(Medicare Claims Processing Manual)

We are also changing the dispensing fee for inhalation drugs furnished through durable medical equipment.  Effective January 1, 2006, Medicare will pay an initial dispensing fee of $57 to a pharmacy for the initial 30- day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time and regardless of the number of pharmacies used by a beneficiary during that time.  This initial 30 -day dispensing fee is a one -time fee applicable only to beneficiari es who are using inhalation drugs for the first time as a Medicare beneficiary.  Except in those circumstances where an initial 30 -day dispensing fee is applicable, Medicare will pay a dispensing fee of $33 to a pharmacy/supplier for each 30- day supply of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during the 30 day period.  Medicare will pay a dispensing fee of $66 to a pharmacy/supplier for each 90 -day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during the 90 days.  Only one 30- day dispensing fee will be payable per 30 -day period, and only one 90- day dispensing fee will be payable per 90-day period, regardless of the numbers of suppliers used during the respective periods.  A 30-day and 90- day supplying fee cannot be paid for drug supplied for the same month.  For a refill prescription, Medicare will allow payment of the dispensing fee no sooner than 7 days before the end of usage for the current 30- day or 90- day period for which a dispensing fee was previously paid.  Each inhalation drug supplier will be allowed no more than 12 months of dispensing fees per beneficiary per year.  Medicare will not pay separately for compounding drugs.  This cost  is in the dispensing fees.    Supply fees and dispensing fees must be billed on the same claim as the drug.  HCPCS Codes and Fees:   GO369, G0370, G0371, G0374 -  not recognized by Medicare as of 1/1/06.   Q0510 -  First immunosuppressive prescription after a transplant , $50.00 fee   Q0511 -  Pharmacy supplying fee for immunosuppressive, oral -anti-cancer, and oral anti -emetic drugs, first prescription in a one month period.  Each pharmacy may receive this fee once in a 30 -day period.  Fee is $24.00.   Q0512 -  Pharmacy supplying fee for immunosuppressive, oral anti -cancer, and oral anti -emetic drugs -  each subsequent prescription in a 30- day period.  Fee is $16.00.  Q0513 -  Pharmacy dispensing fee for inhalation drug(s); per 30 -days.   Effective 1/1/06, Medicare will pay a dispensing fee of $33.00 to a pharmacy for a 30 -day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time and regardless of the number of pharmacies used by a beneficiary during that period.  Payment will be made on the first claim received.   Q0514 -  Pharmacy dispensing fee for inhalation drugs(s); per 90 -days.  Effective 1/1/06, Medicare will pay a dispensing fee of $66.00 to a pharmacy for a 90 -day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time and regardless of the number of pharmacies used by a beneficiary during that period.  Payment will be made on the first claim received.   G0333-  Pharmacy dispensing fee for initial inhalation drug(s); initial 30 day supply to a beneficiary.   Effective January 1, 2006, Medicare will pay an initial dispensing fee of $57.00 to a pharmacy for the initial 30- day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time and regardless of the number of pharmacies used by a beneficiary during that time.  This initial 30- day dispensing fee is a one -time fee applicable only to beneficiaries who are using inhalation drugs for the first time as a Medicare beneficiary.   Based on the code descriptions above, a supplying fee and a dispensing fee is not appropriate for one drug.  The supplying fee is for immunosuppressives, oral anti -cancer drugs and oral anti -emetic drugs.  The dispensing fee is for inhalation drugs only.  A supplier cannot be paid for more than one of the following -- an initial dispensing fee  (G0333), a 30 -day dispensing fee (Q0513), or a 90 -day dispensing fee (Q0514) -  for a beneficiary for the same period.   80.8 - Reporting of Hematocrit and/or Hemoglobin Levels  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  Effective January 1, 2008, the following claims must report the most recent hematocrit or hemoglobin reading:   1.  All claims billing for the administration of an ESA (HCPCS J0881, J0882, J0885, J0886 and Q4081).  2.  All claims for the administration of a Part B anti -anemia drug (other than ESAs) used in the treatment of cancer that are not self -administered.   For institutional claims the hemoglobin reading is reported with a value code 48 and a hematocrit reading is reported with the value code 49.  Claims not reporting a value code 48 or 49 will be returned to the provider.   For professional paper claims, test results are reported in item 19 of the Form CMS -1500 claim form.  For electronic claims (ASC X12 837 professional claim format), providers report the hemoglobin or hematocrit readings in Loop 2400 MEA segment.  