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Administering Lovenox in the Hospital Outpatient Setting, Is It a Self-Administered Drug?
Published on Apr 21, 2021
20210421
 | FAQ 
Question:

Is Lovenox in the outpatient setting a self-administered drug for Medicare? Can we charge for the administration?

Answer

For Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, Lovenox is NOT a self-administered drug, so you can charge for the subcutaneous / intramuscular injection, CPT code 96372. If you are under the jurisdiction of a different MAC, check their self-administered drug list as the drugs can vary from one MAC to the next.

Here is a link to Palmetto’s self-administered drug list. It lists all of the injectable drugs they consider to be self-administered: Local Coverage Article for Self-Administered Drug Exclusion List (cms.gov)

Jeffery Gordon

Coding Multiple Rib Fractures due to CPR
Published on Apr 07, 2021
20210407
 | FAQ 

Question:

What is the code for multiple rib fractures due to Cardiopulmonary Resuscitation (CPR)?

 

Answer:

Assign Other Intraoperative and Postprocedural Complications and Disorders of the Musculoskeletal System (M96.89). Also, use Other Medical Procedures as the Cause of Abnormal Reaction of the Patient, or of Later Complication without Mention of Misadventure at the Time of the Procedure to identify the external cause the injury.

 

Fractures of the ribs are sometimes seen following CPR. Elderly patients with Osteoporosis are at increased for this type of injury.

 

References:        

·        Coding Clinic response to a submitted question.

·        First Quarter 2021, page 5-6

Anita Meyers

CMS Payment for Remdesivir in Outpatient Setting
Published on Mar 16, 2021
20210316
 | FAQ 

On March 5th, CMS updated their COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing document. Below is one of the recently added FAQs regarding payment for administering Remdesivir in the outpatient setting.  Note, I encourage you to check for updates to this document as it gets updated frequently.

Q:

“The current FDA approval for Veklury (Remdesivir) indicates that the drug “should only be administered in a hospital or healthcare setting capable of providing acute care comparable to inpatient hospital care.” (Indications and Usage section at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c0978fa8-53ff-4ca2-82a7-567fd3e958ca retrieved February 18, 2021). Will CMS pay for Remdesivir if it is administered in the outpatient setting?

A:

CMS expects that the vast majority of infusions of Remdesivir will take place in inpatient settings, consistent with the current drug labeling. These inpatient infusions could occur in traditional inpatient settings, or in alternate care sites that furnish inpatient care and bill under the Inpatient Prospective Payment System. Additional information regarding hospital flexibilities in place during the COVID-19 Public Health Emergency is available here: https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers.

Questions about coverage of Remdesivir when a patient is not an inpatient, such as treatment occurring in outpatient hospital departments or in physician offices, should be directed to the Medicare Administrative Contractor that processes a provider or supplier’s claims. This includes questions about off label uses of Remdesivir, such as its use in outpatient acute care settings.”

Beth Cobb

Coding Rabies Vaccine, TDAP Vaccine, and Rabies Immune Globulin
Published on Mar 09, 2021
20210309
 | FAQ 

Q:

As a follow-up to the outpatient Rabies Immune Globulin FAQ, we have another question. What CPT codes should be billed when three separate intramuscular (I.M.) injections are given: (1) rabies vaccine, (2) TDAP vaccine, and (3) rabies immune globulin?


A:

For the rabies vaccine, use CPT code 90471 (immunization administration, 1 vaccine).

For the TDAP vaccine, use CPT code 90472 (immunization administration, each additional vaccine)

For the rabies immune globulin, use CPT code 96372 (IM / subcutaneous injection of a therapeutic drug.

Remember, you should also charge for the respective drugs/vaccines in addition to the injections / administrations.

Jeffery Gordon

Coding Rabies Immune Globulin
Published on Mar 02, 2021
20210302
 | FAQ 

Q:

We have ER patients who get intramuscular (I.M.) injections of Rabies Immune Globulin. What CPT code should be billed for the injection of Rabies Immune Globulin?


