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Transcript
DME Drugs And Supplies 1554_0714_dmedrugs_supplies.pptx Today’s Presenters • Charity Bright – Provider Outreach and Education Consultant • Stacie McMichel – Provider Outreach and Education Consultant 2014 Jurisdiction B Medicare Seminars 2 National Government Services, Inc. Disclaimer • National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) website at http://www.cms.gov. 2014 Jurisdiction B Medicare Seminars 3 National Government Services, Inc. No Recording • Attendees/providers are never permitted to record (tape record or any other method) our educational events – This applies to our webinars, teleconferences, live events, and any other type of National Government Services educational event 2014 Jurisdiction B Medicare Seminars 4 National Government Services, Inc. Acronyms • • • • • • • • • • • ABN – Advance Beneficiary Notice of Noncoverage ACA – Affordable Care Act CMN – Certificate of Medical Necessity CMS – Centers for Medicare & Medicaid Services CNS – certified nurse specialist DIF – DME Information Form DME – durable medical equipment DME MAC – Durable Medical Equipment Medicare Administrative Contractor DMEPOS – durable medical equipment, prosthetics, orthotics and supplies ESRD – End Stage Renal Disease FDA – Federal Drug Administration 2014 Jurisdiction B Medicare Seminars 5 National Government Services, Inc. Acronyms • • • • • • • • • • • • • DO – Doctor of osteopathy DOS – date of service DWO – detailed written order HIV – human immunodeficiency virus HTN – hypertension IOM – Internet-Only Manual LCD – local coverage determination MD – Doctor of medicine MDI – metered dose inhaler NDC – National Drug Code NP – nurse practitioner NPI – National Provider Identifier NSC – National Supplier Clearinghouse 2014 Jurisdiction B Medicare Seminars 6 National Government Services, Inc. Acronyms • • • • • • • • • • • • • NTE – note segment PA – physician assistant PDAC – Pricing, Data Analysis, and Coding Contractor PECOS – Provider Enrollment, Chain and Ownership System PEN – parenteral and enteral nutrition PMD – power mobility device POD – proof of delivery PSC – program safeguard contractor PTAN – Provider Transaction Access Number RUL – reasonable useful lifetime SCIG - Subcutaneous immunoglobulin UOS – Unit of service WOPD – written order prior to delivery 2014 Jurisdiction B Medicare Seminars 7 National Government Services, Inc. Objectives • To provide an understanding of the coverage criteria, documentation requirements, and billing guidelines for DME drugs and supplies. 2014 Jurisdiction B Medicare Seminars 8 National Government Services, Inc. Agenda • • • • • • Program Rules and Regulations Drugs Administered via DME Oral Medications Billing and Coding Guidance Documentation Errors Resources 2014 Jurisdiction B Medicare Seminars 9 National Government Services, Inc. Program Rules And Regulations Program Rules • CMS IOM Publication 100-02, Chapter 15 • CMS IOM Publication 100-04, Chapter 17 – – – – Drugs and Biologicals Meet the definition of drugs and biologicals Not usually self –administered Reasonable and necessary for the diagnosis or treatment of the illness or injury under accepted standards of medical practice – Not excluded as noncovered – FDA has not deemed them to be less than effective 2014 Jurisdiction B Medicare Seminars 11 National Government Services, Inc. Supplies And Accessories • Necessary for the effective use of DME • Must be put directly into the equipment in order to achieve therapeutic benefit of the DME – Drug must be reasonable and necessary for the treatment of the illness or injury to improve the functioning of a malformed body member 2014 Jurisdiction B Medicare Seminars 12 National Government Services, Inc. Limitations Of Coverage • Billed by entity dispensing to beneficiary, and • Entity must be permitted under all applicable federal, state, and local laws and regulations to dispense drugs • Only entities licensed in the state where they are physically located may bill the DME MAC for DME drugs, oral anticancer and oral antiemetic drugs 2014 Jurisdiction B Medicare Seminars 13 National Government Services, Inc. Dispensing Physicians • May bill the DME MAC for drugs if all of the following conditions are met: 1. Enrolled as supplier with the NSC, and 2. Dispensing the drug(s) to the Medicare beneficiary, and 3. Authorized by their state laws 2014 Jurisdiction