Pharmacy Revenue Cycle News

CMS has proposed that non-disable, under age 65 year old kidney transplants have lifetime coverage under Part B for immunosuppressives instead of the 36-month limit currently.

Whoa! IPPS Proposed Rule includes new process that drugs for NTAP be reported with an NDC number rather than an ICD-10-PCS code. Can your IT system handle this change so you don't lose revenue?

Why would an IVPB charge be denied by a payer? In some cases the payer is incorrectly denying the charge. The denial should be clarified and challenged when appropriate.

Billing for ESAs on outpatients requires special modifiers and may include laboratory values.

The Integrated Outpatient Code Editor (I/OCE) is a useful quarterly update to help in producing a reimbursable claim.

Two new HCPCS code and one new product bring the total to six products classified as Car T-cell therapy.

Denied Claims should be reviewed but if the billing is correctly and the service is medically necessary, an appeal is warranted.

CMS has established a HCPCS code for reimbursement when outpatients receive convalescent plasma.

Timing of Dose Administration may lead to claims denials for Pegfilgrastim

When do you issue an ABN and when is it prohibited?

Aduhelm and proposed NCD For Medicare requires a qualifying clinical trial for coverage.

Important information about a new HCPCS code for Remdesivir

Important Dose change with new HCPCS code for Pegfilgrastim

What to do what the actual reimbursement is less that expected. Is it sequestration?

Pharmacy is in a unique position to help with Pharmacy Revenue Cycle when Quarterly Restated Payment Rates are significant.

Have you checked for new HCPCS codes, MUE values, and ASP Prices yet?

Setting hospital drug prices can be complex or simple, but there are basic factors to be considered.

Dietary Supplements and Herbal Products aren't drugs and can't be billed as if they were.

Critical Access Hospitals have different rules and different reimbursement from Part A and Part B.

Sixty-two podcasts and here's our TOP 5!

Some things appear to be drugs but are devices and vice versa. How does this impact revenue?

Summary of the 1394-page OPPS Final Rule For CY2022.

Only certain providers can use C Codes to bill Part B claims to Medicare.

Only certain NDC numbers are eligible for coverage and payment under State Medicaid Programs. CMS has a database where the NDC number can be verified.

Influenza, Pneumonia and Hepatitis B vaccine for high risk patients are covered under Part B regardless of provider location.

We wrote, CMS listened! Cetuximab MUE increased to 150 units to accommodate new dosing regimen.

A new, handy tool for checking all Quarterly Updates to ensure that all systems, business decisions have been reviewed and updated.

Effective 10/1/2021, NTAP eligible drug products.

Pharmacy Revenue Cycle News turns 1!

Car T-cell therapies are new innovative treatments for certain types of cancer. Correct billing is critical due to the expense of the products and clinical resource intensity.

Tocilizumab is administered to inpatients under an EUA. Since it represents a cost to the hospital, how is the best way to bill for it to get separate payment?

With a world-wide shortage of tocilizumab, billing is a challenge when switching patients to alternative drugs for non-COVID-19 indications.

Outlier payments are calculated on both inpatient and outpatient claims, but you have to report all charges to be eligible.

CMS has proposed to rescind the Most Favored Nation Interim Final Rule. Comments are due to CMS by October 12. 2021.

Based upon EUAs revised by the FDA, CMS has issued new billing codes for the administration of a 3rd dose of Pfizer or Moderna COVID-19 vaccine.

There's been a change with CMS instructions for billing drug administration codes.

Back to flu season and all new NDC numbers! Here's a tool for building drug profiles for influenza vaccine.

Not much new for drug reimbursement in the OPPS Proposed Rule for CY 2022

Why did the CMS reimbursement for two drugs decrease by 20% in July 2021? CMS has a new way of calculating ASP based upon new statutes.

Whether to bill a medicare patient for take home medications is dependent upon whether the patient is an inpatient or an outpatient and if an inpatient if it is a “limited supply”.

A new dosing regimen approved by the FDA on April 6, 2021 exceeds the current MUE if administered to a patient with a BSA of 3 m2. Pharmacy Revenue Cycle requested an increase which the NCCIPTP Coordinator has indicated will be implemented in a future quarterly update.

CMS Quarterly updates include new HCPCS codes, replacement codes and changes in payment status as well as updated payment rates.

Revenue Codes are used on hospital claims and there are specific ones assigned to drug products. These track to the Medicare cost report, so its important to set these correctly in the chargemaster.

COVID Infusions have tricky billing rules as some EUAs allow for two drugs to be given together, but CMS has only issues one HCPCS code for billing.

Alphanate, Humate-P, and Wilate present unique billing challenges.

Drugs purchased under 340B require modifiers on Medicare claims based upon whether a drug is separately paid and/or has pass-through status.

CMS pays a DRG with a higher relative weight when TPA is administered to an inpatient. ICD-10-PCS codes are added to the claim to drive the higher payment.

Hemophilia Factors are expensive but Medicare provides extra reimbursement for both inpatients and outpatients for certain diagnosis groups.

The Enhanced Ambulatory Patient Grouping or (EAPG) is among the models focused on transitioning fee for service to a value based payment. Over 25% of the state Medicaid programs in addition to several commercial payers have adopted the EAPG outpatient prospective payment system.

Drugs approved by the FDA can be used by physicians for "off-label" uses. CMS has provided guidance on when and how these uses should be covered and reimbursed.

Pass-through status can apply to new drugs for 2-3 years after an application is approved by CMS.