Billing and Coding Guide. Hospital Outpatient Department

Transcription

1 illing nd oding Guide Hospitl Outptient Deprtment

2 overge, coding, nd pyment in the hospitl outptient deprtment ONPTTRO (ptisirn) received US Food nd Drug dministrtion (FD) pprovl on 10 ug 2018, nd is indicted for the tretment of the polyneuropthy of hereditry trnsthyretin-medited myloidosis in dults. overge For Medicre ptients receiving ONPTTRO who re covered under Medicre Prt enefit, the Medicre dministrtive ontrctors (Ms) my require dditionl chrt documenttion to determine the medicl necessity of the tretment, lthough prior uthoriztion is not required For ptients enrolled in Stte Medicid or commercil helth pln, ONPTTRO coverge will vry y pyer Pyment Medicre Pyer Type Stte Medicid nd ommercil Pyers Pyment Methodology 95% of verge Wholesle Price (WP) Pyment rtes will vry y pyer nd provider contrct It is lwys the provider s responsiility to determine the pproprite helthcre setting nd to sumit true nd correct clims for products nd services rendered. Providers should contct third-prty pyers for specific informtion on their coding, coverge, nd pyment policies. Medicre reimursement for ONPTTRO in the physicin office will vry in its first yer on the mrket. The rte listed is pplicle during the immedite post-lunch period nd is suject to chnge. Due to the implementtion of the 21st entury ures ct, some HOPDs, especilly off-cmpus sites, my e reimursed sed on the wholesle cquisition cost (W) + 6% methodology. Once n verge selling price (SP) hs een estlished, the Medicre pyment for ONPTTRO will e SP + 6%. full 2 qurters of sles dt re required efore n SP cn e estlished. lnylm Field Reimursement Directors re ville to meet with you nd your stff to nswer ny reimursement-relted questions out ONPTTRO. ontct lnylm ssist t Plese see Importnt Sfety Informtion on the following pges nd ccompnying Full Prescriing Informtion. 2

3 oding Plese refer to the tle elow to support pproprite clims sumission for ONPTTRO. ode Type ode ode Description ID-10-M E85.1 Neuropthic heredofmilil myloidosis PT c,d HPS e (Medicre, Medicid, or ommercil Pyers) J3490 J1094 J1200 J2780 Intrvenous infusion, for therpy, prophylxis, or dignosis (specify sustnce or drug); initil, up to 1 hour Intrvenous infusion, for therpy, prophylxis, or dignosis (specify sustnce or drug); ech dditionl hour Intrvenous infusion, for therpy, prophylxis, or dignosis (specify sustnce or drug); dditionl sequentil infusion of new drug/sustnce, up to 1 hour Unlisted therpeutic, prophylctic, or dignostic intrvenous or intr-rteril injection or infusion hemotherpy dministrtion, intrvenous infusion technique; up to 1 hour, single or initil sustnce/drug hemotherpy dministrtion, intrvenous infusion technique; ech dditionl hour Unclssified drugs or iologicls Unclssified drugs Dexmethsone f Diphenhydrmine f Rnitidine f 0250 Generl phrmcy Revenue 0260 Intrvenous therpy 0636 Drugs requiring detiled coding ND g 10-digit: digit: mg/5 ml (2 mg/ml) single-dose vil c PT 2014 mericn Medicl ssocition. ll rights reserved. d One-hour code covers up to 90 minutes. e lims sumitted with miscellneous code 9399 should include product nme, route of dministrtion, nd dosge in ml nd ND (ND ) in Loctor 80 on the U-04 clim form. Providers should contct commercil pyers nd Stte Medicid gencies for specific informtion on reporting drugs using miscellneous HPS codes. f For premedictions not ville or not tolerted intrvenously, equivlents my e dministered orlly. g Given ll the different possile sources for J1094, J1200, nd J2780 NDs s well s different HPS codes for premeds, plese consult with your Field Reimursement Director or the mnufcturers for the pplicle ND nd HPS codes. ID-10-M=Interntionl lssifiction of Diseses, 10th Revision, linicl Modifiction; PT=urrent Procedurl Terminology; HPS=Helthcre ommon Procedure oding System; ND=Ntionl Drug ode.