B Medicare Seminars 14 National Government Services, Inc. Drugs Administered Via DME External Infusion Pump Covered Pumps • E0779 – Ambulatory Mechanical Infusion Pump – Single infusion cycle of at least 8 hours • E0780 – Ambulatory Mechanical Infusion Pump – Single infusion cycle of less than eight hours • E0781 – Ambulatory Electrical or Battery 2014 Jurisdiction B Medicare Seminars 16 National Government Services, Inc. External Infusion Pump Covered Pumps • E0791 – Stationary Electrical Pump – Single or Multiple Channels – Larger and typically mounted pole • E0784 – Ambulatory infusion pump for insulin – External • K0455 – Ambulatory electrical infusion pump – Used for uninterrupted administration of epoprostenol or trespostrinill 2014 Jurisdiction B Medicare Seminars 17 National Government Services, Inc. External Infusion Pumps • General Coverage • A DME infusion pump is covered if – The drug being administered is medically necessary and – A durable type of pump is required to safely and effectively administer the drug • Only those drugs listed in the policy are covered • If the patient owns a pump, the drug and supplies would be covered, if coverage criteria are met 2014 Jurisdiction B Medicare Seminars 18 National Government Services, Inc. Basic Coverage I. II. III. IV. V. Deferoxamine Chemotherapy Morphine Continuous subcutaneous insulin* Use of other drugs I. Anticancer chemotherapy II. Narcotic analgesics III. Antifungal or antiviral drugs IV. Parenteral Inotropic V. Epoprostenil or tresprostinil VI. Gallium nitrate VII. Ziconotide VIII. Subcutaneous immune globulin 2014 Jurisdiction B Medicare Seminars 19 National Government Services, Inc. Subcutaneous Insulin • Treatment of diabetes mellitus (ICD-9 codes 249.00–250.93) if criterion A or B is met and if criterion C or D is met: A. C-peptide testing requirement – must meet criterion 1 or 2 and criterion 3 1. C-peptide level < 110% of the lower limit of normal of the laboratory's measurement method OR 2. Patients with renal insufficiency and a creatinine clearance < 50 ml/min, a fasting C-peptide level < 200% of the lower limit of normal of the laboratory’s measurement method 3. A fasting blood sugar obtained at the same time as the C-peptide level is < 225 mg/dl 2014 Jurisdiction B Medicare Seminars 20 National Government Services, Inc. Subcutaneous Insulin B. Beta cell autoantibody test is positive, only the following test would be acceptable: • Islet Cell Cytoplasmic Autoantibodies (ICA) • The following tests would not be acceptable alternatives to justify reimbursement: • • • • • Glutamic Acid Decarboxylase Auto Antibodies (GADA) GAD65 Autoantibodies ICA512 Autoantibodies Insulinoma-Associated-2 Autoantibodies (IA-2A) Insulin Autoantibodies (IAA) 2014 Jurisdiction B Medicare Seminars 21 National Government Services, Inc. Subcutaneous Insulin C. Meets all the following: • Patient has completed a comprehensive diabetes education program • Been on a program of multiple daily injections of insulin with frequent self-adjustments of insulin dose for at least six months prior to initiation of the insulin pump • Documented frequency of glucose self-testing an average of at least four times per day during the two months prior to initiation of the insulin pump • Meets one or more of the following criteria (1–5) while on the multiple injection regimen: 2014 Jurisdiction B Medicare Seminars 22 National Government Services, Inc. Subcutaneous Insulin 1. Glycosylated hemoglobin level (HbA1C) greater than 7 percent 2. History of recurring hypoglycemia 3. Wide fluctuations in blood glucose before mealtime 4. Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL 5. History of severe glycemic excursions 2014 Jurisdiction B Medicare Seminars 23 National Government Services, Inc. Subcutaneous Insulin D. Patient has been on an external insulin infusion pump prior to enrollment in Medicare and has documented frequency of glucose self-testing an average of at least four times per day during the month prior to Medicare enrollment – If criterion A or B or if criterion C or D is not met, the pump and related accessories, supplies, and insulin will be denied as not medically necessary 2014 Jurisdiction B Medicare Seminars 24 National Government Services, Inc. Subcutaneous Insulin Continued Coverage • Patient has been seen and evaluated by the treating physician at least every six months • The external insulin infusion pump must