2015 Billing Guide for. REMICADE (infliximab)

Transcription

1 2015 Billing Guide for REMICADE (infliximab)

2 Table of Contents Introduction... 1 Factors That Influence Coverage REMICADE (infliximab) Quick Reference Guide... 3 Coding for REMICADE and Drug Administration Services REMICADE Coding Summary... 5 Physician Office Setting... 6 Hospital Outpatient Setting... 7 Home Infusion Providers... 8 Other Coding Considerations REMICADE Billing Units Partial Additional Hours of Infusion Time Modifiers CMS Discarded Drug Policies Same Day Evaluation and Management Services Payment for REMICADE and Drug Administration Services Medicare Payment to Physician Offices Medicare Payment to Hospital Outpatient Departments Medicare Policy for Other Healthcare Providers Medicaid Payment Policies Commercial Payers Home Infusion Reimbursement Medicare Part D References i

3 Appendices Appendix A: Sample Claim Forms Appendix B: Medical Necessity Appendix C: Appeals Appendix D: Working With Specialty Pharmacy Appendix E: Medicare Quality Programs Appendix F: ICD Appendix G: Resources Important Safety Information for REMICADE (infliximab) Please see Important Safety Information, full Prescribing Information, and Medication Guide for REMICADE. The information in this guide is provided to assist you in understanding the reimbursement process. It is intended to help providers in accurately obtaining reimbursement for healthcare services. It is not intended to increase or maximize reimbursement by any payer. We strongly suggest that you consult your payer organization with regard to local reimbursement policies. This document is presented for informational purposes only and is not intended to provide reimbursement or legal advice. Laws, regulations, and policies concerning reimbursement are complex and updated frequently. While Janssen Biotech, Inc., has made an effort to be current as of the issue date of this document, the information may not be as current or comprehensive when you view it. Please consult with your counselor reimbursement specialist for any reimbursement or billing questions. Similarly, all Current Procedural Terminology (CPT ) & Healthcare Common Procedural Coding System (HCPCS) billing codes are supplied for informational purposes only and represent no statement, promise or guarantee by Janssen Biotech, Inc., that these codes will be appropriate or that reimbursement will be made. CPT 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for the data contained or not contained herein. Current Procedural Terminology (CPT) American Medical Association. All rights reserved. ii

4 Introduction Janssen Biotech, Inc., has developed this Billing Guide to help healthcare providers and billing staff understand third-party reimbursement for REMICADE (infliximab). Specifically, this guide presents general information on coverage, coding, reimbursement, and claims submission for REMICADE. In addition, it provides information on how to manage denied claims and information about other reimbursement-related topics that are relevant to the sites of care in which REMICADE is administered. The information contained in this guide is intended to provide a general understanding of the reimbursement process and is not intended to assist providers in obtaining reimbursement for any specific claim. Additional information about coding, billing, and coverage of REMICADE may be obtained through AccessOne, a single source of services designed to simplify access to therapy with REMICADE. You may contact AccessOne at: 1 (888) ACCESS-1 ( ), Monday through Friday, 8 AM to 8 PM, ET, or visit their website at: 1

5 Factors That Influence Coverage Most third-party payers (eg, commercial insurers, Medicare, Medicaid) cover REMICADE (infliximab) for its approved U.S. Food and Drug Administration indications (see Indications on page 5 of this guide). However, benefits may vary depending upon a patient s insurer or specific insurance plan (or product ) offered by a payer. When third-party payers review claims for REMICADE, first they will determine if the reported service is covered under their contract or rules. Most payers cover drug infusions as part of their core benefits. Next, payers will look for evidence supporting the medical necessity of therapy. This evidence may include: Information about the patient s medical condition and history A physician s statement or letter of medical necessity Supporting literature (eg, peer-reviewed studies and compendia monographs) Prescribing information Availability of other treatment alternatives Administrative issues may also affect coverage of therapy with REMICADE. For example, payers may consider the following: Does the payer s contract specifically preclude physician offices from billing for infusion services or infused drugs? A small portion of payers have exclusive contracts with designated preferred providers for infusion services. This may include certain clinics or specialty pharmacies that deliver drugs to healthcare providers or other infusion centers. Does the payer cover the therapy only when provided through a specific treatment site? Payers may have site-specific coverage rules that restrict provision of infused therapies. For example, currently Medicare does not cover infusions when they are billed by Medicare-certified ambulatory surgery centers. Medicare and other payers also may restrict coverage for certain infused drugs in the home or hospital outpatient setting. Is the billing provider a participating member of, or in-network provider, for that particular plan? Payers contract with providers to deliver services to the plan s members. Providers are thus participating or within that plan s network, requiring them to abide by the contract charge structure when providing care for that plan s members. Did the patient obtain the appropriate referral or prior authorization if required by their plan? Many plans require that non-emergency services be pre-approved or that a primary care physician make the referral for specialty care. Failing to obtain appropriate referrals or pre-authorization can result in non-payment by the plan. 2