4 Hospitl outptient: smple U-04 clim form ONPTTRO (ptisirn) nd the ssocited services provided in hospitl outptient setting re illed on the U-04 clim form or its electronic equivlent. smple U-04 clim form for illing ONPTTRO is provided on the next pge. The following U-04 clim form for ONPTTRO is for illustrtive purposes It is the provider s responsiility to determine the pproprite helthcre setting nd to sumit true nd correct clims for the products nd services rendered Providers should contct pyers for specific informtion on their coding, coverge, nd pyment policies Some pyers my require the use of JW modifier when illing for the unused portion of the single-dose vil (wstge) providers should contct pyers out specific coding nd pyment policies Providers should contct their illing softwre vendors to ensure they re utilizing the recommended loops nd segments Dosing clcultion exmple ONPTTRO is supplied s 10 mg/5 ml (2 mg/ml) solution in single-dose vil The recommended dose of ONPTTRO is 0.3 mg/kg dministered vi n 80-minute intrvenous (IV) infusion once every 3 weeks Dosing is sed on ctul ody weight. For ptients weighing 100 kg, the recommended dose is 30 mg lcultion How to clculte mg (ody weight (kg) x 0.3 mg/kg) = mg How to clculte ml (mg x 5 ml/10 mg) = ml Proper preprtion of ONPTTRO requires filtrtion to remove prticultes. n dditionl vil my e required depending on the type of filter used nd the mount of product tht remins in the filter (hold-up volume). The clcultor found in the ONPTTRO Dosing & dministrtion Guide ssumes tht 1 ml of drug product remins in the filter when determining the numer of vils needed. Exmple - 68 kg ptient mg ml 68 kg x 0.3 mg/kg = 20.4 mg 20.4 mg x 5 ml/10 mg = 10.2 ml Plese see Importnt Sfety Informtion on the following pges nd ccompnying Full Prescriing Informtion. 4