be ordered and follow-up care rendered by a physician who manages multiple patients on continuous subcutaneous insulin infusion therapy • Subcutaneous insulin is administered using ambulatory infusion pump E0784, all other pumps will be denied as not medically necessary 2014 Jurisdiction B Medicare Seminars 25 National Government Services, Inc. Subcutaneous Immune Globulin (J1562, J1559, J1561, J1569) • SCIG is covered only if criteria 1 and 2 are met – The SCIG preparation is a pooled plasma derivative which is approved for the treatment of primary immune deficiency disease – Patient has a diagnosis of primary immune deficiency disease (ICD-9 codes 279.04, 279.05, 279.06, 279.12, 279.2) • An E0779 infusion pump is covered, if an E0781 or E0791 pump is used, payment will be based on the allowance for the least costly medically appropriate alternative, E0779 2014 Jurisdiction B Medicare Seminars 26 National Government Services, Inc. Intravenous Immune Globulin • An infusion pump is not covered for the administration of intravenous immune globulin 2014 Jurisdiction B Medicare Seminars 27 National Government Services, Inc. Intravenous Immune Globulin • Intravenous immune globulin (IVIG) is covered if all of the following criteria are met: 1. It is an approved pooled plasma derivative for the treatment of primary immune deficiency disease; and 2. The patient has a diagnosis of primary immune deficiency disease (ICD-9 codes 279.04, 279.05, 279.06, 279.12, 279.2); and 3. The IVIG is administered in the home; and 4. The treating physician has determined that administration of the IVIG in the patient’s home is medically appropriate. 2014 Jurisdiction B Medicare Seminars 28 National Government Services, Inc. Not Medically Necessary • When other drugs (including but not limited to intravenous antibiotics) are administered using a DME infusion pump, CMS instruction is that they should be denied as not medically necessary – This is not because the drug itself is not medically necessary, but because a DME infusion pump is not medically necessary to administer them – CMS policy is that if a DME item is denied as not medically necessary, then accessories, supplies, and drugs used with the item are also denied as not medically necessary 2014 Jurisdiction B Medicare Seminars 29 National Government Services, Inc. Not Medically Necessary • Treatment of thromboembolic disease and/or pulmonary embolism by heparin infusion in home setting • An infusion controller device (E1399) • An IV pole (E0776) billed with an ambulatory infusion pump (E0779, E0780, E0781, E0784, or K0455) 2014 Jurisdiction B Medicare Seminars 30 National Government Services, Inc. Noncovered • Disposable drug delivery systems, including elastomeric infusion pumps (A4305, A4306, A9274) – Not meet the Medicare definition of durable medical equipment – Drugs and supplies used with disposable drug delivery systems are also noncovered items 2014 Jurisdiction B Medicare Seminars 31 National Government Services, Inc. Supplies – Catheter (A4221) • Code A4221 includes catheters, cannulas, needles, infusion sets, catheter insertion devices, flushing solutions, and any type of dressing used at the insertion site • UOS for A4221 is per week • It is never acceptable to bill > 1 UOS per week, regardless of the type and/or quantity of supplies that are dispensed – Billing for > 1 UOS per week is incorrect coding and can not be appealed 2014 Jurisdiction B Medicare Seminars 32 National Government Services, Inc. Supplies – Catheter (A4221) • Supplies for the maintenance of a parenteral drug infusion catheter (A4221) are covered during the period of covered use of an infusion pump and the weeks in between covered infusion pump use, not to exceed four weeks per episode • Drugs and supplies that are dispensed but not used for completely unforeseen circumstances (e.g., emergency admission to hospital, drug toxicity, etc.) are covered 2014 Jurisdiction B Medicare Seminars 33 National Government Services, Inc. Supplies – Bag/Cassette (A4222) Syringe (K0552) • Supplies used with an external infusion pump, A4222 or K0552, are covered during the period of covered use of an infusion pump • A4222 is used with pumps E0779, E0780, E0781, E0791, K0455 (IV epoprostenol/treprostinil) • K0552 is used with pumps E0779 (subcutaneous immune globulin), E0784, and K0455 (subcutaneous treprostinil) 2014 Jurisdiction B Medicare Seminars 34 National Government