(Medicare Claims Processing Manual)

EXAMPLE 1   HCPCS  Drug  Dosage  J7189  Factor VIIa  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  Drug  Dosage  J9355  Trastuzumab  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  Drug  Dosage  J3100  Tenecteplase  50 mg   Actual Dosage: 40 mg  The provider would bill for 1 unit, even though less than 1 full unit was furnished.  At times, the facility provides less than the amount provided in a single use vial and there is waste, i.e.; some drugs may be available only in packaged amounts that exceed the needs of an individual patient. Once the drug is reconstituted in the hospital s pharmacy, it may have a limited shelf life. Since an individual patient may receive less than the fully reconstituted amount, we encourage hospitals to schedule patients in such a way that the hospital can use the drug most efficiently. However, if the hospital must discard the remainder of a vial after administering part of it to a Medicare patient, the provider may bill for the amount of drug discarded plus the amount administered.  Example 1:   Drug X is available only in a 100- unit size. A hospital schedules three Medicare patients to receive drug X on the same day within the designated shelf life of the product. An appropriate hospital staff member administers 30 units to each patient.  The rem aining 10 units are billed to Medicare on the account of the last patient.  Therefore, 30 units are billed on behalf of the first patient seen and 30 units are billed on behalf of the second patient seen. Forty units are billed on behalf of the last patien t seen because the hospital had to discard 10 units at that point.   Example 2:   An appropriate hospital staff member must administer 30 units of drug X to a Medicare patient, and it is not practical to schedule another patient who requires the same drug. For example, the hospital has only one patient who requires drug X, or the hospital sees the patient for the first time and did not know the patients condition. The hospital bills for 100 units on behal f of the patient, and Medicare pays for 100 units.   When the number of units of blood clotting factor administered to hemophiliac inpatients exceeds 99,999, the hospital reports the excess as a second line for revenue code 0636 and repeats the HCPCS code.  One hundred thousand fifty (100,050) units are repo rted on one line as 99,999, and another line shows 1,051.   Revenue Code 0636 is used.  It requires HCPCS.  Some other inpatient drugs continue to be billed without HCPCS codes under pharmacy.   No changes in beneficiary notices are required.  Coverage is applicable to hospital Part A claims only.  Coverage is also applicable to inpatient Part B services in SNFs and all types of hospitals, including CAHs.  Separate payment is not made to SNFs for beneficiaries in an inpatient Part A stay.   B. - A/B MAC (A) Action   The contractor is responsible for the following:    It accepts HCPCS codes for inpatient services;    It edits to require HCPCS codes with Revenue Code 0636.  Multiple iterations of the revenue code are possible with the same or different HCPCS codes.  It does not edit units except to ensure a numeric value;    It reduces charges forwarded to Pricer by the charges for hemophilia clotting factors in revenue code 0636.  It retains the charges and revenue and HCPCS codes for CWF; and    It modifies data entry screens to accept HCPCS codes for hospital (including CAH) swing bed, and SNF inpatient claims (bill types 11X, 12X, 18x, 21x and, 22x).   The September 1, 1993, IPPS final rule (58 FR 46304) states that payment will be made for the blood clotting factor only if diagnosis code for hemophilia is included on the bill.  Inpatient blood- clotting factors are covered only for beneficiaries with hemophilia. One of the following hemophilia diagnosis codes must be reported on the claim for payment to be made for blood clotting factors.   Table 1 -  Effective for discharges September 1 1993 through the implementation of ICD -10  ICD-9-CM code  Description  286.0  Congenital factor VIII disorder  286.1  Congenital factor IX disorder  286.2  Congenital factor XI deficiency  286.3  Congenital deficiency of other clotting factors  286.4  von Willebrands' disease   Table 2 -  Effective for discharges August 1, 2001 through the implementation of ICD -10, payment may be made if a diagnosis codes from either Table 1 or Table 2 is reported is reported:   ICD-9-CM code  Description  286.5  Hemorrhagic disorder due to intrinsic circulating anticoagulants (terminate effective September 30, 2011)  286.7  Acquired coagulation factor deficiency   Table 3 -  Effective for discharges on October 1, 2011, through the implementation of ICD -10 paymen t may be made if a diagnosis code from any of Table 1, Table 2 or Table 3 is reported:   ICD-9-CM code  Description  286.52  Acquired hemophilia  286.53  Antiphospholipid antibody with hemorrhagic disorder  286.59  Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors   Effective for discharges on or after the implementation of  ICD-10-CM, the following codes are applicable, and payment may be made for blood clotting factors only if a hemophilia code from the range D66 -  D68.4 is reported   A crosswalk of ICD 9 to ICD10 hemophilia diagnosis codes follows:   ICD-9-CM Code  Description  ICD-10-CM Code  Description  286.0  Congenital factor VIII disorder  D66 Hereditary factor VIII deficiency  286.1  Congenital factor IX disorder  D67 Hereditary factor IX deficiency  286.2  Congenital factor XI deficiency  D68.1  Hereditary factor XI deficiency  286.3  Congenital deficiency