02/05/2019

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February 2019, Frequently Asked Questions

Question: I'm confused with the updated HCPCS codes for bortezomib (Velcade) this year.  I see there is a new code, J9044 - Injection, bortezomib, not otherwise specified, 0.1 mg.  Did the J9041 code get deleted?  If the J9041 code is still valid, then what is the difference?

Answer:   Both the J9044 and the J9041 HCPCS codes are valid.  

J9041 is specifically for Velcade, which is given by intravenous or subcutaneous injection.  They revised the J9041 code this year from; "Injection, bortezomib, 0.1 mg" to instead read; "Injection, bortezomib (VELCADE), 0.l mg" and this was effective 1/1/10.  Velcade is supplied as individual cartons of 10mL vials containing 3.5 mg of bortezomib as powder.

J9044 is "Injection, bortezomib, not otherwise specified, 0.1 mg" and was effective 1/1/19.  This code was requested by Fresenius Kabi USA, LLC, to identify their bortezomib which is administered as a bolus intravenous injection.  This bortezomib is supplied in a single-dose vial that contains 3.5 mg as a lyophilized powder for reconstitution.

Question:  We have a payer we bill our drugs based on the NDC code.  Are we required to document the NDC in the patients medical record?

Answer:  The answer is yes, if you bill based on the NDC and are paid based on the NDC, then you must document the NDC you utilized in the patient's record.  With that said, some payers will allow providers to store the information in the Pyxis or inventory management system you are utilizing.  You want to be sure the records are complete, are not deleted, are considered part of your patient's medical record (you may have a blanket statement to that effect in the patient's actual record) and, if you are asked to send your records to a payer, they are included in the medical records sent.  If you are considering this, I would also recommend that you confirm this with your top payers to be sure they would find this acceptable.  Medicare does not reimburse claims based on the NDC.

Question:  We received a positive adjustment for MIPS this year and notice that we are getting positive adjustments on our drugs too.  I thought the adjustments were only supposed to be applied to physician services.

Answer:  With the 2019 MIPS adjustments so far, CMS is applying the adjustments to not only the services, but also the drugs.  There is dispute whether this is correct or it is an error and they will be taking the payment back.  The MIPS adjustment is based on services from 2017 and in 2017 the MIPS adjustment was to apply to drugs as well.  In the 2018 Final Rule this was removed.  The question is whether this change was retroactive to 2017.  We are awaiting clarification from CMS.  

Question: We are in a dilemma.  When our nurses give a push, sometimes it just takes a second and sometimes it can take a LONG time.  We have two questions... 1) Are we required to have a start and stop time for a push documented in the EMR?  2) If the push is longer than 15 minutes, can we bill an infusion?

Answer: 1) Start and stop times are required on any code that is time based.  Therefore, since a push is not a time based code, there wouldn't be a requirement to document the total time, just that the service of a push was rendered.  It isn't a bad idea to document the times, but it isn't a requirement.  2)  A push MUST be billed as a push regardless of the time.  It is not a time based code.  While short infusions (15 minutes or less) must be billed utilizing the push codes, pushes are always billed as pushes.

Question: Does CMS have documentation requirements specific to discarded drug waste, such as who is required to document the amount that is discarded?  Is there a specific area in the medical record it must be?  Where can I find a reference specific to this?

Answer:  CMS does not have a specific documentation requirement outside of the same requirement they have for all services.  They do not have anything we can reference which says where in the medical record the information must be or who must put it there.  In some cases, the pharmacist may enter the information in record, and other cases it is done by the nurse administering the medication.  CMS expects that providers will maintain accurate records for all beneficiaries for the amount of drug given and the amount discarded, as well as accurate purchasing and inventory records for all drugs that were purchased and billed to Medicare.  Do keep in mind you can only bill for waste that is discarded from a single dose vial.  This information can be found in the Medicare Claims Processing Manual, Chapter 17, Section 40.

Question: We are receiving denials on our Procrit.  We are giving 80,000 units of Procrit.  They say we are over the dosing limit. Where can I find this type of information?

Answer: The Medically Unlikely Edit for Procrit is 60,000.  If your patient dosing is above the CMS MUE, you will likely be rejected and will need to show medical necessity with your appeal.  You can do this by referencing the drug package insert or the compendia in most cases, and of course, with your medical records.  You may consider including a letter of medical necessity written by the ordering. 

CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. All HCPCS/CPT codes do not have an MUE, but you will find MUEs for administration codes and most drugs on the CMS site. 

Keep in mind, just because there is a MUE, it doesn’t mean that CMS will only reimburse up to that amount.  For example, because some drugs are dosed by weight, we occasionally have doses that are above the MUE, especially with heavy patients.  In those situations, be prepared to receive a rejection because of the MUE, and appeal the claim based on medical necessity, showing the FDA approved weight based dosing.

You can download the MUE table from the CMS site:  CLICK HERE

Question: We are an outpatient hospital facility.  If a drug we have used is packaged by Medicare for payment, do we have to report it on our claims?

Answer: Hospitals should report charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged, using the correct HCPCS codes for the items used. Hospitals billing for these products also should make certain that the reported units of service of the reported HCPCS code are consistent with the quantity of a drug, biological, or radiopharmaceutical that was used in the care of the patient.