Services, Inc. Supplies – Bag/Cassette (A4221) Syringe (K0552) • Allowance is based on the number of cassettes or bags (A4222) prepared or syringes (K0552) used • Intermittent infusions – One cassette or bag is covered for each dose of drug • Continuous infusion – Concentration of the drug, and – Size of the cassette, bag, or syringe • Maximize to result in the fewest cassettes, bags, or syringes 2014 Jurisdiction B Medicare Seminars 35 National Government Services, Inc. Supplies/Accessories – Misc. • Replacement batteries (K0601–K0605) are not separately payable when billed with a rented infusion pump 2014 Jurisdiction B Medicare Seminars 36 National Government Services, Inc. Common Errors • Orders – ACA requirements – Incomplete or missing • • • • Request for refill for DME drugs Proof of delivery for Method 2 Continued Use Continued Need 2014 Jurisdiction B Medicare Seminars 37 National Government Services, Inc. Nebulizers Coverage Criteria • Small volume nebulizer (A7003, A7004, A7005), related compressor (E0570), and FDA-approved inhalation solutions of the drugs are covered for the management of the covered medical conditions 2014 Jurisdiction B Medicare Seminars 39 National Government Services, Inc. Drug Classes Beta agonists: • Short-acting beta agonists (SABA) • Long-acting beta agonists (LABA) Albuterol, levalbuterol, metaproterenol Arformoterol, formoterol Anticholinergic Ipratropium Combination drugs Albuterol and ipratropium Corticosteroid Budesonide Mucolytic – nonspecific Acetylcysteine Anti-inflammatory Cromolyn (almost exclusive for asthma) Mucolytic enzyme Dornase alpha Antibiotic Tobramycin Anti-HIV drug Pentamidine Pulmonary artery vasodilator Iloprost Treprostinil 2014 Jurisdiction B Medicare Seminars 40 National Government Services, Inc. Coverage Criteria • Small volume ultrasonic nebulizer (E0574) – Reasonable and necessary to administer treprostinil inhalation solution only – E0574 used with other inhalation solutions will be denied as not reasonable and necessary • Large volume ultrasonic nebulizer (E0575) – Will be denied as not medically necessary – Any related accessories and supplies will also be denied 2014 Jurisdiction B Medicare Seminars 41 National Government Services, Inc. Not Medically Necessary • Compounded inhalation solutions – (J7604, J7607, J7609, J7610, J7615, J7622, J7624, J7627, J7628, J7629, J7632, J7634, J7635, J7636, J7637, J7638, J7640, J7641, J7642, J7643, J7645, J7647, J7650, J7657, J7660, J7667, J7670, J7676, J7680, J7681, J7683, J7684, J7685, – Compounded solutions billed with J7699 2014 Jurisdiction B Medicare Seminars 42 National Government Services, Inc. Modifiers • KO – Single drug unit dose formulation – Not used with J2545 and Q4074 • KP – First drug of a multiple drug unit dose formulation • KQ – Second or subsequent drug of a multiple drug unit dose formulation • If a unit dose does not have one of these modifiers (with the exception of J7620), it will be denied as an invalid code • The KO, KP, and KQ modifiers are not to be used with the concentrated form codes 2014 Jurisdiction B Medicare Seminars 43 National Government Services, Inc. KX, GA, GZ Modifier Requirement • HCPCS codes E0574, J7686, K0730 and Q4074 only: • Append KX modifier only if: – Requirements specified in the medical policy have been met • When policy criteria are not met: – Execute ABN – Append GA modifier – If ABN is not executed, append GZ modifier 2014 Jurisdiction B Medicare Seminars 44 National Government Services, Inc. Billing E1399 And J7699 • HCPCS E1399 billed for miscellaneous equipment or accessories – Claim must be accompanied by a clear description of the item including the manufacturer and the model name/number if applicable • HCPCS J7699 for miscellaneous inhalation drugs – Include the name of the drug, the manufacturer, the NDC number, the dosage amount (i.e., 50 mg) and the number ampules/bottles dispensed • Report in NTE segment of electronic claim or Item 19 of CMS-1500 paper claim 2014 Jurisdiction B Medicare Seminars 45 National Government Services, Inc. Dispensing Fee • G0333 – Initial dispensing fee – Once in a lifetime fee for the first time as a Medicare beneficiary on or after 01/01/2006 • Q0513 – 30 day dispensing fee • Q0514 – 90 day dispensing fee 2014 Jurisdiction B Medicare Seminars 46 National Government Services, Inc. Allowances Drug Name HCPCS Unit of Service (UOS) Maximum/ Month Maximum UOS/Month