January 2014
Jean C. Russell, MS, RHIT jrussell@epochhealth.com
Richard Cooley, BA, CCS rcooley@epochhealth.com
Matthew H. Lawney MSPT, MBA, CHC, mlawney@epochhealth.com
518-430-1144
2
Agenda
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•
•
•
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Payment Basics
Code & Payment Changes 2014-2015
• Drugs
• Vaccines
Self Administered Drugs
Drug Wastage
Billing units
3
Outpatient Payment
Medicare Outpatient
 Drugs, biologicals and vaccines are paid under
APCs
 Roughly 900 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 and F (reasonable cost)
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-andGuidance/Guidance/Manuals/Downloads/clm104c18.pdf
5
Payment
Medicaid
 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- “Never Pay APGs”
APG
430
431
432
433
434
441
443
APG Desc
Class I Chemotherapy Drugs
Class II Chemotherapy Drugs
Class III Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class V Chemotherapy Drugs
Class VI Chemotherapy Drugs
CLASS VII CHEMOTHERAPY DRUGS
CLASS XIII COMBINED
CHEMOTHERAPY AND
465 PHARMACOTHERAPY
495 MINOR CHEMOTHERAPY DRUGS
Alternative Payment Date added to
APG Type
Available*
Never Pay List
Drug
Yes - carve out
12/1/2008
Drug
Yes - carve out
12/1/2008
Drug
Yes - carve out
12/1/2008
Drug
Yes - carve out
12/1/2008
Drug
Yes - carve out
12/1/2008
Drug
Yes - carve out
1/1/2010
Drug
Yes - carve out
1/1/2011
Drug
Drug
Yes - carve out
Yes - carve out
7/1/2011
7/1/2012
http://www.health.ny.gov/health_care/medicaid/rates/methodology/apg_
carve_out.htm
7
Carve Outs
 Report as referred ambulatory- no rate
code
 Report with National Drug Code (NDC)
 NDC maintained by pharmacist in formulary
 Report with Acquisition Cost
8
Rev Codes
 25x










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
Code & Payment Changes
2014-2015
10
Drug Cost Threshold
 Moved from $80 in 2013 to $90 for 2014
 Drugs greater than $90 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
11
2014 Payment for Drugs
Drugs, Biologicals, and Radiopharmaceuticals
 Pass- through drugs will be paid at Average Sale
Price plus 6%
 If ASP data is not available then Wholesale
Acquisition Cost plus 6%
 If no WAC then 95% of most recent Average
Wholesale Price
12
Pass-Through Drugs
 Temporary “at least” 2 to “not more than” 3
year “pass-through” of cost for new drugs
 Fourteen pass-through drugs and
biologicals will expire, five became
packaged, the rest became status K (non
pass-through)
 Fourteen new pass-through drugs in 2014
13
New Pass-through Drugs 2014
14
2013 Status K No Longer Paid
in 2014
Drug Description
HCPCS
10/2013 SI
1/2014 SI
Adenosine Inj Dx 30mg
J0152
K
D
Certolizumab Pegol Inj 1mg
J0718
K
D
Filgrastim Inj 300mcg
J1440
K
D
Filgrastim Inj 480mcg
J1441
K
D
Zoledronic Acid Inj NOS 1mg
Q2051
K
D
Interferon Beta 1A IM Inj 11mcg
Q3025
K
D
Rotovirus Vacc 2 Dose Oral
90681
K
E
Alglucerase Inj 10u
J0205
K
E
Estrone Inj 1mg
J1435
K
E
Immune Globulin SC Inj 100mg
J1562
K
E
Gonadorelin HCL Inj 100mcg
J1620
K
E
Diazoxide Inj up to 300mg
J1730
K
E
Itraconazole Inj 50mg
J1835
K
E
Protirelin Inj 250mcg
J2725
K
E
Urokinase Inj 250,000iu vial
J3365
K
E
Leuprolide Acetate Impl 65mg
J9219
K
E
Sermorelin Acetate Inj 1mcg
Q0515
K
E
Arbutamine HCL Inj 1mg
J0395
K
E
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2013 Status K to Packaged in
2014
Drug Description
HCPCS
10/2013 SI
1/2014 SI
Clevidipine Butyrate Inj 1mg
C9248
K
N
Methyldopate HCL Inj up to 250mg
J0210
K
N
Amphotericin B Cholesteryl Inj 10mg
J0288
K
N
Anidulafungin Inj 1mg
J0348
K
N
Testosterone Enanthate Inj up to 1cc
J0900
K
N
Dimethyl Sulfoxide Inj 50% 50ml
J1212
K
N
Fomivirsen Na Intraocular Inj 1.65mg
J1452
K
N
Gatifloxacin Inj 10mg
J1590
K
N
Minocycline Hydrochloride Inj 1mg
J2265
K
N
Oxacillin Sodium Inj up to 250mg
J2700
K
N
Regadenoson Inj 0.1mg
J2785
K
N
Rho-D Immune Globulin Inj 50mcg
J2788
K
N
Somatropin Inj 1mg
J2941
K
N
Human Fibrinogen Conc Inj 1mg
J7178
K
N
Everolimus Oral 0.25mg
J7527
K
N
Busulfan Oral 2mg
J8510
K
N
Fludarabine Phosphate Oral 1mg
J8562
K
N
Epirubicin HCL Inj 2mg
J9178
K
N
Gemcitabine Inj HCl 200mg
J9201
K
N
Interferon Alfacon 1 Recom Inj 1mcg
J9212
K
N
Visualization Adjunct Inj 1mg
Q9968
K
N
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2013 Status N or E to K in
2014
Drug Description
HCPCS
10/2013 SI
1/2014 SI
Interferon Alfa N3 Inj 250,000iu
J9215
N
K
Interferon Alfa 2A Inj 3mu
J9213
N
K
Factor VIII (porcine) 1iu
J7191
N
K
Foscarnet Sodium Inj 1000mg
J1455
N
K
Pentobarbital Sodium Inj 50mg
J2515
N
K
Phentolanine Mesylate Inj up to 5mg
J2760
N
K
Totazoline HCL Inj up to 25mg
J2670
E
K
Urea Inj up to 40gm
J3350
N
K
Mumps Vacc SC
90704
N
K
Verify Multipliers!
