Pharmacy Revenue Cycle Podcast

Self-administered drugs (SAD) have been a long-standing controversy when administered in a hospital outpatient setting from the perspectives of a patient, frontline healthcare workers, and billing. “Why does my Tylenol cost $10 per tablet, but the 1,000-count bottle I have at home was purchased for $3?” This question is often difficult to answer and may lead to unintended operational consequences.

The new year brings a new focus on resolutions including prior authorization processes. In July 2020, Medicare implemented a prior authorization process for select services including botulinum toxin. Its time to revisit workflow processes and, if not exempt, confirm with respective teams that a prior authorization is obtained prior to providing the service.

The Pharmacy Revenue Cycle is starting out with a new fashion design for 2023 as there are 36 new brand-specific HCPCS codes. CMS has been reviewing its approach for assigning HCPCS Level II codes for drugs that have been approved under the Food, Drug and Cosmetic Act 505(b)(2) New Drug Application (NDA) or the Biologics License Application (BLA) after October 2003. These drugs are not rated therapeutically equivalent to the reference drug listed in the FDA’s Orange Book and therefore are considered single-source products according to section 1847A(c)(6) of the Social Security Act. Each single source product should be assigned a unique billing and payment code which now includes the brand name in the description to differentiate the HCPCS. Additionally, CMS removes brand names from the HCPCS description when the code is used for multiple source drugs.

In efforts to decrease the use of “not otherwise specified codes” and align with the definitions embedded within the Social Security Act for single and multisource products, CMS plans to continue their review of products that were approved under separate NDA or BLA pathways after October 2003 and are not considered therapeutically equivalent to a listed reference product in an existing code.

Shout Outs!

1. Pharmacy and revenue integrity teams should ensure their HCPCS codes have been updated to reflect the changes effective 1/1/2023 and be on the lookout for additional brand-specific HCPCS codes in quarterly updates.
2. Pharmacy and IT teams should evaluate their processes to ensure each NDC is matched to the correct HCPCS and that the NDC being administered to the patient is the NDC that is represented on the claim.
3. Don’t forget to check out our updated tools to help you manage your pharmacy revenue cycle!

The Centers for Medicare & Medicaid Services (CMS) provided the OPPS Final Rule for CY2023 in the Federal Register on November 23, 2022. Provisions in this rule will be effective for dates of service on or after January 1, 2023.

Significant changes for drug reimbursement and coding occur in three areas: 340B-acquired drugs, non-opioid pain management reimbursement in Ambulatory Surgery Centers (ASC) and Hospital Outpatient Departments (HOPD), and new requirements for reporting waste in HOPD.

340B-acquired Drugs

In light of the Supreme Court decision in American Hospital Association v. Becerra, 142 S. Ct. 1896 (2022), CMS is applying the default rate, generally average sales price (ASP) plus 6 percent, to 340B acquired drugs and biologicals and removing the increase to the conversion factor that was made in CY 2018 to implement the 340B policy in a budget neutral manner. These changes are reflected in posted ASP Pricing Files and Addendum B reimbursement rates.

Non-opioid pain management

CMS will provide separate payment for five drugs in the ASC setting (but not in the HOPD setting) as non-opioid pain management drugs that function as supplies (Exparel, Omidria, Dextenza, Xaracoll, and Posimir). Note that Zynrelef received pass-through payment status on April 1, 2022, and is therefore eligible for separate payment in both the ASC and HOPD setting in CY2023.

Drug Waste Reporting in Hospital Outpatient Departments

New reporting requirements for drugs where there is no discarded waste were detailed in the CY2023 Physician Fee Schedule Rule and summarized in a recent Visante newsletter and podcast.