of other clotting factors  D68.2  Hereditary deficiency of other clotting factors  286.4  von Willebrands' disease  D68.0  Von Willebrand's disease  286.5  Hemorrhagic disorder due to intrinsic circulating anticoagulants (terminate effective September 30, 2011)  N/A  286.52  Acquired hemophilia  D68.311  Acquired hemophilia  286.53  Antiphospholipid antibody with hemorrhagic disorder  D68.312  Antiphospholipid antibody with hemorrhagic disorder  286.59  Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors  D68.318  Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors  286.7  Acquired coagulation factor deficiency  D68.32  Antiphospholipid antibody with hemorrhagic disorder  286.7  Acquired coagulation factor deficiency  D68.4  Acquired coagulation factor deficiency   C. - Part A Remittance Advice  For remittance reporting PIP and/or non- PIP payments, the Hemophilia Add On is included in the overall claim payment (Provider Reimbursement, CLP04).    If an inpatient claim has a Hemophilia Add On payment, the payment to the provider is increased in the PLB segment with a PLB adjustment HM.  The Hemophilia Add On amount will always be included in the CLP04 Claim Payment Amount.   For remittance reporting PIP payments, the Hemophilia Add On will also be reported in the provider level adjustment (element identifier PLB) segment with the provider level adjustment reason code HM.  For remittances reporting PIP payments, the sum of inpa tient claims, CLP04, is backed out at PLB with PI/PA.  If an inpatient claim has a Hemophilia Add On payment, the payment to the provider is increased in the PLB segment with a PLB adjustment HM.   D. - Standard Hard Copy Remittance Advice   For paper remittances reporting non- PIP payments involving Hemophilia Add On, add a "Hemophilia Add On" category to the end of the "Pass Thru Amounts" listings in the "Summary" section of the paper remittance.  Enter the total of the Hemophilia Add On amounts due for the claims covered by this remittance next to the Hemophilia Add On heading.   The following reflects the remittance advice messages and associated codes that will appear when processing claims under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.  Group Code: OA  CARC: 94  RARC: MA103  MSN: N/A  This will be the full extent of Hemophilia Add On reporting on paper remittance notices; providers wishing more detailed information must subscribe to the Medicare Part A specifications for the ASC X12 835 remittance advice, where additional information is  available.   See chapter 22, for detailed instructions and definitions.   20.7.4 - Cost Outlier Bills With Benefits Exhausted  (Rev. 1, 10- 01-03)  PM -  A-99-17 (CR -749)  Providers under IPPS, LTCH PPS, and IRF PPS follow this scenario when benefits are exhausted.   The methodology for using benefit days and reimbursing cost outliers is based on the beneficiary having a lifetime reserve (LTR) benefit day which the beneficiary elects to use or a regular benefit (regular or coinsurance) day beginning the day after the day covered charges are incurred in an amount that results in a cost outlier payment for the provider.  Additional charges are considered covered for every day thereafter for which a beneficiary has, and elects to use, an available benefit day.   DRG claims with cost outlier payments with discharge dates on or after October 1, 1997, must have an Occurrence Code (OC) 47 on the claim unless there are enough full and/or coinsurance days to cover all the medically necessary days or the only available benefits are LTR days and there are enough LTR days to cover all the med ically necessary days.  DRG claims without cost outlier payments can never have regular benefit days combined with LTR benefit days.   Once the cost outlier threshold is known, providers must add the daily covered charges for the claim until they determine the day that covered charges reach the cost outlier threshold.  Providers must exclude days and covered charges during noncovered spans, e.g., during Occurrence Span Code (OSC) 74, 76, or 79 dates.  Providers must then submit the date of the first full day of cost outlier status (the day after the day that covered charges reach the cost outlier threshold) on the bill using OC 47.  The OC  47 date cannot be equal to or during OSC 74, 76, or 79 dates.  Providers must determine the amount of regular, coinsurance, and LTR days the beneficiary has available per CWF inquiry or their FI.   Any nonutilization days after the beneficiary exhausts coinsurance or LTR days before the OC 47 date will be identified using OSC 70.  LTR days should be used as necessary and as elected by the beneficiary.  If coinsurance days are exhausted during the inl ier portion of the stay and there is a period of nonutilization indicated by the presence of OSC 70 and the beneficiary elects not to use LTR days, covered charges are limited to the exact amount of the cost outlier threshold and both OC A3, which shows the last covered day, and OC 47, which shows the following day which is the first full day of cost outlier status, must be shown.  When coinsurance and/or LTR days are exhausted during the cost outlier portion of the stay, OC A3 should be used as appropriate  to report the date benefits are exhausted.  Covered charges should be accrued to reflect the entire period of the bill if the bill is fully covered or the entire period up to and including the date benefits were exhausted, if benefits were exhausted.   Assumptions for all of the following examples:   1. Cost outlier threshold amount is $50,000.  2. Threshold amount is reached on the 25th day.