Acetylcysteine J7608 Per 1 gram 74 grams/month 74 Albuterol J7611, J7613 Per 1 mg 465 mg/month** 465 Albuterol/Ipratropium combination J7620 Up to 2.5 mg albuterol and 0.5 mg of ipratropium – 3.0mg total – 1 vial 558 mg total/month – 186 vials** 186 Arformoterol J7605 15 mcg 930 mcg/month 62 Budesonide J7626 Up to 0.5 mg – 1 vial 31 mg/month 62 Cromolyn sodium J7631 Per 10 mg 2480 mg/month 248 Dornase alpha J7639 Per 1 mg 78 mg/month 78 Formoterol J7606 20 mcg 1240 mcg/month 62 Ipratropium bromide J7644 Per 1 mg 93 mg/month 93 Levalbuterol J7612, J7614 Per 0.5 mg 232.5 mg/month** 465 Metaproterenol J7669 Per 10 mg 2800 mg/month** 280 Pentamidine J2545 Per 300 mg 300 mg/month 1 Treprostinil J7686 1.74 mg – 1 ampule/vial 31 ampules/vials month 31 Sterile saline or water A4216, A4218 10 ml – 1 unit 560 ml/month 56 Distilled water, sterile water, or sterile saline in large volume nebulizer A4217, A7018 500 ml 18,000 ml – 18 liters/month 36 2014 Jurisdiction B Medicare Seminars 47 National Government Services, Inc. Allowances • When albuterol, levalbuterol, or metaproterenol are prescribed as rescue/supplemental medication for patients who are taking formoterol or arformoterol, the maximum milligrams/month that are reasonably billed are: Drug Name HCPCS Unit of Service (UOS) Maximum/ Month Maximum UOS/Month Albuterol J7611, J7613 1 mg 78 mg/month 78 Albuterol/Ipratropium combination J7620 Up to 2.5 mg albuterol and 0.5 mg of ipratropium – 3.0 mg total – 1 vial 93 mg/month – 31 vials 31 Levalbuterol J7612, J7614 0.5 mg 39 mg/month 78 Metaproterenol J7669 Per 10 mg 470 mg/month 47 • Claims for more than these amounts will be denied as not medically necessary 2014 Jurisdiction B Medicare Seminars 48 National Government Services, Inc. Accessories • Table lists the compressor/generator, which is related to the accessories described • Other compressor/generator/accessory combinations are considered medically unnecessary Compressor/Generator Related Accessories E0565 A4619, A7006, A7007, A7010, A7011, A7012, A7013, A7014, A7015, A7017, A7525, E1372 E0570 A7003, A7004, A7005, A7006, A7013, A7015, A7525 E0572 A7006, A7014 E0574 A7013, A7014, A7016 E0585 A4619, A7006, A7010, A7011, A7012, A7013, A7014, A7015, A7525 K0730 A7005 2014 Jurisdiction B Medicare Seminars 49 National Government Services, Inc. Accessories Accessory Usual Maximum Replacement A4619 One/month A7003 Two/month A7004 Two/month (in addition to A7003) A7005 One/6 months A7005 One/3 months only with K0730 A7006 One/month A7007 Two/month A7010 One unit (100 ft.)/2 months A7011 One/year A7012 Two/month A7013 Two/month A7014 One/3 months A7015 One/month A7016 Two/year A7017 One/3 years A7525 One/month E1372 One/3years 2014 Jurisdiction B Medicare Seminars 50 National Government Services, Inc. HCPCS A9270 • Drugs that are not administered through DME (e.g., Foradil Aerolizer® and MDIs) are statutorily noncovered • If the supplier chooses to submit a claim for drugs not administered through DME, the drug must be billed using code A9270 (noncovered item or service) • Disposable equipment 2014 Jurisdiction B Medicare Seminars 51 National Government Services, Inc. Common Errors • Orders – ACA requirements – Incomplete or missing • Continued use • Continued need 2014 Jurisdiction B Medicare Seminars 52 National Government Services, Inc. Oral Medication Immunosuppressive Drugs Coverage Criteria 1. Following an organ transplant: • • • • • • • V42.0 Kidney V42.1 Heart V42.6 Lung V42.7 Liver V42.81 Bone Marrow V42.82 Peripheral Stem Cells V42.83 Pancreas (for diabetes) – Whole organ (V42.83), partial (V42.89) organ, islet cell (V42.89) • V42.84 Intestines 2014 Jurisdiction B Medicare Seminars 54 National Government Services, Inc. Immunosuppressive Drugs Coverage Criteria 2. Criteria for the transplant met: – – – – Approved facility NCD criteria LCD criteria Carrier/fiscal intermediary LCD criteria 2014 Jurisdiction B Medicare Seminars 55 National Government Services, Inc. Immunosuppressive Drugs Coverage Criteria 3. Medicare Part A enrolled during eligible transplant: – Medicare paid for transplant, or – Other primary insurance paid 4. Enrolled in Medicare Part B when drugs dispensed 5. Drugs furnished on or after the date of discharge from the hospital 2014 Jurisdiction B Medicare Seminars 56 National Government Services, Inc. Specified Coverage • Parenteral azathioprine (J7501) or Methylprednisolone (J2920, J2930) – Medication