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Week of October 6, 2008

Pharmacy Compliance Question of the Week

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September 29, 2008

Question:

How do the new Joint Commission safety goals on medication reconciliation differ from the current ones?

Answer:

Under the current (2008) National Patient Safety Goals (NPSGs), the Joint Commission requires hospitals to document only the patient's current medication list at admission. Requirements increase in 2009 to also include documentation of discrepancies and their reconciliation.

Documentation also must include notations that the complete and reconciled medication list has been given to the next provider of service (either inside or outside the organization). When a patient leaves the organization for home, the organization must document that 1) a complete and reconciled medication list is being provided to the patient's primary care provider, or the original referring provider, or next known provider of service, and 2) a complete and reconciled medication list is being provided and explained to the patient or family.

For more on the above, go to http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/09_NPSG_HAP.pdf.

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September 22, 2008

Question:

I am looking for information on medication reconciliation as it applies to accreditation from the Joint Commission. What exactly is required?

Answer:

Answer:

Answer:

Chapter 12, section 30.5.D, of the Medicare Claims Processing Manual states the following.

We have done an extensive amount of research to try and clarify which non-chemotherapy drugs can be billed with the chemotherapy admin codes (BRMs, etc). However, everything we are seeing doesn't seem to indicate that the drug must also have an indication for cancer.

We're trying to adjust our administration code crosswalk to reflect the correct information. Can you provide additional details as to what you're seeing from the contractors?

Answer:

Our recommendation for billing of administration codes for BRM and monoclonal antibodies is based on Q&As posted by a variety of regional payers (intermediaries / MACs). The American Medical Association has been questioned about this guidance but its response is in the gray zone. At this time, each facility must confirm with the intermediary or carrier as to the appropriate use of the 96XXX codes for administration of BRMs and MAs, but the conservative approach is to report the codes only for drugs with a primary indication as antineoplastic (such as Rituxan for treatment of rheumatoid arthritis).

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May 12, 2008

Question:

We're trying to adjust our administration code crosswalk to reflect the correct information. Can you provide additional details as to what you're seeing from the contractors?

If a physician, hospital or other provider must discard the remainder of a single-use vial or other single-use package after administering a dose/quantity of the drug or biological to a Medicare patient, the Medicare program pays for the amount of drug or biological discarded along with the amount administered, up to the amount of the drug or biological as indicated on the vial or package label. However, note that multi-use vials are not subject to payment for discarded amounts of drug or biological.

You can find more details on this topic in the Medicare Claims Processing Manual at
http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf. Be sure to review subsection 100.2.9 of that chapter, which relates to submission of claims with the modifier JW (drug or biological amount discarded/not administered to any patient.)

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March 31, 2008

Question:

Are any pharmaceuticals separately paid?

Answer:

So far in 2008, the two drug codes below are separately payable under the hospital outpatient prospective payment system (OPPS).

Code --- Long Descriptor
C9237 -- Injection, lanreotide acetate, 1 mg
C9240 -- Injection, ixabepilone, 1 mg

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March 24, 2008

Question:

How does Medicare pay for radiopharmaceuticals?

Answer:

Answer:

Question:

How should drug units be reported?

Answer:

Question:

What will be the threshold for separately payable drugs in 2008 according to the Medicare outpatient proposal?

Answer:

The Centers for Medicare & Medicaid Services (CMS) proposes to raise the threshold for separately payable drugs, biologicals, and therapeutic radiopharmaceuticals to $60 in 2008, up from $55 in 2007. This means that when they cost $60 or less per administration, they will be packaged with their related procedures. (Note that CMS has proposed to package all diagnostic radiopharmaceuticals in 2008.) CMS will continue to exempt from the packaging rule oral and injectable anti-nausea drugs for cancer patients.

For separately payable drugs (i.e., those not subject to packaging), CMS plans to reimburse at 105 percent of the average sales price (ASP)-down from 106 percent of
the ASP in both 2006 and 2007. The proposed reimbursement rate for 2008 could
change, however, in the final rule-just as it did last year after CMS considered all the
public comments.

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August 20, 2007

Question:

Is there any difference in Medicare payment for single-use and multi-use vials in regard to discarded drugs?

Answer:

Answer:

In most cases, the Centers for Medicare & Medicaid Services will require that Part D vaccines, including the administration costs, be billed on one claim. If a participating Part D pharmacy dispenses and administers the vaccine, it would send a single claim to the Part D Plan and collect any cost-sharing monies from the beneficiary.