6 REMICADE (infliximab) Quick Reference Guide This section provides general information about the payers and payment mechanisms for the different sites of care in which REMICADE is administered (Table 1) and lists the codes commonly associated with billing for REMICADE and the related drug administration services (Table 2). Table 1: REMICADE Reimbursement Summary by Payer Type and Site of Care Payer Hospital Outpatient Department Physician Office Medicare Part B* Medicaid Commercial Insurance Outpatient Prospective Payment System (OPPS) ASP+6% Covered incident to physician services Local Coverage Determinations (LCD) may apply Variable reimbursement methodology Coverage policies may apply May require preauthorization Variable reimbursement methodology May require use of specialty pharmacy May require preauthorization Physician Fee Schedule (PFS) ASP+6% Covered incident to physician services Local Coverage Determinations (LCD) may apply Variable reimbursement methodology Coverage policies may apply May require preauthorization Variable reimbursement methodology May require use of specialty pharmacy May require preauthorization * Note: while REMICADE is covered under Medicare Part B some Part D formularies also list REMICADE. If the physician and patient conclude that obtaining REMICADE through Part D (at a Part D retail pharmacy provider or a Part D participating specialty pharmacy) is clinically better for the patient, that option is available. Under these circumstances providers may not bill Part B for the drug, only the services for drug administration. Medicare payment rates may be subject to change based on mandated budget cuts or Congressional legislation. Please see Important Safety Information, full Prescribing Information, and Medication Guide for REMICADE. 3

7 Coding for REMICADE (infliximab) and Drug Administration Services It is important to accurately and fully complete claim forms for the therapy, whether the claim is submitted by physician offices using the CMS-1500 claim form or by hospital outpatient departments using the UB-04 claim form. This section identifies procedure and supply codes that are likely to be most relevant to healthcare provider claims for therapy with REMICADE. Please note that healthcare providers are responsible for selecting appropriate codes for any particular claim based on the patient s condition and the items and services that are furnished. Contact your local payer with regard to local payment and policies. The Table on the following page summarizes the relevant codes for REMICADE claims. See Appendix A for sample CMS-1500 and UB-04 REMICADE claims, along with tips for successful claims submission. INDICATIONS AND USAGE FOR REMICADE Crohn s Disease REMICADE is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in adult and pediatric patients 6 years of age and older with moderately to severely active Crohn s disease who have had an inadequate response to conventional therapy. REMICADE is indicated for reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing Crohn s disease. Pediatric Crohn s Disease REMICADE is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 6 years of age or older with moderately to severely active disease who have had an inadequate response to conventional therapy. Ulcerative Colitis REMICADE is indicated for reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy. Pediatric Ulcerative Colitis REMICADE is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 6 years of age or older with moderately to severely active disease who have had an inadequate response to conventional therapy. Rheumatoid Arthritis in combination with methotrexate REMICADE is indicated for reducing signs and symptoms, inhibiting the progression of structural damage, and improving physical function in patients with moderately to severely active disease. Ankylosing Spondylitis REMICADE is indicated for reducing signs and symptoms in patients with active disease. Psoriatic Arthritis REMICADE is indicated for reducing signs and symptoms of active arthritis, inhibiting the progression of structural damage, and improving physical function. Plaque Psoriasis REMICADE is indicated for treatment of adult patients with chronic severe (i.e., extensive and /or disabling) plaque psoriasis who are candidates for systemic therapy and when other systemic therapies are medically less appropriate. REMICADE should only be administered to patients who will be closely monitored and have regular follow-up visits with a physician. SELECTED IMPORTANT SAFETY INFORMATION Serious and sometimes fatal side effects have been reported with REMICADE (infliximab). Infections due to bacterial, mycobacterial, invasive fungal, viral, or other opportunistic pathogens (e.g., TB, histoplasmosis) have been reported. Lymphoma, including cases of fatal hepatosplenic T-cell lymphoma (HSTCL), and other malignancies have been reported, including in children and young adult patients. Due to the risk of HSTCL, mostly reported in Crohn s disease and ulcerative colitis, assess the risk/benefit, especially if the patient is male and is receiving azathioprine or 6-mercaptopurine treatment. REMICADE is contraindicated in patients with severe hypersensitivity reactions to REMICADE and certain patients with congestive heart failure. Other serious side effects reported include melanoma and Merkel cell carcinoma, hepatitis B reactivation, hepatotoxicity, hematological events, hypersensitivity, neurological events, and lupus-like syndrome. Please see related and other Important Safety Information. 4