not tolerated or absorbed if taken orally, and – Self-administered by the patient 2014 Jurisdiction B Medicare Seminars 57 National Government Services, Inc. Not Medically Necessary • Parenteral cyclosporine (J7516), Antithymocyte globulin (J7504, J7511), Muromonab-CD3 (J7505), Tacrolimus (J7525), and Daclizumab (J7513) are not proven safe when – Administered in the home setting, and – Therefore will be denied not medically necessary 2014 Jurisdiction B Medicare Seminars 58 National Government Services, Inc. Modifiers • EY – No physician or other licensed health care provider order for this item or service • GY – Item or service statutorily excluded or does not meet the definition of any Medicare benefit 2014 Jurisdiction B Medicare Seminars 59 National Government Services, Inc. KX Modifier • Beneficiary enrolled in Medicare Part A at the time of transplant • Documentation regarding the beneficiary’s transplant date are on file, and • The beneficiary’s transplant date precedes the DOS for furnishing the drug 2014 Jurisdiction B Medicare Seminars 60 National Government Services, Inc. Supply Fee • Q0510 – First month of initial immunosuppressive drug following transplant • Q0511 – First prescription in a 30-day period • Q0512 – Subsequent prescription in a 30-day period If drug on claim is denied as noncovered, the supply fee will be denied as noncovered 2014 Jurisdiction B Medicare Seminars 61 National Government Services, Inc. Billing • Supply fee must be billed on the same claim as the drug • Quantity of drugs dispensed should be limited to a 30-day supply • Bill a separate claim line if two different dosage strengths of the same drug are dispensed 2014 Jurisdiction B Medicare Seminars 62 National Government Services, Inc. Billing • J7599 NOC immunosuppressive drugs require the following information in the NTE segment field: – – – – Name of the drug, Dosage strength, Number dispensed, and Administration instructions 2014 Jurisdiction B Medicare Seminars 63 National Government Services, Inc. Other Points To Remember • Number of units billed must accurately reflect the definition of one unit of service • ICD-9 code(s) that justify the need must be included on the claim • Coverage is limited to 36 months for beneficiaries whose Medicare entitlement is based solely on ESRD 2014 Jurisdiction B Medicare Seminars 64 National Government Services, Inc. Common Errors • Medical need documentation • Continued use • Continued need 2014 Jurisdiction B Medicare Seminars 65 National Government Services, Inc. Oral Anticancer Drugs Oral Anticancer Drug Coverage • An oral anticancer drug is covered if all of the following criteria (1–4) are met: 1. FDA approved 2. Has the same ingredients as the comparable IV chemotherapeutic drug or biological that is covered when furnished incident to a physician's service 2014 Jurisdiction B Medicare Seminars 67 National Government Services, Inc. Oral Anticancer Drug Coverage • Covered Oral Anticancer Drugs – – – – – – – – Busulfan Capecitabine Cyclophosphamide Etoposide Melphalan Methotrexate Temozolomide Topotecan 2014 Jurisdiction B Medicare Seminars 68 National Government Services, Inc. Oral Anticancer Drug Coverage 3. Used for the same indications, including unlabeled uses, as the non-self-administrable form of the drug • All drugs except topotecan, prescribed for the treatment of cancer (ICD-9 codes 140.0–208.91, 230.0–239.9, 259.2, 273.3, V58.11) • For topotecan, prescribed for the treatment of relapsed small cell lung (ICD-9 codes 162.2–162.9) 4. Prescribed by a physician or other practitioner licensed under state law If criterion 1–4 are not met, the drug will be denied as noncovered 2014 Jurisdiction B Medicare Seminars 69 National Government Services, Inc. Covered Diagnosis • The ICD-9 diagnosis code describing the condition for which the drug is used must be included on each claim Drug Name ICD-9 or Corresponding Covered Diagnosis Codes Topotecan 162.2-162.9 Busulfan, Capecitabine, Cyclophosphamide, Etoposide, Melphalan, Methotrexate, and Temozolomide 140.0-208.91, 230.0-239.9, 259.2, 273.3, V58.11 2014 Jurisdiction B Medicare Seminars 70 National Government Services, Inc. HCPCS J8999 • HCPCS code J8999 should only be used if the oral anticancer drug 11-digit NDC number is not yet in the DME MAC claims processing system – Currently the only drug that should be billed using the J8999 is topotecan • Claims using code J8999 must include