Pharmacy Revenue Cycle News: Recent Episodes
Agatha Nolen
Pharmacy Revenue Cycle News aims to provide you with helpful tips, resources, and emerging updates that can improve your pharmacy revenue. We have one very simple goal. We take complex and ever changing rules and regulations to bring you awareness and practical tools that can help you understand and enhance your pharmacy revenue cycle. Our website is full of resources, tools, explanations and links that can help you navigate the pharmacy revenue cycle. Each newsletter provides you with practical tips for you to put into practice.
CMS has proposed that non-disable, under age 65 year old kidney transplants have lifetime coverage under Part B for immunosuppressives instead of the 36-month limit currently.
Whoa! IPPS Proposed Rule includes new process that drugs for NTAP be reported with an NDC number rather than an ICD-10-PCS code. Can your IT system handle this change so you don't lose revenue?
Why would an IVPB charge be denied by a payer? In some cases the payer is incorrectly denying the charge. The denial should be clarified and challenged when appropriate.
Billing for ESAs on outpatients requires special modifiers and may include laboratory values.
The Integrated Outpatient Code Editor (I/OCE) is a useful quarterly update to help in producing a reimbursable claim.
Two new HCPCS code and one new product bring the total to six products classified as Car T-cell therapy.
Denied Claims should be reviewed but if the billing is correctly and the service is medically necessary, an appeal is warranted.
CMS has established a HCPCS code for reimbursement when outpatients receive convalescent plasma.
Aduhelm and proposed NCD For Medicare requires a qualifying clinical trial for coverage.
Pharmacy is in a unique position to help with Pharmacy Revenue Cycle when Quarterly Restated Payment Rates are significant.
Setting hospital drug prices can be complex or simple, but there are basic factors to be considered.
Dietary Supplements and Herbal Products aren’t drugs and can’t be billed as if they were.
Critical Access Hospitals have different rules and different reimbursement from Part A and Part B.
Some things appear to be drugs but are devices and vice versa. How does this impact revenue?
Only certain NDC numbers are eligible for coverage and payment under State Medicaid Programs. CMS has a database where the NDC number can be verified.
Influenza, Pneumonia and Hepatitis B vaccine for high risk patients are covered under Part B regardless of provider location.
We wrote, CMS listened! Cetuximab MUE increased to 150 units to accommodate new dosing regimen.
A new, handy tool for checking all Quarterly Updates to ensure that all systems, business decisions have been reviewed and updated.
Car T-cell therapies are new innovative treatments for certain types of cancer. Correct billing is critical due to the expense of the products and clinical resource intensity.
Tocilizumab is administered to inpatients under an EUA. Since it represents a cost to the hospital, how is the best way to bill for it to get separate payment?
With a world-wide shortage of tocilizumab, billing is a challenge when switching patients to alternative drugs for non-COVID-19 indications.
Outlier payments are calculated on both inpatient and outpatient claims, but you have to report all charges to be eligible.
CMS has proposed to rescind the Most Favored Nation Interim Final Rule. Comments are due to CMS by October 12. 2021.
Based upon EUAs revised by the FDA, CMS has issued new billing codes for the administration of a 3rd dose of Pfizer or Moderna COVID-19 vaccine.
Back to flu season and all new NDC numbers! Here's a tool for building drug profiles for influenza vaccine.
Why did the CMS reimbursement for two drugs decrease by 20% in July 2021? CMS has a new way of calculating ASP based upon new statutes.
Whether to bill a medicare patient for take home medications is dependent upon whether the patient is an inpatient or an outpatient and if an inpatient if it is a “limited supply”.
A new dosing regimen approved by the FDA on April 6, 2021 exceeds the current MUE if administered to a patient with a BSA of 3 m2. Pharmacy Revenue Cycle requested an increase which the NCCIPTP Coordinator has indicated will be implemented in a future quarterly update.
CMS Quarterly updates include new HCPCS codes, replacement codes and changes in payment status as well as updated payment rates.
Revenue Codes are used on hospital claims and there are specific ones assigned to drug products. These track to the Medicare cost report, so its important to set these correctly in the chargemaster.
COVID Infusions have tricky billing rules as some EUAs allow for two drugs to be given together, but CMS has only issues one HCPCS code for billing.
Drugs purchased under 340B require modifiers on Medicare claims based upon whether a drug is separately paid and/or has pass-through status.
CMS pays a DRG with a higher relative weight when TPA is administered to an inpatient. ICD-10-PCS codes are added to the claim to drive the higher payment.
Hemophilia Factors are expensive but Medicare provides extra reimbursement for both inpatients and outpatients for certain diagnosis groups.
The Enhanced Ambulatory Patient Grouping or (EAPG) is among the models focused on transitioning fee for service to a value based payment. Over 25% of the state Medicaid programs in addition to several commercial payers have adopted the EAPG outpatient prospective payment system.
Drugs approved by the FDA can be used by physicians for "off-label" uses. CMS has provided guidance on when and how these uses should be covered and reimbursed.
Pass-through status can apply to new drugs for 2-3 years after an application is approved by CMS.