8 Table 2: REMICADE (infliximab) Coding Summary Type of Claim Information Diagnosis Procedures, Services and Supplies REMICADE Type of Code Code Description Physician Office Location on CMS-1500 Form Hospital Outpatient Department Location on UB-04 Form Crohn s Disease Regional enteritis, small intestine Regional enteritis, large intestine Regional enteritis, small intestine with large intestine Regional enteritis, unspecified site Fistula (use in addition to codes for Crohn s Disease) Anal fistula Fistula of intestine, excluding rectum and anus Ulcerative Colitis Ulcerative (chronic) enterocolitis Ulcerative (chronic) ileocolitis Ulcerative (chronic) proctitis Ulcerative (chronic) proctosigmoiditis Item 21 Form Locator 67 ICD-9-CM Left-side ulcerative (chronic) colitis Diagnosis Universal ulcerative (chronic) colitis Other ulcerative colitis Ulcerative colitis, unspecified Rheumatoid Arthritis (RA) Rheumatoid arthritis Other RA with visceral or systemic involvement Ankylosing Spondylitis Ankylosing spondylitis Psoriatic Arthritis Psoriatic arthropathy Plaque Psoriasis Other psoriasis 96413* IV infusion, up to 1 hour (chemo/monoclonal antibody) 96415* IV infusion for each additional hour CPT 96365* IV infusion, up to 1 hour (therapeutic) 96366* IV infusion for each additional hour Item 24D Form Locator to 99215,, Evaluation and management services HCPCS J7050 Infusion, normal saline solution, 250 ml N/A Form Locator Pharmacy, no detailed coding AHA 0258 IV solutions Form Revenue 0260 IV therapy N/A Locator 42 Codes 0636 Pharmacy, with detailed coding (requires HCPCS) and Clinic visit Medicare HCPCS J1745 Infliximab, 10 mg (1/10th vial) Item 24D Form NDC (11 digit) # REMICADE (infliximab vial, 100 mg) Shaded area above Item 24D or Item 24A or Item 19 Locator 44 or Electronic Comment Field * Payer policies for codes used to describe IV therapy may vary. Consult local payers for policies regarding use of and or and CPT code is not billable or payable on physician office Medicare claims when used in conjunction with CPT codes 96413, 96415, 96365, or Code all hospital outpatient clinic visits ( and ) with G0463. Use of evaluation and management codes require documentation of medically appropriate services performed on the same day as the infusion. ll Medicare suggests use of revenue code 0636 along with HCPCS J1745 to describe REMICADE on hospital outpatient claim forms. 10 units = 1 vial of REMICADE, 100 mg. # The NDC is not usually listed as a line item. When required in the shaded area above Item 24A-D, it also usually requires a Unit of Measure identifying the quantity per NDC; the units of measure will likely be 1 unit = one 100-mg vial. Please consult with your local payer for additional guidance. 5

9 Physician Office Setting Drug Medicare Administrative Contractors (MACs), many private payers, and most Medicaid agencies require healthcare providers to use Healthcare Common Procedure Coding System (HCPCS) codes to identify infused drugs on claim forms. HCPCS codes have a 5-character alphanumeric format and are used to bill for supplies and services not described by the Current Procedural Terminology (CPT), 4th Edition, coding system. The following HCPCS code may be used to describe REMICADE (infliximab) on claim forms submitted from the physician office setting: J1745 Infliximab 10 mg Although the National Drug Code (NDC) is usually reserved for billing by pharmacies, some private payers and the majority of Medicaid fee-for-service programs require an NDC for billing instead of, or in addition to, an HCPCS code, for physicians and other service providers as well. Although the FDA uses a 10-digit format when registering NDCs, payers usually recognize and often require an 11-digit NDC format on claim forms for billing purposes. It is important to confirm with your payer which NDC format they require. Guidelines for reporting the NDC in the appropriate format, quantity, and unit of measure vary by state and by payer, and should be reviewed prior to submitting a claim. The 10-digit NDC and 11-digit alternative NDC formats used for REMICADE 100 mg are: 10-Digit NDC format: Digit NDC format (used by most payers): Drug Administration Services 2 Physician services are reported on claim forms using the Current Procedural Terminology (CPT), 4th Edition, coding system. The CPT codes most commonly associated with the administration of REMICADE are: Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug Each additional hour (Use in conjunction with 96413; report for infusion intervals of greater than 30 minutes beyond 1 hour increments.) According to the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), these codes also cover certain complex biologic infusions such as monoclonal antibodies, including infliximab. Non-Medicare payer policies regarding the use of and may vary. Alternatively, some may require the use of CPT codes: Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour Each additional hour (List separately in addition to code for primary procedure; report for infusion intervals of greater than 30 minutes beyond 1 hour increments.) Please contact your local payers for specific coding policies and more information on correct billing and claims submission, or call AccessOne for assistance: 1 (888) ACCESS-1 ( ). 6