the name of the drug, the manufacturer, the NDC number, and the number of tablets or capsules dispensed – Enter in the NTE segment of an electronic claim or Item 19 for paper submission 2014 Jurisdiction B Medicare Seminars 71 National Government Services, Inc. Concurrent Antiemetic Drugs Coverage • A self-administered antiemetic drug billed with code J8498 or J8597 is covered if all of the following criteria are met 1. Used in conjunction with a covered oral anticancer drug, and 2. Administration of the covered oral anticancer drug will likely induce emesis if the antiemetic drug is not administered, and 3. Administered within two hours before the covered oral anticancer drug is administered 2014 Jurisdiction B Medicare Seminars 72 National Government Services, Inc. Concurrent Antiemetic Drugs Coverage • If all of the criteria are not met, the antiemetic drug will be denied as noncovered • Doses of antiemetic drugs administered after the administration of the oral anticancer drug are noncovered • Coverage of oral antiemetic drugs (replacement for intravenous antiemetics) used in conjunction with intravenous cancer chemotherapeutic regimens, refer to the oral antiemetic drugs (replacement for intravenous antiemetics) policy) 2014 Jurisdiction B Medicare Seminars 73 National Government Services, Inc. Noncovered Drugs • Drugs which are not covered under the oral anticancer drug benefit (i.e., those that are not specifically listed in this policy) must be billed using code A9270 (noncovered item or service) if the supplier chooses to submit a claim • Contact the PDAC contractor for guidance on the correct coding of these items 2014 Jurisdiction B Medicare Seminars 74 National Government Services, Inc. Supply Fee • Q0511 – First covered oral anticancer drug dispensed in a 30-day period • Q0512 – Each subsequent covered oral anticancer drug dispensed in a 30-day period If drug on claim is denied as noncovered, the supply fee will be denied as noncovered 2014 Jurisdiction B Medicare Seminars 75 National Government Services, Inc. Billing • Supply fee must be billed on the same claim as the drug • Quantity of drugs dispensed should be limited to a 30-day supply 2014 Jurisdiction B Medicare Seminars 76 National Government Services, Inc. Oral Anticancer Drug Billing • Suppliers must use the 11-digit NDC that matches the product dispensed – 1 unit of service = 1 tablet or 1 capsule • A list of valid NDC numbers for covered oral anticancer drugs can be found on the PDAC website http://www.dmepdac.com 2014 Jurisdiction B Medicare Seminars 77 National Government Services, Inc. Concurrent Antiemetic Drugs Billing • J8498 (Rectal/Suppository) or J8597 (Oral) • Must identify – – – – – Drug Name Manufacturer Dosage strength (each tablet/suppository) Frequency of administration, and The concurrent oral anticancer drug being used • Enter in the NTE segment of an electronic claim or Item 19 for paper submission • Do NOT enter corresponding oral antiemetic drug NDC number 2014 Jurisdiction B Medicare Seminars 78 National Government Services, Inc. Common Errors • Medical need documentation • Proof of delivery for Method 2 • Request for refill 2014 Jurisdiction B Medicare Seminars 79 National Government Services, Inc. Oral Anti-Emetic Drugs Oral Antiemetic Drug Coverage Criteria 1. FDA approved 2. Ordered by the treating physician as part of a cancer chemotherapy regimen 3. Used as a full therapeutic replacement for an intravenous antiemetic drug prior to IV chemotherapy 4. Initial dose of the oral antiemetic drug is administered within two hours before or 48 hours after the administration of the chemotherapy drug 2014 Jurisdiction B Medicare Seminars 81 National Government Services, Inc. Covered Diagnosis • The ICD-9 diagnosis code describing the condition for which the drug is used must be included on each claim ICD-9 Code Corresponding Diagnosis Definition 140.0-208.91 230.0-239.9 273.3 V58.0-V58.12 Malignant neoplasm Carcinoma in situ Macroglobulinemia Radiotherapy chemotherapy 2014 Jurisdiction B Medicare Seminars 82 National Government Services, Inc. Oral Antiemetic Drug Coverage • If all the criteria (1–4) are met, the quantity covered for each episode of chemotherapy cannot exceed the initial loading dose plus 48 hours of therapy – For granisetron (Q0166) and dolasetron (Q0180), the quantity covered for each episode of chemotherapy is limited to the initial loading dose plus 24 