5 LOTOR 42 List the pproprite revenue code for the service provided. For Medicre, use the revenue code 0636 Drugs requiring detiled coding. For pyers other thn Medicre, the revenue code for ONPTTRO my vry, lthough some privte pyers nd Medicid plns ccept revenue code 0250 Generl phrmcy PT. 4 TYPE NTL # OF ILL. MED. RE. # 8 PTIENT NME 10 IRTHDTE 11 SEX DMISSION 12 DTE 13 HR 14 TYPE 15 SR Smple U-04 lim Form 16 DHR 9 PTIENT DDRESS c d 5 FED. TX NO. 6 STTEMENT OVERS PERIOD FROM THROUGH c d 17 STT ONDITION ODES DT 30 STTE 31 OURRENE 32 OURRENE 33 OURRENE 34 OURRENE 35 OURRENE SPN 36 OURRENE SPN 37 ODE DTE ODE DTE ODE DTE ODE DTE ODE FROM THROUGH ODE FROM THROUGH VLUE ODES VLUE ODES VLUE ODES ODE MOUNT ODE MOUNT ODE MOUNT 42 REV. D. 43 DESRIPTION 44 HPS / RTE / HIPPS ODE 45 SERV. DTE 46 SERV. UNITS 47 TOTL HRGES 48 NON-OVERED HRGES 49 7 e LOTOR 40 There re 3 different scenrios for PT codes (listed elow). For ech, the first clim line should lwys e for ONPTTRO with J3490 followed y the premed HPS codes /96366 nd comintion /96415 nd comintion scenrio LOTOR 45 Enter the service dte LOTOR 43 Enter the corresponding description for the revenue code listed in Loctor PGE OF RETION DTE TOTLS 52 REL. 53 SG. INFO EN. 50 PYER NME 51 HELTH PLN ID 54 PRIOR PYMENTS 55 EST. MOUNT DUE 56 NPI 57 OTHER PRV ID 58 INSURED S NME 59 P.REL 60 INSURED S UNIQUE ID 61 GROUP NME 62 INSURNE GROUP NO LOTOR 46 Enter the numer of service units for ech line item. LOTOR 47 Enter the totl chrge for ech line item. LOTOR 44 Enter the pproprite HPS code. For Medicre: 9399 Unclssified drugs nd iologics For Medicid nd ommercil Pyers: J3490 Unclssified drugs 63 TRETMENT UTHORIZTION ODES 66 DX 67 D E F G H I J K L M N O P Q 69 DMIT 70 PTIENT 71 PPS DX RESON DX c ODE EI c 74 PRINIPL PROEDURE. OTHER PROEDURE. OTHER PROEDURE 75 ODE DTE ODE DTE ODE DTE 76 TTENDING NPI QUL c. d. OTHER PROEDURE OTHER PROEDURE ODE DTE ODE DTE 80 REMRKS U-04 MS-1450 PPROVED OM NO e. OTHER PROEDURE ODE DTE LST FIRST c 64 DOUMENT ONTROL NUMER 65 EMPLOYER NME 77 OPERTING 78 OTHER 79 OTHER d LST FIRST Ntionl Uniform NU illing ommittee LST LST NPI NPI NPI FIRST QUL FIRST QUL QUL THE ERTIFITIONS ON THE REVERSE PPLY TO THIS ILL ND RE MDE PRT HEREOF. 68 LOTOR 66 Enter 0 to indicte use of the ID-10-M dignosis coding system. LOTOR 67 Enter the primry dignosis code. LOTOR 80 Until permnent HPS code for ONPTTRO is issued, enter the product nme, route of dministrtion, dosge in ml (refer to exmple on the left to find out how to clculte dosing), nd ND (ND ). onfirm with the pyer whether dditionl informtion is required in this field (e.g., wstge, invoice price, strength in mg/ml).

6 Loop nd segment guide Importnt considertions when including ND informtion long with unlisted codes on your U-04 clims Medicre nd commercil insurers require tht dditionl informtion e included on your clims when illing NDs, especilly when the corresponding HPS code is Not Otherwise lssified (NO) code like 9399 (Medicre) or J3490 (commercil insurers). In ddition, some pyers my lso require tht unlisted PT code e used to report n ONPTTRO (ptisirn) infusion. The tle elow is quick loop nd segment reference guide when illing your U-04 clims electroniclly. Plese e sure to contct your pyers to inquire out dditionl informtion tht my e required. Informtion ode(s) or dditionl Informtion U-04 Loctor Electronic Loop Equivlent Segment HPS or PT ode For Medicre: 9399 nd/or For Medicid nd ommercil Pyers: J3490 nd/or Loctor SV Unlisted PT ode Descriptor ONPTTRO IV, ND , XmL dose, Xmg strength c Loctor SV202-7 PT ode(s) 96365/96366/ /96415/96367 Loctor SV202-2 HPS Level II ode Units 1 Loctor SV205 dditionl Product Informtion ONPTTRO IV, ND , XmL dose, Xmg strength c Loctor NTE01 nd NTE02 ID-10-M ode (primry) E85.1 Loctor HI01-2 ill Type ode Provide specific Loctor LM05-1 Revenue ode(s) Other revenue codes my pply, s pproprite Loctor SV201 ND Identifier N4 Loctor LIN02 ND Numer Loctor LIN03 Quntity/Dosge (Numer of ND units) sed on ptient weight. Refer to ONPTTRO dosing clcultion exmple on pge 4 Loctor TP04 Unit of Mesure ml Loctor TP05-1 When required. Pyers my prefer tht unlisted PT ode nd NO descriptors e included in one loop/segment comintion over nother. Including ONPTTRO IV, ND , XmL dose, Xmg strength in oth sections of your electronic clims is cceptle nd ensures you re sumitting this importnt informtion to your pyers. c The recommended dose of ONPTTRO is 0.3 mg/kg. For ptients weighing 100 kg, the recommended dose is 30 mg. Plese see Importnt Sfety Informtion on the following pges nd ccompnying Full Prescriing Informtion. 6