There will be situations when the vaccine ingredient and vaccine administration will have to be billed and reimbursed separately. Take for example a situation in which a Part D vaccine has special storage conditions. It may be more practical for most physician offices to have the pharmacy dispense and deliver the vaccine for administration. The pharmacy would file a claim for the ingredient costs and dispensing fee. The physician would bill the beneficiary for the administration fee, and the beneficiary would then file a paper claim with the Part D plan.

For more details, see the CMS document entitled "Vaccine Administration Under Medicare Part D in 2008," available from
http://cms. hhs.gov/Pharmacy/Downloads/MemoVaccineAdministration_05.14.07.pdf.

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July 23, 2007

Question:

I am looking for details about Medicare's vaccine administration policy that will take effect in 2008. Specifically, how will payments be determined?

Answer:

The Centers for Medicare & Medicaid Services expects Part D sponsors to negotiate vaccine administration fees with participating pharmacists. Plans are to take into consideration all the elements needed to provide the service, including the immunizing professional's time in physically delivering the vaccine to the beneficiary, supplies (syringe, gauze, Band-aid, alcohol prep pad, etc.), office overhead, and professional liability. Furthermore, the total negotiated price for the Part D vaccine service will comprise the vaccine ingredient cost, a dispensing fee (if applicable), and the vaccine administration fee.

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July 16, 2007

Question:

What is the proper way to report drug units on Medicare claims?

Answer:

The Centers for Medicare & Medicaid Services has issued many transmittals related to properly reporting the units of drugs administered so that they are consistent with the dosages specified in the HCPCS code descriptor. The guidance goes like this.

Hospitals should report drug units in multiples of the units in the HCPCS descriptor. If the description for the drug code is 50 mg, for example, and the patient received 200 mg of the drug, then the hospital would bill for four units.

Do not bill units based on how the drug is packaged, stored, or stocked. Take the case of a HCPCS descriptor of 1 mg and a patient who receives a 10-mg vial of the drug. The hospital should bill 10 units, even though the patient received 1 vial. In addition, make it a practice to review the complete long descriptors before submitting the Medicare claim for a drug or biological because the drugs' short descriptors do not always contain complete information.

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July 9, 2007

Question:

In last week's QA, you've mentioned that there are three initial e-prescribing standards. Can you provide the names of these and a resource for learning more?

Answer:

The first standard (the formulary and benefit standard) gives prescribers drug coverage information for a patient at the point of care. By providing this information during the prescription process, the prescriber can make the most appropriate drug
choice without time-consuming exchanges with the pharmacy or health plan. It works in conjunction with foundation standard ASC X12N-270/271-eligibility request and response.

The prescribing industry has already widely adopted the second standard--the medication history standard, which enables providers, dispensers, and payers to communicate drugs prescribed or claimed for a patient. It helps prevent medication
errors and facilitates medication management.

Pharmacy software systems are critical to the last standard for fill-status notification because the message originates in the pharmacy. This standard allows the pharmacy to notify the prescriber when a prescription has been dispensed, partially dispensed, and not dispensed and returned to stock.

For detailed information, check under Key Topics at the web site of the Agency for Healthcare Research and Quality:
Click here

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July 2, 2007

Question:

Does Medicare require pharmacies to use electronic transcribing technology?

Answer:

Under Medicare Part D, prescribers and pharmacists are not required to use e-prescribing technology; however, if they do choose to use it, they must employ federally adopted e-prescribing standards. The Department of Health & Human Services (HHS) requires prescription drug plans and other Part D sponsors to support and adhere to these standards.

HHS adopted three foundation standards that took effect on January 1, 2006. Recently, HHS announced that three new electronic-prescribing standards have passed pilot testing and are ready to support related transactions in the Medicare Part D program.

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June 25, 2007

Question:

When the government refers to "electronic prescribing," is it referring just to the drug order from the physician?

Answer:

Answer:

In Transmittal 1212 (Change Request 5480, March 30), the Centers for Medicare and Medicaid Services (CMS) asked providers to voluntarily report two new modifiers (as appropriate) to indicate the method of administration used to provide ESAs. As you probably know, patients with end stage renal disease (ESRD) receiving ESAs, such as epoetin alfa (EPO) and darbepoetin alfa (Aranesp), for the treatment of anemia may receive intravenous or subcutaneous administrations. Current claims processing requirements do not provide for reporting the method of administration used to provide the ESAs.

Effective for dates of service on or after January 1, 2007, providers may report modifier JA for intravenous administration and modifier JB for subcutaneous administration on claims with the following codes:

Q4081 Injection, epoetin alfa, 100 units (for ESRD on dialysis)
J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis) (Use this code for ranesp.)
J0886 Injection, epoetin alfa, 1000 units (for ESRD on dialysis) (Use this code for Epogen, Procrit.)

