Connecticut Department of Social Services Medical Assistance Program Provider Bulletin. PB July 2008

Transcription

1 Connecticut Department of Social Services Medical Assistance Program Provider Bulletin PB July 2008 TO: Hospital Providers SUBJECT: Most Frequently Asked Questions related to the billing requirements necessary to support and comply with the implementation of the Deficit Reduction Act (DRA) of The Department has been contacted by a number of providers requesting clarification of billing requirements related to the implementation of the Deficit Reduction Act (DRA) of The purpose of this bulletin is to share those questions along with the corresponding answers, to assist providers with understanding the billing requirements. This will help providers transition to and comply with the new federal directive more easily. Q 1. Why do I need to report both HCPCS units and NDC quantity which may be different values? A. The HCPCS code defines the unit increments for billing. The NDC quantity is based on NCPDP Standard billing units per NDC. NCPDP standards are used to report drug utilization data to manufacturers. Utilization data required for rebate reporting includes NDC, NDC quantity, and units of measure. Q 2. Are the HCPCS code units different from the NDC units? A. Yes. Use the same Revenue Center Codes (RCC) with the corresponding HCPC code and HCPC service units. The billed amount will continue to be the basis of your reimbursement. NDC units are based upon the numeric quantity administered to the patient and the unit of measurement. The unit of measurement (UOM) codes are: UN = Unit (Each) GR = Gram ML = Milliliter F2 = International Unit The actual metric decimal quantity administered and the unit of measurement are required for billing. If reporting a fraction, use a decimal point. For example: Three 0.5ml vials are dispensed, the correct quantity to bill is 1.5 ml. Q 3. How do I know which Unit of Measure (UOM) to use for the NDC quantity? If the physician administered a vial of medication to a patient, do I bill the NDC units in grams, milliliters, or units?

2 A. It depends on how the manufacturer and CMS have determined the rebate unit amount. The following table provides the drug form, NDC Unit of Measure (UOM) and examples of drugs that match the drug form and UOM. 2 of 7

3 A general guideline: a. If a drug comes in a vial in powder form and has to be reconstituted before administration, then bill each vial (unit/each) used. (UN) b. If a drug comes in a vial in a liquid form, bill in milliliters. (ML) c. Grams are usually used when an ointment, cream, inhaler, or a bulk powder in a jar are dispensed. This unit of measure will primarily be used in the retail pharmacy setting and not for physician-administered drug billing. (GR) d. International Units will mainly be used when billing for Factor VIII-Antihemophilic Factors. (F2) For example: A patient received Lovenox 120mg in the ER. The NDC , was used for Lovenox 120mg /.8ml. You would bill J1650 (Injection, Enoxaparin Sodium, 10 MG) with 12 HCPCS units. The NDC unit of measure would be billed as 0.8ml. Be sure to use the unit description of the HCPC for the Service Unit calculation of the HCPC. Please Note: NDCs listed above have hyphens between the segments for easier visualization. When submitting NDCs on claims, submit as an eleven digit number with no hyphens or spaces between segments. Q 4. How do I Calculate the NDC Quantity? 3 of 7

4 A. If a drug s HCPCS quantity is provided, it must be converted to NDC quantity before entering it on the claim. You may administer a drug that does not match the concentration or strength of the HCPCS. It will need to be converted as the NDC quantity submitted, will be based on the actual drug administered. The example below demonstrates how to convert the NDC quantity. Example: Adenosine injection (Adenoscan 3mg/ml) the NDC Unit of Measure = ML HCPCS J0152 (injection Adenoscan for diagnostic use per 30mg) NDC administered NDC (3mg/ml) = 30mg/10ML HCPCS Units = 1 Q 5. How do I convert HCPCS Units to the equivalent NDC Quantity? A. The following table provides quantity conversion examples of HCPCS units to NDC quantity. This is meant to be a general guideline to assist with converting the HCPCS billing units to the NDC quantity. Each NDC Unit of Measure (UOM) is represented, followed by the administered dosage, drug dose, NDC UOM, NDC billing quantity, HCPCS description and HCPC billing units 4 of 7

