1 MG | SIROLIMUS (COATED) 0.5 MG | PO |
68382-0591-01 | Q0175 | PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN | PERPHENAZINE (USP,FILM COATED) 2 MG | PO |
68382-0592-01 | Q0175 | PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN | PERPHENAZINE (USP,FILM COATED) 4 MG | PO |
68382-0593-01 | Q0175 | PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN | PERPHENAZINE (USP,FILM COATED) 8 MG | PO |
68382-0594-01 | Q0175 | PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN | PERPHENAZINE (USP,FILM COATED) 16 MG | PO |
HCPCS Code | Description | Billing Unit | SA Type |
|---|---|---|---|
S9355 | Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem | Day | N |
S9357 | Home infusion therapy, enzyme replacement intravenous therapy (e.g., Imiglucerase); administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem | Day | N |
S9359 | Home infusion therapy, antitumor necrosis factor intravenous therapy (e.g., Infliximab); administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem | Day | N |
S9361 | Home infusion therapy, diuretic intravenous therapy; administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem | Day | N |
E0217 | Water circulation heat pad, with pump | Each | N |
E0217RR | Water circulation heat pad, with pump | Day | N |
A4555 | Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only. Must be reviewed by OCMO. | Each | Y |
A4558 | Conductive gel or paste, for use with electrical device (E.G., TENS, NMES) per oz | Tube | N |
A4595 | Electrical stimulator supplies, 2 lead, per month (e.g. TENS, NMES) | Pair | N |
A4630 | Replacement batteries for medically necessary transcutaneous electrical nerve stimulator (TENS) owned by patient | Each | N |
E0731 | Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from patient's skin by layers of fabric) | Each | Y |
E0720 | TENS Units, Two Lead, localized stimulation | Each | Y |
bottom of page