October 2020 Quarterly code updates

10/05/20 • 6 min

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

Shout-outs!

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...

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

Shout-outs!

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...

Previous Episode

TRICARE NTAP and Investigational Drugs related to COVID-19

The Department of Defense published an Interim Final Rule in the Federal Register on September 3, 2020 with two provisions which directly impact payment for drugs on TRICARE inpatient and outpatient claims.

The first provision is that TRICARE will adopt the payment criteria and formulas for new technology add-on payments (NTAP) as outlined in CMS Inpatient Prospective Payment System (IPPS) Final Rule. This is a new payment provision and will be made retroactive to January 1, 2020. In the future, TRICARE will adopt CMS’s effective date of October 1 of each year. This is listed as a permanent change. For a tool listing the FY2020 and FY2021 drugs eligible for CMS NTAP payments (and now applying to TRICARE), see: NTAP Tool.

The second provision is a temporary provision where TRICARE, for the first time, will cover not just the care associated with administration of an investigational drug, but the investigational drug itself, when the investigational drug is for the treatment of COVID–19 or its associated sequelae. This use may be authorized in any setting for which the FDA allows treatment use of an investigational drug under expanded access to proceed.

The change under this provision is temporary for the duration of the President’s national emergency for the COVID–19 outbreak, but the drug may continue to be covered beyond the national emergency if the course of treatment was started prior to the end of the national emergency.

TRICARE indicated that it intends to use this national emergency period to re-evaluate their current exclusion on coverage of treatment INDs and may revise the regulation to cover investigational drugs for treatment use under expanded access for all indications if appropriate after they evaluate the costs, benefits, risks, and other considerations. Coverage for investigational drugs may impact both inpatient and outpatient TRICARE claims as the charges may contribute to outlier payments and there may be additional separate reimbursement on outpatient claims depending upon the cost incurred by the facility.

TRICARE has 9.4 million beneficiaries who receive healthcare in a network of civilian providers and military hospitals and clinics. TRICARE beneficiaries are the men and women of the Armed Forces and their families including active duty and retirees, as well as National Guard and Reserve members

SHOUTOUTS!

1. The Finance Team will want to review all FY2020 CMS NTAP-eligible drugs to determine if any were used on TRICARE inpatients with claim dates on or after January 1, 2020. The appropriate ICD-10-PCS codes should be added if not already on the claim and rebilled to TRICARE.

2. The Finance Team will want to include TRICARE accounts in any edits or monitoring for FY2021 NTAP drugs (similar to their current process for Medicare), to ensure that appropriate ICD-10-PCS codes are added to the claim.

3. The Pharmacy and P&T Committee should include Medicare and TRICARE data when evaluating NTAP-designated drugs for formulary status.

Next Episode

Let’s Talk About Billing Drug Waste

Have you ever questioned...

“Is charging for waste worth the effort?”

“Am I required to charge for drug waste?”

“My organization states we have been charging for waste for over a decade, what is all the hoopla for now?”

Billing for the waste of drugs and biologicals has been embedded in the CMS manuals for many years. CMS has always encouraged providers to administer drugs in a manner that minimizes waste when clinically appropriate. For example, providers may consider scheduling patients in a way that allows multiple patient doses prepared from the same vial(s) reducing any waste. However, the direction on billing drug waste has been left murky.

In 2007 CMS revised their manual to include language surrounding discarded drugs and biologicals. Educational material and information directed by the Medicare Administrative Contractors (MAC) was unclear and contractors inconsistently mandated the use of the JW modifier (Drug amount discarded/Not administered to any patient). In 2016 CMS attempted to require the use of the JW modifier but rescinded the change requests several times pushing back the effective date. Finally, effective January 1, 2017, CMS implemented a change to Section 40 - Discarded Drugs and Biologicals of Chapter 17 of the Claims Processing Manual 100-04. The change requires the use of a JW modifier to identify unused portions of a single dose vial or package for Part B drugs and biologicals. Additionally, the unused drug or biologics must be properly discarded and documented in the patient's medical record.

CMS has published an FAQ that provides more answers to specific questions. Listed below are a few key points to take into consideration.

If the provider (hospital or supplier) seeks payment for the billed waste, the JW modifier is required for separately payable drugs or biologics. These are identified by the status indicator of G (Pass-Through Drugs and Biologicals) or K (Nonpass-Through Drugs and Biologicals). Status indicator N (items or services packaged into APC rates) drugs are not required to report the JW modifier.
The unused drug or biologic must be reported on a separate line on the claim with a JW modifier and appropriately reflect the amount of drug waste in terms of billed units.
CMS does not allow for fractional billed units; thus, when the wasted portion of the vial is less than 1 billed unit the waste should be left off the claim.

Example:

Patient X was administered cyclophosphamide 1450 mg dose with 50 mg of waste. The medical record documented the use of a 1,000 mg vial and a 500 mg vial to create the dose. This resulted in 50 mg of waste in the medical record.

Cyclophosphamide represents 100 mg per billing unit. The 50 mg of waste are less than the one billed unit; thus, cannot be reported on the claim. The dose of 1450 mg will be rounded up to 15 billed units on the claim and accounts for all the billing units in the vials. Billing for waste in the scenario would represent overbilling as the 50 mg would also round up to 1 billing unit totally 16.

Shoutouts!

“Is charging for waste worth the effort?”

YES! Organizations should work with their finance team or analyst to help determine the annual net revenue impact on your high cost drugs. Waste is inevitable and can lead to large amounts of revenue leakage for not charging.

“Am I required to charge for drug waste?”

Not necessarily. However, if you are seeking payment for the unused portion of a drug or biologic it is required that you identify the line appropriately with a JW modifier.

“My organization states we have been charging for waste for over a decade, what is all the hoopla for now?”

It is great if your organization has already developed a mechanism to apply the JW modifier; however, the regulations effective January 1, 2017 expanded the direction to all MACs to require the use of the JW modifier for unused portions of a single use vial or package for Part B drugs and biologicals AND documentation in the medical record must support the billed waste.