Effective January 1, 2025: ASP+6% reimbursement for EXPAREL when billing with code J0666 across all outpatient surgical settings.1-3 Discover more

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DAYS TO PREPARE FOR EXPANDED REIMBURSEMENT

Centers for Medicare & Medicaid Services (CMS) is ready to expand reimbursement to qualifying non-opioids like EXPAREL. Now it's your turn.

Starting January 1, 2025, the NOPAIN Act will mandate that Medicare provide ASP+6% reimbursement for qualifying non-opioid options such as EXPAREL when used in outpatient surgeries.2,3

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ASP+6% = reimbursement of 106% of the average sales price

ABOUT THE NOPAIN ACT

The NOPAIN Act mandates that Medicare reimburse for qualified non-opioids, like EXPAREL, across all outpatient settings (both ASC and HOPD)2,3

The bipartisan and bicameral NOPAIN Act was designed to increase patient and provider access to non-opioid pain management options by removing the barriers associated with reimbursement for the Medicare population. With Congress passing the NOPAIN Act, you can now provide branded non-opioids—like EXPAREL—to your Medicare patients for improved management of postsurgical pain while minimizing financial barriers.2,4,5

reimbursement

Congress has mandated that Medicare provide ASP+6% reimbursement for qualifying non-opioid options2,3

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The NOPAIN Act will expand access across ASC and HOPD settings2

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The NOPAIN Act will cover reimbursement for drugs and devices that have demonstrated the ability to reduce or avoid intraoperative or postoperative opioid use, including EXPAREL2,5,6

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The Act was designed to take steps to stop future addiction before it can begin by ensuring that Medicare patients have access to non-opioids while dealing with postsurgical pain2,4

EXPAREL Billing and Reimbursement

Effective January 1, 2025

New HCPCS code J0666 when billing for EXPAREL across all outpatient surgical settings1,3

  • ASP+6% Medicare reimbursement is available for EXPAREL across all outpatient settings when using code J0666 (1 mg = 1 unit)
  • This unique J-code can be used to bill for EXPAREL use across outpatient settings for dates of service on or after January 1, 2025
  • When billing for EXPAREL, be sure to bill as milligram (mg) dosage for the number of units (eg, 133 or 266), not vials or mL
  • For dates of service prior to January 1, 2025, Medicare reimbursement is available in ASCs when billing with C9290

For reimbursement support or questions:

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Helpline 1-855-793-9727

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reimbursement@pacira.com
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EXPARELpro.com/reimbursement

Learn more about EXPAREL
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IMPLEMENTING THE ACT

Five steps to help your health system get ready for the NOPAIN Act reimbursement

Consider the following steps to help ensure that your system is ready to implement this new Medicare policy change.

ensure
ENSURE

billing and coding teams thoroughly understand the key tenets of the NOPAIN Act, focusing specifically on additional reimbursement for non-opioid pain management options like EXPAREL

capture
CAPTURE

the current utilization of qualifying non-opioid options in postsurgical settings, and explore service lines with high outpatient volume or potential of outpatient transition to better understand coding needs

integrate
INTEGRATE

HCPCS code J0666 to capture the additional Medicare reimbursement for EXPAREL across all patient settings for dates of service on or after January 1, 20251,2*

inform
INFORM

financial, clinical, and operational stakeholders to ensure system-wide readiness. Educate stakeholders on the importance of accurate documentation to support billing and coding

track
TRACK

claims submissions and key outcomes to monitor reimbursement and impact of implementation

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MAKE THE PACT TODAY AND COMMIT TO BRINGING
THE NOPAIN ACT TO YOUR HEALTH SYSTEM

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Support the use of non-opioid pain management