The speci fics are MEA01=TR (for test results), MEA02=R1 (for hemoglobin) or R2 (for hematocrit), and MEA03=the test results.   Effective for dates of service on and after January 1, 2008, contractors will return paper and electronic professional claims when the most recent hemoglobin or hematocrit test results are not reported.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 16  RARC: N764  MSN: N/A  80.9 - Required Modifiers for ESAs Administered to Non -ESRD Patients  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  Effective January 1, 2008, all non- ESRD claims billing HCPCS J0881 and J0885 must begin reporting one of the following modifiers:   EA: ESA, anemia, chemo -induced   EB: ESA, anemia, radio -induced  EC: ESA, anemia, non- chemo/radio  Institutional claims that do not report one of the above modifiers will be returned to the provider.   Professional claims that are billed without the required modifiers will be returned as unprocessable.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 4  RARC: N/A   MSN: N/A  ESAs administered for more than one of the indicated therapies are billed as separate line items (i.e., ESAs for chemo- induced anemia (EA modifier) are reported as separate line items (e.g., J0881EA); ESAs for radio- induced anemia (EB modifier) are reported as separate line items (e.g., J0885EB); ESAs for non- chemo/radio induced anemia (EC modifier) are reported as separate line items (e.g., J0881EC).  Only one of the three ESA modifiers may be reported at the line item level.    To return HCPCS J0881 or J0885 billed with more than one ESA modifier at the line item level, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.   Group Code: CO  CARC: 16  RARC: N63  MSN: N/A  80.10 - Hospitals Billing for Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) for Non -ESRD Patients  (Rev. 1412, Issued: 01- 11-08, Effective: 01 -01-08, Implementation: 04- 07-08)  NOTE:  For EPO and Aranesp billing instructions for beneficiaries with ESRD, see the Claims Processing Manual, Chapter 8, sections 60.4 and 60.7.  For patients with chronic renal failure who are not yet on a regular course of dialysis, EPO and Aranesp administered in a hospital and billed as an outpatient service on type of bill 13x or inpatient Part B bill type 12x are paid under the Outpatient Pros pective Payment System (OPPS).  Non- OPPS hospitals are paid on reasonable charges.   Hospitals report charges under revenue code 0636.  For EPO, hospitals report charges under revenue code 0636 with HCPCS code J0885 effective January 1, 2006.  Aranesp is reported with HCPCS code J0881 effective January 1, 2006.  80.11 - Requirement for Providing Route of Administration Codes for Erythropoiesis Stimulating Agents (ESAs)  (Rev. 1212; Issued:  03- 30-07; Effective:  01 -01-07; Implementation:  06 -29-07)  Patients with end stage renal disease (ESRD) receiving administrations of erythropoiesis stimulating agents (ESA), such as epoetin alfa (EPO) and Darbepoetin alfa (Aranesp) for the treatment of anemia may receive intravenous administration or subcutaneous administrations of the ESA.   Effective for claims submitted on or after February 1, 2007 with dates of services on or after January 1, 2007, all providers billing for injections of ESA for ESRD beneficiaries are encouraged to include the modifier JA on the claim to indicate an intrave nous administration or modifier JB to indicate a subcutaneous administration.  All providers billing for injections of ESAs for ESRD beneficiaries will be required to include route of administration when claims processing system changes are completed.  Renal dialysis facilities claim including charges for administrations of the ESA by both methods must report separate lines to identify the number of administration provided using each method.  80.12 - Claims Processing Rules for ESAs Administered to Cancer  Patients for Anti -Anemia Therapy  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  The national coverage determination (NCD) titled, The Use of ESAs in Cancer and Other Neoplastic Conditions lists coverage criteria for the use of ESAs in patients who have cancer and experience anemia as a result of chemotherapy or as a result of the cancer itself.  The full NCD can be viewed in Publication 100- 03 of the NCD Manual, section 110.21.  Effective for claims with dates of service on and after January 1, 2008, non- ESRD ESA services for HCPCS J0881 or J0885 billed with modifier EC (ESA, anemia, non-chemo/radio) shall be denied when any one of the following diagnosis codes is present on the claim:  ICD- 9-CM Applicable   any anemia in cancer or cancer treatment patients due to folate deficiency (281.2),   B-12 deficiency (281.1, 281.3),  iron deficiency (280.0- 280.9),  hemolysis (282.0, 282.2, 282.9, 283.0, 283.2, 283.9- 283.10, 283.19), or   bleeding (280.0, 285.1),    anemia associated with the treatment of acute and chronic myelogenous leukemias (CML, AML) (205.00- 205.21, 205.80- 205.91); or   erythroid cancers (207.00- 207.81).