(Medicare Claims Processing Manual)

EXAMPLE 1  HCPCS  J7189  Drug  Factor VIIa  Dosage  1 mcg  Actual dosage:  13,365 mcg  On the bill, the facility shows J7189 and 13,365 in the units field (13,365 mcg divided by 1 mcg = 13,365 units).  NOTE:   The process for dealing with one international unit (IU) is the same as the process of dealing with one microgram.   EXAMPLE 2  HCPCS  J9355  Drug  Trastuzumab  Dosage  10 mg   Actual dosage:  140 mg   On the bill, the facility shows J9355 and 14 in the units field (140 mg divided by 10mg = 14 units).  When the dosage amount is greater than the amount indicated for the HCPCS code, the facility rounds up to determine units.  When the dosage amount is less than the amount indicated for the HCPCS code, use 1 as the unit of measure.   EXAMPLE 3  HCPCS  J3100  Drug  Tenecteplase  Dosage  50 mg   Actual Dosage:  40 mg  The provider would bill for 1 unit, even though less than 1 full unit was furnished.  See 10 for a description of drug payment rules.     70.1 - Billing Drugs Electronically - NCPDP (Rev. 3085, Issued: 10- 03-14, Effective: ICD -10: Upon Implementation of ICD -10; ASC X12: January 1, 2012, Implementation: ICD -10: Upon Implementation of ICD -10; ASC X12: November 4, 2014)   The National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard Version D.0 and Batch Standard 1.2 is the HIPAA standard for electronic retail pharmacy drug claims and coordination of benefits (COB).  See the NCPDP web site at http://www.ncpdp.org for additional information.  DME MACs that process retail pharmacy drug transactions require their retail pharmacy claimants to use this standard.  Retail pharmacies must use the ASC X12 837 professional claim format to submit claims other than retail pharmacy claims to the DME MACs.   DME MACs and VMS shall accommodate quarterly and monthly NDC crosswalk updates as needed.  DME MACs shall provide such crosswalks to CEDI.   DME MACs and CEDI shall reject NDC codes that have been deactivated/end dated.   A - Requirements for Implementing the NCPDP Standard   Retail pharmacies are identified by a value of A5 in the specialty code as received by the National Supplier Clearinghouse.  Only suppliers with an A5 specialty code may use the NCPDP standard.  DME MACs, EDI submitters, and other DME MAC trading partners are required to transmit the NDCs in the NCPDP standards for identification of prescription drugs dispensed through a retail pharmacy.  NDCs replace the drug HCPCS codes for retail pharmacy drug transactions billed via the NCPDP standards.   B - Certificate of Medical Necessity (CMN)   The CMN for Parenteral Nutrition (Form CMS -852) is required.  The DME Information Form for Immunosuppressive Drugs (Form DMERC -08.02) is not required when billing for immunosuppressive drugs with dates of service on or after April 1, 2006.  As with other e lectronic formats, CMN data must be submitted within the valid transaction.   For claims submitted on the paper Form CMS -1500, retail pharmacies will continue to supply hard copy CMNs when required.  C - NCPDP Companion Document   The NCPDP Companion Guide is available at: http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/downloads/NCPDPD0CG.pdf    CEDI provides supplemental instructions as needed to retail pharmacy drug claim submitters (either provider, billing agent, or clearinghouse) that will submit retail pharmacy drug claims to Medicare electronically.   70.1.1 - Reporting Modifiers in the Compound Drug Segment  (Rev. 1, 10- 01-03)  Certain informational modifiers are required on compound ingredients.  The NCPDP format does not currently support reporting modifiers in the compound segment.  Therefore, the narrative portion in the prior authorization segment must be used to report thes e modifiers.  The following must be entered in positions 001- 003 of the narrative (Example, MMN or MNF).  Starting at position 355, indicate the two-byte ingredient number followed by the two -position modifier:   MMN -  Indicates that the Supporting documentation that follows is Medicare modifier information and CMN information or DIF information  MNA -  Indicates that the Supporting documentation that follows is Medicare modifier information, CMN information or DIF information and narrative information   MFA -  Indicates that the Supporting documentation that follows is Medicare modifier information, CMN information or DIF information and Facility Name and Address   MNF -  Indicates that the Supporting documentation that follows is Medicare modifier information, CMN information or DIF information, narrative information and Facility Name and Address   MAC -  Indicates that the Supporting documentation that follows is Medicare modifier information and Facility Name and Address   MAN -  Indicates that the Supporting documentation that follows is Medicare modifier information, narrative information and Facility Name and Address   MAR -  Indicates that the Supporting documentation that follows is Medicare modifier information and narrative information   70.1.2 - Coordination of Benefits (COB)  (Rev. 1, 10- 01-03)  The NCPDP has approved the following use of qualifiers for reporting Medicare COB amounts:   Qualifier  Description  07 Medicare Allowed Amount  08 Medicare Paid Amount  99 1st Occurrence - Deductible Amount  99 2nd Occurrence - Coinsurance Amount  99 3rd Occurrence - Co-Payment Amount   70.1.3 - Inbound NCPDP Claim (Rev. 1, 10- 01-03)  The DME MAC needs to be able to determine whether a beneficiary has Medicaid coverage and in which state.  