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References

  1. CMS.gov. Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS) Application Summaries and Coding Recommendations. Published October 30, 2024. Accessed October 31, 2024. https://www.cms.gov/files/document/2024-hcpcs-application-summary-quarter-3-2024-drugs-and-biologicals-posted-10-02-2024.pdf;
  2. Consolidated Appropriations Act 2023. Accessed October 31, 2024. https://www.congress.gov/117/bills/hr2617/BILLS-117hr2617enr.pdf;
  3. CMS.gov. Medicare part B drug average sales price. Updated October 29, 2024. Accessed October 31, 2024. https://www.cms.gov/medicare/payment/fee-for-service-providers/part-b-drugs/average-drug-sales-price;
  4. Voices for non-opioid choices. Voices for non-opioid choices coalition applauds Congress for expanding access to non-opioid pain management options in end-of-year legislative package to combat addiction crisis. Published December 23, 2022. Accessed October 31, 2024. https://nonopioidchoices.org/wp-content/uploads/2022/12/Voices-Press-Statement-NOPAIN-Act-Passage-12.23.22.pdf;
  5. Federal Register. Medicare and Medicaid programs: Hospital outpatient prospective payment and ambulatory surgical center payment systems; quality reporting programs, including the Hospital Inpatient Quality Reporting Program; health and safety standards for obstetrical services in hospitals and critical access hospitals; prior authorization; requests for information; Medicaid and CHIP continuous eligibility; Medicaid clinic services four walls exceptions; individuals currently or formerly in custody of penal authorities; revision to Medicare special enrollment period for formerly incarcerated individuals; and all-inclusive rate add-on payment for high-cost drugs provided by Indian Health Service and tribal facilities. Accessed October 23, 2024. https://www.federalregister.gov/documents/2024/07/22/2024-15087/medicare-and-medicaid-programs-hospital-outpatient-prospective-payment-and-ambulatory-surgical;
  6. CMS.gov. CY 2025 Medicare hospital outpatient prospective payment system and ambulatory surgical center payment system proposed rule (CMS 1809-P). Published July 10, 2024. Accessed October 31, 2024. https://www.cms.gov/newsroom/fact-sheets/cy-2025-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center

ASC, ambulatory surgical center; HCPCS, Healthcare Common Procedure Coding System; HOPD, hospital outpatient department; NOPAIN Act, Non-Opioids Prevent Addiction in the Nation Act.

*For dates of service prior to January 1, 2025, Medicare reimbursement is available in ASCs when billing with C9290. For commercial or Medicare Advantage plans, please confirm with the individual payer.

EXPAREL® (bupivacaine liposome injectable suspension) and Pacira are registered trademarks of the respective subsidiaries of Pacira BioSciences, Inc. All other trademarks referenced herein are the property of their respective owners.

Indication

EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block. Safety and efficacy have not been established in other nerve blocks.

Important Safety Information
  • EXPAREL is contraindicated in obstetrical paracervical block anesthesia.
  • Adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via nerve block were nausea, pyrexia, headache, and constipation.
  • Adverse reactions with an incidence greater than or equal to 10% following EXPAREL administration via infiltration in pediatric patients six to less than 17 years of age were nausea, vomiting, constipation, hypotension, anemia, muscle twitching, vision blurred, pruritus, and tachycardia.
  • Do not admix lidocaine or other non-bupivacaine local anesthetics with EXPAREL. EXPAREL may be administered at least 20 minutes or more following local administration of lidocaine.
  • EXPAREL is not recommended to be used in the following patient populations: patients <6 years old for infiltration, patients younger than 18 years old for nerve blocks, and/or pregnant patients.
  • Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease.
Warnings and Precautions Specific to EXPAREL
  • Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL.
  • EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and adductor canal block, or intravascular or intra-articular use.
  • The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.
Warnings and Precautions for Bupivacaine-Containing Products
  • Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression.
  • Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability, which may lead to dysrhythmias, sometimes leading to death.
  • Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients.
  • Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use.
  • Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use.

Please refer to full Prescribing Information.

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EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block. Safety and efficacy have not been established in other nerve blocks.