A:

When an I.M. injection of an immune globulin is administered, use CPT code 96372, representing an intramuscular / subcutaneous injection of a therapeutic drug. This applies to all immune globulins given by I.M. route, such as Rhogam, Hepatitis B immune globulin, and the others listed on the first page of the Medicine section in CPT. This instruction is part of the parenthetical CPT guidelines on the same page, and as such, would apply to all payers.

Jeffery Gordon

Bipolar Disorder with Major Depression
Published on Feb 23, 2021
20210223
 | FAQ 

Q:

We have a record with documentation of Recurrent Depression (F33.x) and Bipolar Disorder (F31.x).  The excludes1 note under each code seem to exclude each other.  Do we code both conditions?

A:

Bipolar Disorder includes Depression, so only the code for Bipolar Disorder (F31.9) would be coded and reported.  A separate code for Depression would not be reported in addition.

Reference

Coding Clinic for ICD-10-CM/PCS, First Quarter 2020: Page 23

Susie James

Methotrexate Injection in the ER
Published on Feb 15, 2021
20210215
 | FAQ 

Q:

We had a patient in the ER who was having a miscarriage, and she received an intramuscular injection of Methotrexate.  What CPT code should be used to report the Methotrexate injection in this scenario?

A:

Methotrexate is classified as a chemotherapy drug, specifically an antimetabolite. Therefore, the intramuscular injection of Methotrexate should be reported with CPT code 96401, representing injection of a non-hormonal antineoplastic.  You should not report the injection using CPT code 96372 for a therapeutic drug.

Per CPT guidelines, the CPT codes for chemotherapy administration should be used when an anti-neoplastic drug is given, even if the diagnosis is not related to cancer.

It is unusual for a chemotherapy type drug to be given in the ER, so you may need a new charge code created for those rare circumstances when a drug such as Methotrexate is given by intramuscular route.

Jeffery Gordon

Effective Date for Revised Transcatheter Edge-to-Edge Repair (TEER) Requirements
Published on Feb 09, 2021
20210209
 | FAQ 

Q:

On January 19, 2021, CMS issued a final Decision Memo that included revised criteria for Medicare coverage of Transcatheter Edge-to-Edge Repair (TEER) for mitral regurgitation formerly known as Transcatheter Mitral Valve Repair (TMVR). When should our hospital start following the new criteria such as the requirements for treatment of functional (secondary) mitral regurgitation?

A:

Medicare is a huge bureaucracy and to change rules is not simply a snap of the fingers – there are manuals to update, Medicare contractors and providers to educate, and electronic systems to tweak. This means changes are not instantaneous and take some time to fully implement.

 

There are differences in the expected compliance with a coverage decision memorandum and a National Coverage Determination (NCD).  CMS addresses this in the Medicare Program Integrity Manual, Chapter 13, section 13.1.1:

A Decision Memo is not immediately binding on Medicare contractors though they are encouraged to consider it. Here is the language from the Medicare Program Integrity Manual, Chapter 13 concerning decision memos:

“Coverage Decision Memorandum- CMS prepares a decision memorandum before preparing the national coverage decision. The decision memorandum is posted on the CMS Web site, that tells interested parties that CMS has concluded its analysis, describes the clinical position, which CMS intends to implement, and provides background on how CMS reached that stance. Coverage Decision Memos are not binding on contractors or ALJs. However, in order to expend MR funds wisely, contractors should consider Coverage Decision Memo posted on the CMS Web site. The decision outlined in the Coverage Decision Memo will be implemented in a CMS-issued program instruction within 180 days of the end of the calendar quarter in which the memo was posted on the Web site.”

Providers need to bear in mind however, that the final NCD backdates the effective date of the changes to the date of the decision memo. The issue lies with the implementation date which is communicated in a CMS Transmittal once the NCD changes are finalized. Medicare Administrative Contractors (MACs) will not start enforcing the new rules until the implementation date, but then they will enforce rules for dates of service on and after the date of the decision memo. This means once the final update to the NCD is made and manualized, the effective date will revert to the date of the decision memo but following the new rules will be based on an implementation date.  Claims submitted on and after the implementation date, will follow the new guidelines for dates of service on and after January 19, 2021 (decision memo date).

