February 2013 Jean C. Russell, MS, RHIT jrussell@epochhealth.com Richard Cooley, BA, CCS rcooley@epochhealth.com 518-430-1144 2 Payment Basics Agenda Code & Payment Changes 2013 Drugs Vaccines Self Administered Drugs Drug Wastage Billing units Devices and POS 3 Outpatient Payment Medicare Outpatient Drugs, biologicals and vaccines are paid under APCs Roughly 800 drugs, biologicals and vaccines are identified by HCPCS code Roughly 320 are paid while the rest are packaged or non-covered Paid drugs are Status G (pass-through), K (nonpass through), or L (reasonable cost) 1
4 Medicare IP Some Drugs paid in addition to DRGs Report clotting factors Use rev code 636 Report Vaccines Use rev code 636 Use bill type 12x (inpatient part B) rather than type 11x (inpatient bill) Chapter 18, Preventative Services, Medicare Claims Processing Manual, website: http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c18.pdf) 5 Medicaid Payment APG- CLASS PHARMACOTHERAPY Report drug HCPCS on claim Paid by weight x rate (based on rate code) http://www.health.ny.gov/health_care/medicaid/rates/apg/rates/hospital/ index.htm Most OP drugs billed under 1432 Clinic 1402 - ER Carve-out drugs reported separately 6 Carve Outs APG APG Desc Carve Out 430 Class I Chemotherapy Drugs Yes 431 Class II Chemotherapy Drugs Yes 432 Class III Chemotherapy Drugs Yes 433 Class IV Chemotherapy Drugs Yes 434 Class V Chemotherapy Drugs Yes 441 Class VI Chemotherapy Drugs Yes 443 CLASS VII CHEMOTHERAPY DRUGS Yes 465 CLASS XIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY Yes 495 MINOR CHEMOTHERAPY DRUGS Yes Complete carve-out (never pay) list available at: http://www.health.ny.gov/health_care/medicaid/rates/methodology/a pg_carve_out.htm 2
7 Carve Outs Report as referred ambulatory- no rate code Report with National Drug Code (NDC) NDC maintained by pharmacist in formulary 8 25x Rev Codes 250 General Pharmacy 251 Generic Drugs Pharmacy 252 Nongeneric Drugs Pharmacy 253 Take Home Drugs Pharmacy 254 Drugs Incident To Other Diagnostic Services 255 Drugs Incident To Radiology 256 Experimental Drugs 257 Nonprescription Drugs 258 IV Solutions Pharmacy 259 Other Pharmacy 636- Drugs Requiring Detailed Coding 637- Self-Administrable Drugs 9 Drug Cost Threshold Moved from $75 in 2012 to $80 for 2013 Drugs greater than $80 per day cost (national average) will be paid Used ASP+6 percent per unit payment amount across all dosage levels of a specific drug or biological by the estimated units per day 3
10 5-HT3 Antiemetics 5-HT3 chemo antiemetics are not exempt from cost-per-day threshold rule Most are packaged J2469 (Injection, palonosetron hcl, 25 mcg) falls above $80/day and will paid as a status K (non-pass through) drug 11 Pass-Through Drugs Temporary at least 2 to not more than 3 year pass-through of cost for new drugs Twenty-three pass-through drugs and biologicals will expire, though only one will become packaged, the rest will become status K (non pass-through) Twenty-six pass-through drugs and biologicals for 2013- status G (passthrough)- thirteen new 12 Status Change G to N Hexaminolevulinate HCl Inj 100mg- C9275 4
13 New Pass-through Drugs 2013 Short Descriptor Injection, pertuzumab Injection, glucarpidase Inj, taliglucerase alfa Injection, carfilzomib Injection, ziv-aflibercept Aflibercept injection Belatacept injection Centruroides immune f(ab) Erwinaze injection Brentuximab vedotin inj Epifix Grafix core Grafix prime CI SI APC HCPCS Code NI G 9292 C9292 NI G 9293 C9293 NI G 9294 C9294 NI G 9295 C9295 NI G 9296 C9296 NI G 1420 J0178 NI G 9286 J0485 NI G 1431 J0716 NI G 9289 J9019 NI G 9287 J9042 NI G 9366 Q4131 NI G 9368 Q4132 NI G 9369 Q4133 14 Medicare Drug Changes Desc HCPCS 2012 stat 2013 Replace Brentuximab Vedotin Inj 1mg C9287 G D report use J9042 Doxorubicin HCL liposome Inj 10mg Q2048 K D report use J9002 Aflibercept Inj 1mg Q2046 G D report use J0178 Asparaginase Erwinia Chrysanthemi Inj 1000iu C9289 G D report see J9019 Belatacept Inj 1mg C9286 G D report use J0485 Centruroides (Scorpion) Immune f(ab)2 (equine) Inj 1vial C9288 G D report see J0716 Everolimus Oral 0.25mg J8561 K D report use J7527 Human Fibrinogen Conc Inj 1mg Q2045 K D report use J7178 Ibuprofen Inj 100mg C9279 G D report use J1741 Peginesatide Inj 0.1mg (for ESRD on Dialysis) Q2047 A D report use J0890 Medroxyprogesterone Acetate Inj 50mg J1051 N D report see J1050 15 Code and Dose Change Desc HCPCS 2012 stat 2013 Replace Centruroides (Scorpion) Immune f(ab)2 (equine) Inj 1vial C9288 G D report see J0716 Centruroides Immune f(ab)2 Inj up to 120mg J0716 N/A G 5