hours of therapy • Quantities of drugs in excess of these amounts are noncovered 2014 Jurisdiction B Medicare Seminars 83 National Government Services, Inc. Aprepitant (J8501) and Dexamethasone (J8540) • Are covered only if – Criterion 1-4 are met, and – Administered as part of an oral antiemetic three-drug regimen • Including a 5-HT3 antagonist – Granisetron (Q0166), ondansetron (Q0179), or dolasetron (Q0180) • The oral antiemetic three-drug combination should be submitted on the same claim • If not used as part of this three-drug regimen, the drugs will be denied as noncovered 2014 Jurisdiction B Medicare Seminars 84 National Government Services, Inc. Aprepitant (J8501) and Dexamethasone (J8540) • Covered when administered to patients who are receiving one or more of the following anti-cancer chemotherapeutic agents – – – – – − − − − Carmustine Cisplatin Cyclophosphamide Dacarbazine Mechlorethamine 2014 Jurisdiction B Medicare Seminars 85 Streptozocin Doxorubicin Epirubicin Lomustine National Government Services, Inc. HCPCS Q0181 • HCPCS code Q0181 should only be used if the oral antiemetic drug provided does not have a specified HCPCS code • Claims using code Q0181 must include – – – – – Drug Name Manufacturer Dosage strength dispensed Number of tablets, and Frequency of administration during the covered time period (24-48 hours) as specified on the order • Enter in the NTE segment of an electronic claim or Item 19 for paper submission 2014 Jurisdiction B Medicare Seminars 86 National Government Services, Inc. Supply Fee • Q0511 − First covered oral antiemetic drug dispensed in a 30-day period • Q0512 − Each subsequent covered oral antiemetic drug dispensed in a 30-day period If drug on claim is denied as noncovered, the supply fee will be denied as noncovered 2014 Jurisdiction B Medicare Seminars 87 National Government Services, Inc. Modifiers • EY − Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code • KX − If aprepitant (J8501) and dexamethasone (J8540) are used in conjunction with one of the covered anticancer chemotherapeutic agents, a KX modifier should be added to each code – Should be billed with one of the following to be covered as part of the three-drug regimen; granisetron (Q0166), ondansetron (Q0179), or dolasetron (Q0180) 2014 Jurisdiction B Medicare Seminars 88 National Government Services, Inc. Common Errors • • • • Orders Medical need documentation Continued use Continued need 2014 Jurisdiction B Medicare Seminars 89 National Government Services, Inc. Questions Resources • Centers for Medicare & Medicaid Services http://www.cms.gov • National Government Services website http://www.NGSMedicare.com • • • • Local Medical Policies Dear Physician Letters Policy Education Page Tools and Materials Page • IVR 877-299-7900 2014 Jurisdiction B Medicare Seminars 91 National Government Services, Inc. Resources • Customer Care Contact Center 866-590-6727 • Connex http://www.NGSConnex.com • Medicare University http://www.MedicareUniversity.com • Self-Service Tools 2014 Jurisdiction B Medicare Seminars 92 National Government Services, Inc. E-mail Updates • Subscribe to receive the latest, up-to-date Medicare information. 2014 Jurisdiction B Medicare Seminars 93 National Government Services, Inc. Website Survey • This is your chance to have your voice heard—Say “yes” when you see this pop-up so National Government Services can make your job easier! 2014 Jurisdiction B Medicare Seminars 94 National Government Services, Inc. Medicare University • http://www.MedicareUniversity.com • Interactive online system available 24/7 • Educational opportunities available – Computer-based training courses – Teleconferences, webinars, live seminars/face-to-face training • Self-report attendance 2014 Jurisdiction B Medicare Seminars 95 National Government Services, Inc. Medicare University Self-Reporting Instructions • Log on to the National Government Services Medicare University site at http://www.MedicareUniversity.com – Topic = 2014 Jurisdiction B Medicare Seminars – Medicare University Credits (MUCs) = 8 – Catalog Number and Course Code = To Be Given During Live Presentation – For step-by-step instructions on self-reporting please visit the Accessing the Self-Reporting Tool page on the NGSMedicare.com website 2014 Jurisdiction B Medicare Seminars 96 National Government Services, Inc. Thank You! 2014 Jurisdiction B Medicare Seminars 97 National Government Services, Inc.