01/08/2019

ASK MSHO

January 2018, Frequently Asked Questions

Question: We are being questioned about the physician signing the infusion treatment note in order to bill incident to. Is this true - does Medicare expect a physician’s signature on every infusion?  I would appreciate your answer.

Answer: Some Medicare MACs require the signature of the supervising physician.  As a consultant, I recommend to my clients they have the supervising physician sign the note.  There are a few MACs who require the NAME of the supervising physician, but the signature is not required - such as WPS Medicare.

Novitas Medicare MAC says....  

• The documentation submitted to support billing “incident to” services must clearly link the services of the NPP auxiliary staff to the services of the supervision physician. 
• Evidence of the link may include: 
  • Co-signature or legibly identify and credentials (i.e., MD, DO, NP, PA, etc.) of the both the practitioner who provided the service and the supervising physician on documentation entries.
  • Documentation from other dates of service, for example the initial visit establishing the link between the two providers. 
  • Make sure the name and professional designation of the person rendering the service is legible in the documentation of each service.

Here is a link to the reference above: CLICK HERE 

Question:  I am worried about billing the new code for Rituxan, J9312 for 10 mg  (instead of the J9310 for 100 mg).  I am afraid the payers, including Medicare, will not have this in their system and will not pay correctly.  

Answer:  Medicare/Medicaid should not have a problem because it is loaded on the ASP file on the CMS website effective January 1, 2019.  Private payers do have up to 45 days to load new HCPCS codes, however, you are not allowed to use the old code after December 31. 2018.  As a general rule, most private payers have been good about getting the files loaded timely.

Question: With drug companies doing price increases at the top of year and top of quarters, how do practices get reimbursed by Medicare the correct amount reflecting that change in price? What is the process, how does that happen?

Answer: They don't.  They (the practices) don't get the increase until the ASP file at CMS is updated which can take 3 to 6 months.  Seems unfair, but the concept is, it works the other way too.... when a drug goes generic and there is a price reduction... that also takes 3 to 6 months for that to reflect within the file.

Follow-up Question: So they can't resubmit for the increased amount from the time it increased?

Answer:  No, they can't resubmit for more money..... the changes aren't retroactive.

Question: Have you heard anything officially about Medicare not approving Neulasta as a first line agent and instead requiring something else or a step therapy?  I know we have discussed this previously, but I have not seen anything official yet.

Answer:  Traditional Medicare will approve all drugs utilized in your office which are utilized for the FDA approved indication or follow NCCN 1 or 2a guidelines as long as the other criteria are met, such as "incident to". Brand new in 2019 - Medicare Advantage plans were given authority to apply step edits, so you have to check with each advantage plan to make sure they will prior auth/authorize the use of Neulasta, and any other drug.

Question: Is J1094 the correct code to report injectable dexamethasone?

Answer: HCPCS code J1094 (injection, dexamethasone acetate, 1 mg) is no longer manufactured. However, HCPCS code J1100 (injection, dexamethasone sodium phosphate, 1 mg) is currently available. In the National Correct Coding Initiative Manualfor Medicare Services, the Centers for Medicare & Medicaid Services (CMS) caution physicians, when billing for dexamethasone, to be careful to report the correct formulation with the correct HCPCS code.

Question:  How much will CMS pay for 340B drugs in 2019?

Answer: In 2018, the Centers for Medicare & Medicaid Services (CMS) finalized a policy to pay the average sales price (ASP) minus 22.5 percent under the Medicare Physician Fee Schedule (MPFS) for separately payable 340B-acquired drugs furnished in hospital departments paid under the outpatient OPPS. For 2019, CMS adopted the same policy for nonexcepted, off-campus provider-based departments (PBDs) of a hospital.