16 Status E Drug Changes Desc HCPCS 2012 stat 2013 Replace Doxorubicin HCL liposome Inj 10mg J9001 E D Human Fibrinogen Conc Inj 100mg J1680 E D report see J9002 report see J7178 MA/EC Contraceptive Inj J1056 E D Valid through 12/31/2012 Medroxyprogesterone Acetate for Contraceptive Use Inj 150mg J1055 E D Valid through 12/31/2012-- to report see J1050 17 Now Paid for 2013 Desc HCPCS 2012 stat 2013 Estrone Inj 1mg J1435 E K Interferon Alfacon-1 Recom Inj 1mcg J9212 N K Arbutamine HCL Inj 1mg J0395 E K Calcitonin Salmon Inj up to 400u J0630 N K Desmopressin Acetate Inj 1mcg J2597 N K Diazoxide Inj up to 300mg J1730 N K Fomivirsen Na Intraocular Inj 1.65mg J1452 E K Gatifloxacin Inj 10mg J1590 N K Testosterone Enanthate Inj up to 1cc J0900 N K Visualization Adjunct Inj 1mg Q9968 N K 18 New Vaccines HCPCS Description Status Valid Q2034 Influenza virus vaccine, split virus, for intramuscular use (Agriflu) L 7/1/2012 90672 Flu vaccine 4 valent nasal L 1/1/2013 90653 Flu vaccine adjuvant im E 1/1/2013 90687 Flu vaccine 4 val 6-35 mo im E 1/1/2013 90688 Flu vacc 4 val 3 yrs plus im E 1/1/2013 90739 Hep b vacc adult 2 dose im E 1/1/2013 6
19 Deleted Vaccines HCPCS Description Status Invalid 90665 Lyme disease vaccine im D 1/1/2013 90701 Dtp vaccine im D 1/1/2013 90718 Td vaccine > 7 im D 1/1/2013 G9142 Influenza A H1N1, vaccine D 1/1/2013 20 Drug Administration No major changes Continue to reimburse using the five-level APC structure for drug administration services 21 Self Administered Drugs Self-administered drugs (SAD) are considered a statutory exclusion from Medicare benefits Reported in the non-covered portion of the outpatient bill Use Rev Code 637 for OP billing For most commercial payers report with a 250 revenue code 7
22 SAD Medicare Part B does not cover drugs that are usually (i.e., more than 50% of the time) selfadministered by the patient It is a benefit category denial and not a denial based on medical necessity An Advance Beneficiary Notice ( ABN ) is not required Therefore providers may charge the beneficiary for an excluded drug If Hospital pharmacy participates (most don t) in Part D drug plan, then some SAD may be covered 23 NGS SAD List Contractors (FI/MACs) must publish a list of the injectable drugs that are subject to the selfadministered exclusion on their Web site Link to NGS SAD list-- http://www.cms.gov/medicare-coveragedatabase/indexes/articlelist.aspx?cntrctr=63&name=national%20government%20services,%20inc.%20%20( 00450,%20FI)&DocStatus=SAD&ContrNum=00450&CntrctrType=FI&LCntrctr=63&bc =BAACAACAAAAA&#ResultsAnchor J1675 INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS Histrelin acetate 10mg J1815 INJECTION, INSULIN, PER 5 UNITS Insulin J1817 INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS Insulin for administration 24 Billing for Wastage The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer to patients in such a way that they can use drugs or biologicals most efficiently When a provider must discard the remainder of a single use vial or other single use package after administering a drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label Medicare Claims Processing Manual Chapter 17 - Drugs and Biologicals 8
