January 2014 Jean C. Russell, MS, RHIT [email protected] Richard Cooley, BA, CCS [email protected] Matthew H. Lawney MSPT, MBA, CHC, [email protected] 518-430-1144 2 Agenda • • • • • • Payment Basics Code & Payment Changes 2014-2015 • 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 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 Status K No Longer Paid 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 15 Status K to Packaged 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 16 Status N or E to K 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 10/2013 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 19 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 28 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% 40 Devices 41 Pass-through Devices Category of devices eligible for transitional passthrough payment for at least 2 and up to 3 years Pass-through device list updated quarterly All of the pass-through devices for 2013 are now packaged, one remains a status H in 2014 HCPCS Code Short Descriptor 2013 SI 2014 SI C1841 Retinal Prosthesis N/A H C1830 Power bone marrow bx needle H N C1840 Telescopic intraocular lens H N C1886 Catheter, ablation H N APC 1841 42 FB and FC Modifiers For devices with no cost of a partial credit, the FB and FC modifiers will no longer be reported They will be reported with a value code FD if there is a credit of 50% or most (see Table 30 for list of APCs) FD value will be the credit received from the manufacturer Radiopharmaceuticals will also no longer require these modifiers since they are rarely free 43 Required Device Edit CMS had proposed to eliminate this edit in 2013 In light of the delayed comprehensive APCs and due to comments that were received CMS is going to continue these edits to at least 2015 See Final Rule Table 7 for a listing of the current device-dependent APCs 44 DME-POS Supplies Some supplies, e.g., prosthetics/orthotics, are separately payable from the DMEPOS fee schedule CMS has finalized the proposal to update the SI for all supplies, except prosthetics/orthotics, to unconditionally packaged (“N”) 45 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 46 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-ServicePayment/DMEPOSFeeSched/OTS_Orthotics.html 47 Questions and Discussion 48 Contact Us Richard Cooley Phone: Email: 518-430-1144 [email protected] Matthew Lawney Phone: Email: 845-642-6462 [email protected] Jean Russell Phone: Email: 518-369-4986 [email protected] 49 http://www.EpochHealth.com/ 50 CPT® Current Procedural Terminology (CPT®) Copyright 2012 American Medical Association All Rights Reserved Registered trademark of the AMA 51 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.