Receiving facilities, usually comprehensive stroke centers receive additional reimbursement when tPA was administered at a community hospital and the patient transferred to the stroke center. A specific ICD-10-CM code, Z92.82 is added to the inpatient claim.
CAR T-cell therapy (Chimeric Antigen Receptor) is a new expensive immunotherapy used in the treatment of various cancers. Due to the high cost ($375,000-$500,000 per dose), it is important to ensure that billing and coding is correct and complete on outpatient claims.
CMS has re-started their Targeted Probe and Educate (TPE) Program to identify billing errors. The Medicare Administrative Contractors (MACs) have identified some drugs for review. It is important to understand the denials and correct them as the consequences can be severe if there are continued billing deficiencies.
CMS publishes corrected payment rates for drugs and biologicals each quarter. By comparing the previous posted payment, a health system can determine whether rebilling is appropriate.
Radiopharmaceuticals are drugs, but have special billing rules. And some payers require that the National Drug Code (NDC) number be reported on the outpatient claim.
CMS announced increased payments for COVID-19 vaccine administration on or after March 15, 2021. It is now $40 per dose (with geographic adjustments).
Some Medicare Administrative Contractors (MACs) are requiring that certain drug HCPCS codes have a route of administration modifier added to distinguish the IV route from the SC route. Failure to add the modifier correctly could cause a claim rejection or overpayment.
CMS has not provided instructions for billing for Pharmacists’ Services in a Hospital Outpatient Department. Using an anticoagulation clinic as an example, we provide the key elements that should be considered when billing for these services.
We are hearing of more charge rejections for an 'invalid NDC' number. We've identified six top reasons why this occurs and what you can do to correct it.
Billing Medicare outpatients for self-administered drugs (SADs) isn't popular. In 2015, the OIG published a statement that waiving these charges is permitted when certain conditions are met.
Billing for Pharmacists’ Services in a Physician Office was detailed in the Physician Fee Schedule (PFS) Final Rule published on December 28, 2020. Key elements must be met to bill, and services cannot duplicate what has already been paid under Part D benefits.
New drugs are coded with HCPCS code C9399 and partial vials are used. There are special billing instructions and requirements when billing C9399 with waste.
President Biden issued a Memorandum to Agency Directors for a 60-day Regulatory Freeze impacting at least 5 drug-related rules.
COVID-19 vaccine billing is tricky with distinct HCPCS codes for the product and administration; but when receiving the product for free, the product code should not appear on the claim.
NUBC has announced two new condition codes to be added to claims starting February 1, 2021 for Expanded Access and Emergency Use Authorization services.
A judge in California has issued an injunction prohibiting CMS from implementing the Most Favored Nation (MFN) Model Rule until an appropriate notice and comment period has occurred. Also in this episode is a recap of the 2021 OPPS Rule and updated tools for C9399 and Hemophilia Factor reporting.
A judge in Maryland has issued a 14-day Temporary Restraining Order prohibiting CMS from implementing the Most Favored Nation (MFN) Model Rule on January 1, 2021.
CMS has posted payment rates for The Most Favored Nation (MRN) Model Rule was published on November 27, 2020 by CMS and will decrease drug payments in Hospital outpatient departments, physician offices, and ambulatory surgery centers starting January 1, 2021. We answer a new question on reporting of M1145.
The Most Favored Nation (MRN) Model Rule was published on November 27, 2020 by CMS and will decrease drug payments in Hospital outpatient departments, physician offices, and ambulatory surgery centers starting January 1, 2021. We answer a new question on reporting of M1145.
The Most Favored Nation (MRN) Model Rule was published on November 27, 2020 by CMS and will decrease drug payments in Hospital outpatient departments, physician offices, and ambulatory surgery centers starting January 1, 2021. We answer a few early questions.
Interim Final Rule published on November 27, 2020 outlines Most Favored Nation pricing for drugs in hospital outpatient departments, physician offices, and ambulatory surgery centers. Payments will be reduced starting January 1, 2021.
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Bamlanivimab, a monoclonal antibody infusion has been granted an Emergency Use Authorization (EUA) by the FDA for outpatient care. CMS has provided billing instructions for Medicare and Medicare Advantage plans.
Rabies Immune Globulin and Rabies Vaccine need to be coded as an "exposure" to ensure payment under the medical benefit.
Recently approved by the FDA, Remdesivir may be reported with HCPCS code C9399 in revenue code 636.
TRICARE now covers New Technology Add-on Payments on Inpatients and investigational drugs related to COVID-19.
For FY2021, effective October 1, 2020, nineteen drugs are eligible for maximum NTAP payments ranging from $1014.79 to $125,448.05 per case. This News update provides information about what a provider needs to do to qualify for the extra payment on inpatient claims.
Each year the influenza season brings about its own challenges from distribution to billing. In the midst of a pandemic, influenza billing may seem trivial which is more the reason a simplified tool could boost your accuracy. For our debut of the Pharmacy Revenue Cycle Newsletter and website, we bring you an Influenza Billing Tool.