25 Wastage Document what was wasted Can be per patient documentation Can be included in a drug wastage policy Watch billing wastage for multi-use vials OIG has recommended FIs set up an edit that looks for drug billing units equal to full vials for multi-use vial drugs 26 Multi Use Vials Herceptin comes in a multiuse vial of 440 milligrams Herceptin, when reconstituted with BWFI and stored properly, can be used for up to 28 days For multiuse vials, Medicare pays only for the amount administered to a beneficiary and does not pay for any discarded drug A payment for an entire multiuse vial is likely to be incorrect This audit is part of a nationwide review of the drug Herceptin Report by THE OFFICE OF INSPECTOR GENERAL- December 2012 A-05-11- 00112 27 JW Modifier The JW modifier is only applied to the amount of drug or biological that is discarded Not required by NGS Some Hospitals use the JW modifier as part of there wastage documentation program 9
28 NDC Review National Drug Code maintained in the formulary by the pharmacist 11 digit code represents brand (labeler), drug and dose, vial size NDC is used for billing for some payers e.g., Medicaid Annual review is important https://www.emedny.org/info/formfile.aspx 29 Billing Units Maintain Medicare billing units definition in CDM, not vial size from formulary E.g., CDM description- Tirofiban HCL Inj 0.25mg Formulary description- Tirofiban HCL Inj 12.5mg 1 vial = 50 billing units-- J3246 x 50 Round up partial units to whole billing units 30 Formulary to CDM Review Review at least annually Join Formulary to CDM Reconcile Formulary items not linked to CDM Drug CDM items with no formulary link All multipliers 10
31 Pyxis Review the pharmacy Pyxis (or other automated dispensing system) Links to the CDM need to be verified Pull sample claims and verify charge flow to billing 32 Devices 33 Pass-through Devices Category of devices eligible for transitional pass-through payment for at least 2 and up to 3 years Pass-through device list updated quarterly Devices no longer eligible for pass through payment are packaged into the payment for the procedure it is associated with 11
34 APC Status H Devices 2013 There are three pass-through devices for 2013 HCPCS Code Short Descriptor 2012 SI 2013 SI APC C1749 Endo, colon, retro imaging H N C1830 Power bone marrow bx needle H H 1830 C1840 Telescopic intraocular lens H H 1840 C1886 Catheter, ablation H H 1886 35 No Cost/Full Credit and Partial Credit Devices For 2013 the policy will continue without modification the no cost/full credit and partial credit adjustments Affects payment for recalls of devices as a result of failures Manufacturers have offered devices without cost or with partial cost to the hospital Ensure that payment rates for procedures involving devices reflect only the full costs of those devices 36 POS Prosthetics Orthotics POS are covered under Part B when furnished incident to a physician services or order.. Payment for prosthetics and orthotics is made on the basis of a fee schedule whether it is billed to the DMERC or the FI... Institutional providers bill their FI for prosthetics and orthotics devices and supplies. Generally, Medicare does not pay for DME in a facility. For hospital outpatient DME, bills go to the appropriate DMERC. Source: Medicare Claims Processing Manual, Chapter 20, DMEPOS, https://www.cms.gov/manuals/downloads/clm104c20.pdf 12
37 POS Prosthetics Orthotics Off the Shelf Orthotics Common POS found on hospital CDM and claims Require minimal self-adjustment for appropriate use Source: http://www.cms.gov/medicare/medicare-fee-for-service- Payment/DMEPOSFeeSched/OTS_Orthotics.html 38 Questions and Discussion 39 Richard Cooley Contact Us Phone: 518-430-1144 Email: RCooley@EpochHealth.Com Jean Russell Phone: 518-369-4986 Email: JRussell@EpochHealth.Com 13
40 http://www.epochhealth.com/ 41 CPT Current Procedural Terminology (CPT ) Copyright 2012 American Medical Association All Rights Reserved Registered trademark of the AMA 42 Disclaimer Information and opinions included in this presentation are provided based on our interpretation of current available regulatory resources. No representation is made as to the completeness or accuracy of the information. Please refer to your payer or specific regulatory guidelines as necessary. 14