In order to determine this, the provider must enter the two position state alpha code followed by the word MEDICAID in the Group ID field (Example, NYMEDICAID or FLMEDICAID).  Therefore, XXMEDICAID must be accepted in the Group ID field (301- C1) in order to allow DME MACs to determine that a beneficiary has Medicaid coverage in that specific state.   80 - Claims Processing for Special Drug Categories  (Rev. 1, 10- 01-03)  NOTE :  Preventive vaccines, influenza, pneumococcal and hepatitis B, are covered in Chapter 18 of this manual.   NOTE :  The definition of Off -Label and its uses are described in the Medicare Benefit Policy Manual, Chapter 15.   80.1 - Oral Cancer Drugs  (Rev. 1, 10- 01-03)  A3 3660.13, SNF 536.1  Effective January 1, 1994, oral self administered versions of covered injectable cancer drugs furnished may be paid if other coverage requirements are met.  To be covered the drug must have had the same active ingredient as the injectable drug.  Effective January 1, 1999, this coverage was expanded to include FDA approved Prodrugs used as anti -cancer drugs.  A Prodrug may have a different chemical composition than the injectable drug but body metabolizing of the Prodrug results in the same chemical composit ion in the body.   80.1.1 - HCPCS Service Coding for Oral Cancer Drugs  (Rev. 1, 10- 01-03)  The following codes may be used for drugs other than Prodrugs, when covered:   Generic/Chemical Name  How Supplied  HCPCS  Busulfan  2 mg/ORAL  J8510  Capecitabine  150mg/ORAL  J8520  Capecitabine  500mg/ORAL  J8521  Methotrexate  2.5 mg/ORAL  J8610  Cyclophosphamide  *  25 mg/ORAL  J8530  Cyclophosphamide  *  (Treat 50 mg. as 2 units  50 mg/ORAL  J8530  Etoposide  50 mg/ORAL  J8560  Melphalan  2 mg/ORAL  J8600  Prescription Drug chemotherapeutic NOC  ORAL  J8999   Each tablet or capsule is equal to one unit, except for 50 mg/ORAL of cyclophosphamide (J8530), which is shown as 2 units.  The 25mg and 50 mg share the same code.   NOTE:  HIPAA requires that drug claims submitted to DME MACs be identified by NDC.  80.1.2 - HCPCS and NDC Reporting for Prodrugs  (Rev. 136, 04- 09-04)  A/B MAC (A) claims   For oral anti -cancer Prodrugs HCPCS code J8999 is reported with revenue code 0636.   DME MAC  claims   The supplier reports the NDC code on the claim.  The DME MAC converts the NDC code to a WW HCPCS code for CWF.  As new WW codes are established for oral anti -cancer drugs they will be communicated in a Recurring Update Notification.  80.1.3 - Other Claims Processing Issues for Oral Cancer Drugs  (Rev. 1, 10- 01-03)  Deductible and coinsurance apply.   A cancer diagnosis code must be reported when billing for these HCPCS codes.  If there is no cancer diagnosis the claims is denied.  The number of tablets or capsules is reported as units.   80.1.4 - MSN/Claim Adjustment Message Codes for Oral Cancer Drug Denials (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  If the claim for an oral cancer drug is denied because it was not approved by FDA, is not considered to be a medically accepted treatment for cancer, or is not the chemical equivalent of a covered injectable cancer drug (or a covered Prodrug), use the appr opriate message on the MSN.   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 Three.   Group Code: CO  CARC: 114  RARC: N/A  MSN: 6.2, 6.3  80.2 - Oral Anti-Emetic Drugs Used as Full Replacement for Intravenous Anti -Emetic Drugs as Part of a Cancer Chemotherapeutic Regimen  (Rev. 2931, Issued: 04- 15-14, Effective: 05 -29-13, Implementation: 07- 07-14)  See the Medicare Benefit Policy Manual, Chapter 15, and the National Coverage Determination (NCD) Manual, Section 110.18, for detailed coverage requirements.  Effective for dates of service on or after January 1, 1998, Medicare Part B (including institutional claims processed by A/B MACs (A) and physician/supplier claims processed by DME MACs) pays for oral anti -emetic drugs when used as full therapeutic replacement for intravenous dosage forms as part of a cancer chemotherapeutic regimen when the drug(s) is administered or prescribed by a physician for use immediately before, at, or within 48 hours after the time of administration of the chemotherapeutic agent.   The allowable period of covered therapy includes day 1, the date of service of the chemotherapy drug (beginning at the time of treatment), plus a period not to exceed 2 additional calendar days, or a maximum period up to 48 hours.  Some drugs are limited t o 24 hours; some to 48 hours.  The hour limit is included in the narrative description of the Health Care Common Procedure Coding System (HCPCS) code.   The oral, 3- drug combination is aprepitant, a 5HT3 antagonist, e.g. granisetron, ondansetron, or dolasetron, and dexamethasone, a corticosteroid.   The oral anti -emetic drug(s) should be prescribed only on a per chemotherapy treatment basis.  For example, only enough of the oral anti -emetic(s) for one 24 - or 48 -hour dosage regimen (depending upon the drug) should be prescribed/supplied for each incide nce of chemotherapy treatment.  The 3 -drug combination protocol requires the first dose to be administered before, during, or immediately after the anti -cancer chemotherapy administration.  The second day is defined as within 24 hours and the third day i s defined as within 48 hours of the chemotherapy administration.  These drugs may be supplied by the physician in the office, by an inpatient or outpatient provider (e.g., hospital, critical access hospital (CAH), skilled nursing facility (SNF), or through a supplier (e.g., a pharmacy).