The following links and notes provide additional information on changes in drug reimbursement in HOPD for CY2023:

1. Pass-through expirations CY 2022- 32 drugs will have pass-through payment end on December 31, 2022. Table 57 (page 198 pdf)
2. Pass-through Drugs and biologicals that will receive one to four quarters of separate payment in CY 2023- 43 drugs will receive separate payment in one or more quarters in CY2023. Table 58 (pg 202 pdf)
3. Pass-through Drugs and biologicals with pass-through payment status to expire after CY2023 (with pass-through payment end dates)- 49 drugs will continue with pass-through status throughout CY2023. Table 59 (pg 208 pdf)
4. Packaging Threshold- CMS raises the per-day cost packaging threshold for separate payments from $130 to $135.
5. Biosimilars- Visante has provided a recent newsletter that details payment increases for biosimilars.

Hope this summary is helpful in evaluating your reimbursement for the coming year!

SHOUT-OUT

1. All pharmacy revenue cycle teams should review the OPPS CY 2023 Rule Final Rule and ensure systems are updated by January 1, 2023.

This edition of Pharmacy Revenue Cycle News is a compilation of all quarterly resource files that detail code changes pertinent to drug billing effective October 1, 2020. Here’s a listing of the files and a short description of what each one contains. We recommend that pharmacy, finance, and revenue integrity review all files for changes pertinent to drugs in use at the facility, and update their IT systems to reflect the current information. We have three shoutouts; two pertain to reviewing previous claims for potential rebilling, and also an evaluation of formulary status for drugs with status indicator changes regarding separate payment.

• October 2020 OPPS Update Revised update posted on September 24 with HCPCS code changes (Section 8, page 5 of pdf file)
• MLN Matters: OPPS Update Educational materials for health care professionals on CMS programs, policies, and initiatives
• Outpatient Code Editor (OCE) Release Files Summary of code changes used to edit Medicare outpatient claims
• Addenda A and B Provide payment rates for all services under OPPS (Hospital Outpatient and Ambulatory Surgery Centers
• October 2020 Restated Payment Rates Corrected payment rates for two HCPCS codes (Q5107-Mvasi and J1557-Gammaplex)
• Medically Unlikely Edits (MUE) Maximum units of service expected for a single beneficiary on a single date of service per HCPCS code
• October 2020 ASP Drug Pricing Files ASP Pricing File- Payment rates for drugs with Column J indicating new additions, “Added October 2020” NOC Pricing File- Payment rates for select drugs which have not been assigned a HCPCS code
• October 2020 Drug NDC-HCPCS Crosswalks ASP NDC-HCPCS Crosswalk- all drugs with assigned HCPCS codes that are used in HOPD, ASC, and physician offices OPPS NDC-HCPCS Crosswalk- for assigned codes used only in HOPD and Ambulatory Surgery Centers (ASC) NOC NDC-HCPCS Crosswalk- for Not Otherwise Classified (NOC) codes AWP NDC-HCPCS Crosswalk- for flu, pneumonia, hepatitis B and albumin when paid on an AWP basis
• CMS Medicaid Drug Rebate File (most recent file is for 2ndQU 2020) Listing of National Drug Codes (NDC) covered under State Medicaid Programs
• AMA- CPT Codes for Vaccines New codes are published in January and July, therefore no update in October
• AMA- Annual CPT code release New codes are released in January, therefore no update in October
• FY2021 ICD-10-CM and ICD-10-PCS codes Annual code release for diagnosis, and inpatient procedure codes

1. The Finance Team will want to review previous claims with retroactively revised status indicators. For this quarter, the status indicator for HCPCS code Q5121 (Injection, infliximab-axxq, biosimilar, (avsola), 10 mg) for the period of July 6, 2020 through September 30, 2020 will be changed retroactively from status indicator =”E2” to status indicator = “K” indicating that it will now be separately paid from its FDA approval data of July 6. Facilities who administered Avsola during the 3rd quarter should review outpatient claims to determine if they received payment, and if not, consider rebilling claims to recoup the additional payment. This may impact Medicare, Medicaid, TRICARE, and commercial payers with rate schedules similar to Medicare.

2. The Finance Team will want to review previous claims with two HCPCS codes that have restated payment rates. For October 2020, two drug HCPCS codes are listed wit...