5 Q 6. What if the NDC calculation is a partial unit? A. You may enter a partial unit using up to three decimal places (e.g., 0.625). The following examples can be used for rounding purposes ml would be submitted as ML UN would be submitted as UN3.786 Q 7. How do I bill for a drug when only a partial vial was administered? A. The HCPCS procedure code used for reimbursement with corresponding units should be billed in order to be properly reimbursed for the drug. If the drug is packaged in a multi-dose vial (can be used for more than one patient), then only the units administered should be billed to Medicaid. If the drug is packaged in a single-dose vial that cannot be used for multiple injections, then the whole vial may be billed to Medicaid. When calculating the NDC units, the HCPCS procedure code units should be converted to the NDC units, using the proper decimal units. For example: 1- The patient received only 2 mg of Zofran and NDC was used to administer the injection. Since the NDC is for Zofran 2 mg/ml in a 2 ml vial, the billing should look like this: HCPCS - J2405 (ondansetron hydrochloride, per 1 mg) 2 units NDC - N ML1 2- A patient was administered 75mg of Cisplatin in the Oncology Clinic. The NDC used was for Cisplatin 50 mg/50 ml vial. Even though the 2 vials contain a total of 100mls, the correct billing would be: HCPC - J9060 (Cisplatin powder or solution, per 10 mg) 8 units* NDC N ML75 * In this example the actual HCPCS quantity would be 7.5, however, partial HCPCS cannot be submitted and would need to be rounded to a full unit. Q 8. Is there a crosswalk to reference the correct NDC units of measure with the HCPCS units needed for billing? A. There is not a crosswalk available at this time. However, the drug search on the Web site is a valuable tool which may be of assistance. Go to > Provider > Drug Search, and enter the search criteria. The results will display the dose strength, dose form and package size. 5 of 7

6 The first NDC shows the Dose Strength as 1gm, the Dose Form as vial, and the package size as 1. The second NDC shows the Dose Strength as 1gm/50ml, Dose Form as piggyback, and Package size of 50. If 1gram was to be administered, the first NDC would be billed with the quantity of 1 UN: however, the second NDC would be billed with the quantity of 50ML. In both instances the J-Code would be billed with a quantity of 2. Q 9. Do I need to bill the actual NDC used? A. Yes. Bill the NDC for the actual drug that is administered. Billing an NDC from a reference file, which is not the actual drug administered is considered fraudulent billing practices. Q 10. Do I bill the HCPCS code and NDC of a drug if I just administer the drug? A. No. For example, if the patient has a prescription filled and brings the drug into the facility to have the physician administer it, the drug may not be billed by the physician. The physician should only bill for the administration of the drug. The retail pharmacy would have already billed for the drug. Q 11. When choosing the HCPCS code for an unclassified drug are we limited to using J3490, J3590, J9999 or can we use J8499, which is another HCPCS code used for unclassified for an Oral Non Chemo products? A. HCPCS J8499 has not yet been added to the Fee schedule, and if submitted on a claim, the claim would be denied. There are two methods of verifying if a J-Code is a covered HCPCS, on our Web site at 1-Go to Provider > Provider Fee Schedule Download > scroll down to Physician, then click on the most current Fee Schedule. Or 2-Go to Provider > Drug Search > enter the J-Code > click search. Q 12. What Revenue Center Codes require HCPCS and NDCs to be billed? A. Revenue Center Codes (RCC) , , and require the HCPCS and corresponding NDCs to be submitted on the claim. Upon further review, the Department has removed this requirement for RCC 260 and 273; realizing that these RCCs are only applicable for ancillary supplies. Q 13. What are the DRA requirements for reporting compounded drugs and IV solutions? 6 of 7

7 A. Providers must comply with the DRA requirements for all NDCs used to prepare compounded /IV products. The NDCs for each component contained within the compound/iv solution would need to be submitted on the claim with the corresponding J-code and number of units. An example of a claim submitted with multiple NDCs, is shown below. A Detail signifies the RCC (and HCPCS) code, where as, sequence signifies the corresponding additional NDC. If the RCC code and the HCPCS has multiple NDCs, there would be one detail with multiple sequences. In the example above, Detail 1 for RCC code 636 is being submitted with 2 sequences, which indicates it is comprised of a detail with the same RCC, same HCPCS and 2 different NDCs. Field 43 indicated the qualifier N4, NDC, units of measure, and the NDC quantity. Field 44 indicated the HCPCS Field 46 indicates the HCPCS quantity for all associated sequences Note sequence 2 does not show a value. The total units for a detail that has more than one sequence should be the sum of all the units at the sequence level, but included only on detail 1 and sequence 1. In this example 2 units is the sum of the units from sequence 1 and 2 Field 47 indicates the total cost for all associated sequences - Note sequence 2 shows a value of Zero. The total charges for sequence 1 and 2 must be included in only detail 1, sequence 1. In this example Detail 2 for RCC 305 is not for a physician administered drug, therefore, no sequence or NDC is needed Detail 3 for RCC 636 is displaying 1 sequence to indicate the 1 NDC administered Although the example is not referencing a compound claim, the format for submitting the claim would be the same. Q 14. Vaccines are submitted with RCC 636, are these required to have the NDC information? A. Vaccines are not included in the rebate requirement,. However, RCC 636 requires a HCPCS and corresponding NDC submitted on the claim and therefore, the NDC does need to be included. This bulletin and other program information can be found at Questions regarding this bulletin may be directed to the EDS Provider Assistance Center - Monday through Friday from 8:00 a.m. to 5:00 p.m. at: In-state toll free or EDS Out-of-state or in the PO Box 2991 local Farmington, CT area Hartford, CT of 7