More on these modifiers can be found at http://www.cms.hhs.gov/transmittals/downloads/R1212CP.pdf.

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May 7, 2007

Question:

Does CMS post any data on the drug plans it contracts with?

Answer:

Answer:

Answer:

In 2007, four new Q codes replace J7317, J7319, J7320, and J3490, which have been used for Medicare billing. The interim Q codes listed below are intended to facilitate separate payment for hyaluronate products that have come on the market since 2003, and they apply to dates of service (DOS) on or after January 1, 2007.

- Q4083 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose
- Q4084 Hyaluronan or derivative, Synvisc, for intra-articular injection, per dose
- Q4085 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose
- Q4086 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose

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March 19, 2007

Question:

How does Medicare pay for drugs in hospital outpatient departments?

Answer:

For 2007, Medicare pays separately for drugs, biologicals and radiopharmaceuticals whose median cost per administration exceeds $55, while packaging the cost of drugs, biologicals, and radiopharmaceuticals whose median cost per administration is less than $55 into the procedures with which they are billed.

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March 12, 2007

Question:

Can you provide tips for billing vaccines?

Answer:

The transition policy mentioned in the answer to last week's question will no doubt leave many people confused. The following points may help clarify the billing and payment process.

- Use code G0377-administration of vaccine for Part D drug. A coinsurance and deductible apply. For 2007, the Part B allowable charge for G0377 is $19.33. Medicare pays for 80 percent of that amount or $15.46. The beneficiary would then pay $3.87 as coinsurance in addition to any unmet Part B deductible.
- Submit claims on the 837 electronic format or CMS-1500 paper form. Bill with indicator 05 (pharmacy) and indicate the place of service as home or pharmacy.
- Submit the claim as assigned. The administration of Part D claims are subject to mandatory assignment.
- Retain the physician order or prescription associated with the Part-D vaccine administration.

CMS has established January 29, 2007, as the implementation date for this policy, but it applies to dates of service on or after January 1, 2007.

Information Source: The above information can be found in Transmittal 1146 at www.cms.hhs.gov/transmittals/downloads/R1146CP.pdf

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March 5, 2007

Question:

How do you know whether to bill a vaccine as a Part B benefit versus a Part D benefit?

Answer:

Exceptions include the following:

- Influenza and pneumococcal vaccines and their administration are always covered under Part B.
- Part B always covers vaccines given directly related to the treatment of an injury or direct exposure to a disease or condition.
- In the case of Hepatitus B vaccine, individuals of high or intermediate risk would be covered under Part B. For all other individuals, the Hepatitus B vaccine would be covered under Part D, but some plans may require prior authorization to ensure medical necessity.

More on vaccines can be found in Transmittal 1146 at http://www.cms.hhs.gov/transmittals/downloads/R1146CP.pdf.

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February 26, 2007

Question:

Does the new policy related to coverage of Medicare Part D vaccines mentioned in last week's Q&A include the vaccine itself?

Answer:

No, this policy does not cover payment for the vaccine itself. Part D prescription drug plans determine and make payments for the actual vaccines. More information about this topic can be found in Transmittal 1146 at www.cms.hhs.gov/transmittals/downloads/R1146CP.pdf.

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February 19, 2007

Question:

Does Medicare cover Part D vaccine administration?

Answer:

The Tax Relief and Health Care Act (TRHCA) of 2006 mandates that Medicare cover the administration of Part D vaccines beginning January 1, 2007. This affects Medicare-enrolled pharmacies that bill durable medical equipment regional carriers (DMERCs) or DME Medicare administrative contractors (MACs) for Part D vaccine administration to Medicare beneficiaries. To receive payment, the pharmacy must be enrolled with the National Supplier Clearinghouse, and the beneficiary must be enrolled in a Part D prescription drug plan.

Payment for administration of a vaccine that falls under the statutory definition of a "covered Part D drug" will start January 1, 2008. The TRHCA provides for a transition policy that would allow pharmacies to receive payment under Medicare Part B. This policy is in effect for 2007 only and then coverage will switch to the Part D program.

More information about this can be found in Transmittal 1146 at www.cms.hhs.gov/transmittals/downloads/R1146CP.pdf.

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February 12, 2007

Question:

How does the Pharmacy Quality Alliance you mentioned last week relate to all of the other quality initiatives being pursued by CMS?

Answer:

During the last few years, the has established a clear priority of supporting higher quality and less costly care. It has launched pay for performance (P4P) programs in several areas, including the inpatient prospective payment system (IPPS) payment update.