7 len clim filing checklist Select the pproprite primry dignosis onfirm pproprite clinicl documenttion to support dignosis Understnd ny pyer-specific requirements (prior uthoriztion, coding detils, etc.) Utilize ll pproprite ID-10, PT, HPS nd Revenue codes For Medicre clims in the hospitl outptient deprtment (HOPD), use 9399 s the miscellneous HPS code Rememer: illing Unit = 1 In generl, ll other clims (non-medicre pyers nd Medicre physicin office) use the miscellneous code J3490 (Unclssified drugs) If using miscellneous code, mke sure Loctor 80 d (U-04) is unlocked nd ville for use within the illing softwre Properly document the 11-digit ND, product nme, route of dministrtion, nd dosge in ml (see pge 4 for exmple of dosing clcultion) Rememer to use the smple clim form on pge 5 s guide nticipte requests from pyers for dditionl clinicl informtion prior to clims eing processed for pyment lnylm Field Reimursement Directors re ville to help nswer ny reimursement-relted questions you my hve out ONPTTRO. ontct lnylm ssist t d It is lwys the provider s responsiility to determine the pproprite helthcre setting nd to sumit true nd correct clims for those products nd services rendered. ontct third-prty pyers for specific informtion on their coding nd pyment policies.

8 8m 7pm ET, Mondy Fridy : : To lern more out ONPTTRO, visit Indiction ONPTTRO (ptisirn) is indicted for the tretment of the polyneuropthy of hereditry trnsthyretinmedited myloidosis in dults. Importnt Sfety Informtion Infusion-Relted Rections Infusion-relted rections (IRRs) hve een oserved in ptients treted with ONPTTRO. In controlled clinicl study, 19% of ONPTTRO-treted ptients experienced IRRs, compred to 9% of plceo-treted ptients. The most common symptoms of IRRs with ONPTTRO were flushing, ck pin, nuse, dominl pin, dyspne, nd hedche. To reduce the risk of IRRs, ptients should receive premediction with corticosteroid, cetminophen, nd ntihistmines (H1 nd H2 lockers) t lest 60 minutes prior to ONPTTRO infusion. Monitor ptients during the infusion for signs nd symptoms of IRRs. If n IRR occurs, consider slowing or interrupting the infusion nd instituting medicl mngement s cliniclly indicted. If the infusion is interrupted, consider resuming t slower infusion rte only if symptoms hve resolved. In the cse of serious or life-thretening IRR, the infusion should e discontinued nd not resumed. Reduced Serum Vitmin Levels nd Recommended Supplementtion ONPTTRO tretment leds to decrese in serum vitmin levels. Supplementtion t the recommended dily llownce (RD) of vitmin is dvised for ptients tking ONPTTRO. Higher doses thn the RD should not e given to try to chieve norml serum vitmin levels during tretment with ONPTTRO, s serum levels do not reflect the totl vitmin in the ody. Ptients should e referred to n ophthlmologist if they develop oculr symptoms suggestive of vitmin deficiency (e.g. night lindness). dverse Rections The most common dverse rections tht occurred in ptients treted with ONPTTRO were upper respirtory trct infections (29%) nd infusion relted rections (19%). Plese see ccompnying Full Prescriing Informtion for dditionl informtion. ONPTTRO nd lnylm ssist re trdemrks of lnylm Phrmceuticls, Inc lnylm Phrmceuticls, Inc. ll rights reserved. TTR02-US