Best practice is for providers to educate all key stakeholders on the changes in the decision memo and implement new requirements, such as documentation of persistent symptoms in a patient with functional mitral regurgitation despite maximally tolerated guideline-directed-medical therapy (GDMT), as quickly as possible. Until an implementation date is communicated, providers should not stop complying with the requirements of the current NCD if they are continuing to submit claims for the service.  Another option for providers is to follow the new criteria in the Decision Memo and hold claims until after the implementation date of the revised NCD.

Beth Cobb

New HCPCS code for the Drug Zepzelca
Published on Feb 02, 2021
20210202
 | FAQ 

Q:

Is there a HCPCS code for the drug Zepzelca?

A:

Effective 01-01-2021, there is a new HCPCS code J9223 for this drug.  The generic name is Lurbectedin, which is why you may not have seen it.  The HCPCS code dose is per 0.1 mg, so you want to be sure to assign the appropriate conversion factors / multipliers since the doses with be greater than 0.1 mg.

For Medicare, It has a status indicator G, so you don’t have to worry about assigning modifier JG if you are purchasing it through a 340B discount program.

For Medicare, if

  1. the date of service for the claim was between June 15 2020 and December 31, 2020, and if
  2. the drug was used to treat metastatic small cell lung cancer, look at HCPCS code C9399.

This code represents a new drug that has received FDA approval but for which a HCPCS code has not yet been assigned. Click here for the FDA link. For more information about HCPCS code C9399, refer to the Medicare Claims Processing Manual, chapter 17, section 90.3.

Jeffery Gordon

Most Favored Nation Model for Medicare Part B Drugs and Biologicals
Published on Jan 06, 2021
20210106
 | FAQ 

Q:

Where can one find information about the Most Favored Nation Model and are there any recent updates?

A:

CMS announced the Most Favored Nation (MFN) Model on November 20, 2020. Information about this Model is available on the MFN Model web page on the CMS Innovation Center.

This model was set to begin January 1, 2021 and end December 31, 2027. Similar to the Comprehensive Care for Joint Replacement (CJR) Model, this is a “mandatory nationwide model that requires participation from Medicare-participating providers and suppliers that receive separate Medicare Part B fee-for-service payment for the model’s included drugs, with certain exceptions.” Specifically MFN participants includes:

  • Medicare-participating physicians,
  • non-physician practitioners, supplier groups (such as group practices),
  • hospital outpatient departments (HOPDs) including 340B covered entities,
  • ambulatory surgical centers (ASCs), and
  • other providers and suppliers that receive separate Medicare Part B fee-for-service payment for the model’s included drugs, with certain exceptions

This Model focuses on approximately 50 Medicare Part B drugs that accounts for a high percentage of Medicare Part B drug spending. The January 2021 MFN Model Drug HCPCS Codes List and January 2021 MFN Model Drug Pricing File have both been posted on the MFN Model webpage.

Also available on the MFN webpage is an MLN Fact Sheet (ICN MLN2761019 December 2020) titled Billing Information for Most Favored Nation (MFN) Model Drugs.

You will note that earlier I mentioned that this model “was set to begin January 1, 2021.” However, a December 28, 2020 Update available on the MFN webpage indicates that “on December 28, 2020, the U.S. District Court for the Northern District of California issued a preliminary injunction in Biotechnology Innovation Organization v. Azar, No. 3:20-cv-08603, which preliminarily enjoins HHS from implementing the Most Favored Nations Rule.”

On December 31, 2020, the U.S. District Court for the Southern District of New York issued a preliminary injunction in Regeneron Pharmaceuticals v. United States Department of Health and Human Services, No. 7:20-cv-10488, which preliminarily enjoins HHS from applying the Most Favored Nation Rule to Regeneron's drug EYLEA.

Additionally, the public comment period for the MFN Model Interim Final Rule with Comment Period (IFC) does not end until January 26, 2021. If you have concerns I encourage you to submit comments to CMS.

Beth Cobb

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