When the Centers for Medicare & Medicaid Services (CMS) announced the creation of the Pharmacy Quality Alliance (PQA) last April, it noted that it would parallel similar program developed such as the Hospital Quality Alliance and the Ambulatory Care Quality Alliance (AQA). Ultimately, all of these programs will lead to new payment models related to health outcomes.

More on the PQA can be found at www.PQAalliance.org.

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February 5, 2007

Question:

What is the Pharmacy Quality Alliance, and does it relate in some way to payment for drugs in hospitals?

Answer:

The Centers for Medicare and Medicaid Services (CMS) launched the Pharmacy Quality Alliance (PQA) in April 2006. The PQA consists of a CMS-appointed governing committee and enlists the participation of a broad range of private and public industry players. Its mission is "…to improve health care quality and patient safety through a collaborative process in which the key stakeholders agree on a strategy for measuring performance at the pharmacy and pharmacist levels; collecting data in the least burdensome way; and reporting meaningful information to consumers, pharmacists, employers, payers, and other healthcare decision-makers to help make informed choices, improve outcomes and stimulate the development of new payment models."

To meet this mission, the PQA began its work with two major initiatives: identifying pharmacy quality metrics and developing quality metric reporting systems.

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January 29 , 2007

Question:

Does Medicare have a phone number where pharmacists can call when they have Part D questions?

Answer:

Yes, the Centers for Medicare & Medicaid Services (CMS) recently established a dedicated phone line for this exact purpose. Through this line, pharmacists can determine plan enrollment status and whether or not a patient is eligible for a low-income subsidy (LIS) co-pay. They must have the beneficiary's name, Medicare ID, date of birth, and address. The phone number is 1-866-835-7595.

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January 22, 2007

Question:

What is the E1 system frequently mentioned by CMS?

Answer:

In 2005, the Centers for Medicare and Medicaid Services (CMS) awarded a contract to Per-Se Technologies (then NDCHealth) to provide electronic services for determining Part D eligibility, identifying the appropriate Medicare drug plan to bill, and calculating the beneficiary's "true out-of-pocket" (TrOOP) costs. This process is designed to take place in real-time-at the point of sale at the pharmacy counter-using existing computer systems.

To achieve the above, Per-Se administers a new computer tool called E1, which provides pharmacies with Part D enrollment and eligibility information as well as the correct plan to bill. CMS provides, and constantly updates, this information.

Ultimately, the goal is reduce the amount of time pharmacists and their staff members spend resolving insurance matters.

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January 15, 2007

Question:

Do the new hospital conditions of participation include anything of interest to pharmacies?

Answer:

Yes, the new conditions of participation (COP), which take effect on January 26 for the Medicare and Medicaid programs, include guidelines for securing medications. The short definition of secure, says CMS, is that unauthorized persons are prevented from access. Briefly, all drugs and biologicals must be kept in secure areas, and locked when appropriate. Controlled substances (drugs listed in Schedules II, III, IV and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970) must be locked within a secure area, and only authorized personnel may have access to those areas.

The November 27, 2006, final rule on the COPs is available at http://www.cms.hhs.gov/quarterlyproviderupdates/downloads/cms3122f.pdf.

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January 8, 2007

Question:

In the last compliance Q&A, you indicated that Medicare's policy on preadministration services would not be changed for 2007. Where would I find more detailed billing guidelines for this service?

Answer:

On December 22, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 1140, which summarizes the changes related to Medicare payment for preadministration-related services associated with intravenous immune globulin administration. For this transmittal, go to http://www.cms.hhs.gov/transmittals/downloads/R1140CP.pdf.
Related provider-information memo MM5428 can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5428.pdf.

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January 1, 2007

Question:

How should pre-administration services for intravenous immune globulin (IVIG) be billed to Medicare, and how will they be paid?

Answer:

In order to support patient access to IVIG, Medicare will continue to reimburse IVIG preadministration-related services "as long as it remains appropriate," according to the Centers for Medicare & Medicaid Services in the 2007 final rule for the hospital outpatient prospective payment system. It said that this payment is for the extra resources expended on locating and obtaining appropriate IVIG products and on scheduling patients' infusions during this time when there may continue to be transient disruptions in the marketplace.

Hospitals should continue to bill under the same HCPCS code used in 2006: G0332 (preadministration-related services for IVIG, infusion encounter). This code continues to be grouped into new technology APC 1502, which receives a payment rate of $75. This preadministration-related services' payment is in addition to the separate payment that Medicare makes for the IVIG product itself and its administration.

The 2007 final rule on hospital outpatient prospective payment system and 2007 payment rates can be found at http://www.cms.hhs.gov/HospitalOutpatientPPS/Downloads/CMS1506FC.pdf.