17
Replacement Codes with Units Change
Drug Description
Chlorpromazine HCL Oral
10mg
Chlorpromazine HCL Oral
25mg
HCPCS 1/2014 SI Drug Description
Chlorpromazine HCL Oral
Q0171
D
5mg
Chlorpromazine HCL Oral
Q0172
D
5mg
HCPCS 1/2014 SI
Dronabinol Oral 5mg
Q0168
D
Pertuzumab Inj 10mg
C9292
D
Q0161
N
Q0161
N
Dronabinol Oral 2.5mg
Q0167
N
Pertuzumab Inj 1mg
J9306
G
18
Vaccine Changes
 Deleted vaccine
 Q2033, Influenza vaccine (flublok)
 New vaccine
 90673, Influenza vaccine, trivalent,
derived from recombinant DNA, for IM
use
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Drug Administration
 No major changes
 Continue to reimburse for the add-on
procedures, with the exception of add-on
vaccination codes and pump reset
 90472, immunization, each additional
 90474, immunize oral/nasal, each additional
 96371, therapeutic infusion SC reset pump
 All three are now unconditionally packaged (SI
N)
20
Proposed Rule 2014
 Create 29 Comprehensive APCs with one payment
made for the primary service plus all adjunctive
services performed to support that service
 These were developed from the 29 highest cost
device dependent APCs
 There will be a new status indicator (J1) to identify
the 136 HCPCS codes which map to the 29
comprehensive APCs
21
Proposed Rule
 A single payment will be made that includes the
following when performed as part of the service:
 All DME items
 Rehab codes, including PT/OT/ST
 All drugs, except pass-through drugs (status G),
including self-administered drugs
 Recovery and extended recovery and observation
services
 Two or more comprehensive APC procedures will
result in payment for the higher paid procedure
 Add-on procedures
22
Final Rule 2014
 Comprehensive APCs have been FINALIZED, But
delayed until 1/1/2015
 Extra time to allow hospitals to perform a thorough
analysis of the impact of this change so that they can
implement changes
 CMS will apply a “degree of complexity” to each J1
procedure
23
Drugs/Biologicals/Radiopharm Dx Tests
 In 2013, the following drugs are APC status N
(unconditionally packaged) unless status G (passthru):
 Drugs with a per day cost less than threshold
 Diagnostic radiopharmaceuticals
 Contrast agents
 Anesthesia drugs
 Drugs used as a supply
 Implanted biologicals
24
Drugs/Biologicals/Radiopharm Dx Tests
 For 2014, CMS is adding more categories of
diagnostic drugs unconditionally packaged
 Drugs, biologicals, and radiopharmaceuticals
that function as supplies when used in
diagnostic tests or procedures
 Drugs and biologicals when used as supplies
in surgical procedures
25
Unconditionally Packaged in 2014
 Stress Agents
 HCPCS Code C9275, Injection, hexaminolevulinate
hydrochloride, 100 mg, per study dose
26
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
27
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
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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
29
Don’t Report Admin
 Do not report the injection administration
with the SAD list drugs
30
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
31
Wastage
 Document what was wasted
 Can be per patient documentation
 Can be included in a drug wastage policy
 Don’t bill waste 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
32
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-05-1100112
33
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
34
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
 Periodic review is important
https://www.emedny.org/info/formfile.aspx
35
Billing Units
 Maintain Medicare billing units definition in CDM, not
vial size from formulary
 E.g., J3246 Tirofiban HCL



CDM description- Tirofiban HCL Inj 0.25mg
Formulary description- Tirofiban HCL Inj 12.5mg
1- 12.5 mg vial = 50 billing units-- J3246 x 50
 Round up partial units to whole billing units
36
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
 Review multipliers
37
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
38
Nuclear Medicine Procedureto-Radiolabled Product Edit
 CMS finalized the proposal to discontinue
this edit
 There will no longer be an edit to ensure
that nuclear medicine drugs are reported
with nuclear medicine procedures
 Therefore care must be taken to ensure
these drugs are correctly reported with the
appropriate charges
39
Radiology Drugs
 Drugs used for contrast and diagnostic
radiopharmaceuticals continue to be packaged
 Exception is one new pass-through drug A9520,
TC 99m Tilimanocept, dx, up to 0.5 millicuries
(was C1204 in 2013)
 Will have an off-set applied to the procedure equal to
the amount included in the procedure payment that
represents packaged drugs
 Non pass-through therapeutic
radiopharmaceuticals will be reimbursed on ASP
plus 6%
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Questions and Discussion
41
Contact Us
Richard Cooley
Phone:
Email:
518-430-1144
RCooley@EpochHealth.Com
Matthew Lawney
Phone:
Email:
845-642-6462
MLawney@EpochHealth.Com
Jean Russell
Phone:
Email:
518-369-4986
JRussell@EpochHealth.Com
42
http://www.EpochHealth.com/
43
CPT®
Current Procedural Terminology (CPT®)
Copyright 2012 American Medical
Association
All Rights Reserved
Registered trademark of the AMA
44
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.