10 Hospital Outpatient Setting Drug Medicare Administrative Contractors (MACs), many private payers, and most Medicaid agencies require healthcare providers to use Healthcare Common Procedure Coding System (HCPCS) codes to identify infused drugs on claim forms. HCPCS codes have a 5-character alphanumeric format and are used to bill for supplies and services not described by the Current Procedural Terminology (CPT), 4th Edition, coding system. The following HCPCS code may be used to describe REMICADE (infliximab) on claim forms submitted from the hospital outpatient setting: J1745 Infliximab 10 mg Although the National Drug Code (NDC) is usually reserved for billing by pharmacies, some private payers and the majority of Medicaid fee-for-service programs require an NDC for billing instead of, or in addition to, an HCPCS code, for physicians and other service providers as well. Although the FDA uses a 10-digit format when registering NDCs, payers usually recognize and often require an 11-digit NDC format on claim forms for billing purposes. It is important to confirm with your payer which NDC format they require. Guidelines for reporting the NDC in the appropriate format, quantity, and unit of measure vary by state and by payer, and should be reviewed prior to submitting a claim. The 10-digit NDC and 11-digit alternative NDC formats used for REMICADE 100 mg are: 10-Digit NDC format: Digit NDC format (used by most payers): Payers policies regarding separate payment for saline used to administer IV drugs vary. Hospitals may need to record costs on claims even though saline is not separately reimbursed (ie, it is bundled into the APC payment for infusion services). If billed on the claim form, the following HCPCS code describes saline used to administer REMICADE : J7050 Infusion, normal saline solution, 250 ml Drug Administration Services 2 Hospital outpatient department services are reported on claim forms using the Current Procedural Terminology (CPT), 4th Edition, coding system. The CPT codes most commonly associated with the administration of REMICADE are: Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug Each additional hour (Use in conjunction with 96413; report for infusion intervals of greater than 30 minutes beyond 1 hour increments.) According to the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), these codes also cover certain complex biologic infusions such as monoclonal antibodies, including infliximab. Non-Medicare payer policies regarding the use of and may vary. Alternatively, some may require the use of CPT codes: Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour Each additional hour (List separately in addition to code for primary procedure; report for infusion intervals of greater than 30 minutes beyond 1 hour increments.) 7

11 Please contact your local payers for specific coding policies and more information on correct billing and claims submission, or call AccessOne for assistance: 1 (888) ACCESS-1 ( ). Revenue Codes Many payers require use of American Hospital Association (AHA) revenue codes to bill for services provided in hospital outpatient departments. Revenue codes consist of a leading zero followed by three other digits and are used on claim forms to assign costs to broad categories of hospital revenue centers. The revenue codes that are commonly used with REMICADE (infliximab) are: 0250 Pharmacy, drugs not requiring detailed coding (used for claims to many non-medicare payers) 0636 Pharmacy, drugs requiring detailed coding with HCPCS code (suggested for Medicare and sometimes required for other payers) When AHA revenue code 0636 is used to identify REMICADE, hospital outpatient departments should also record HCPCS code J1745. Home Infusion Providers The Healthcare Common Procedure Coding System (HCPCS) contains the only Health Insurance Portability and Accountability Act (HIPAA)-approved, comprehensive code set available to submit home infusion and ambulatory infusion suite claims that support the typical per diem contracts present in the marketplace. The S codes are used to report drugs, services, and supplies for which there are no national codes but for which codes are needed by the private sector to implement policies, programs, or claims processing. Some combination of the codes may be appropriate for describing therapy with REMICADE when it is provided by ambulatory infusion service providers. The following chart illustrates the codes that may be relevant. Although these codes are used by some private payers, please note that they are not payable by Medicare or other Federal payers. 8

12 Table 3: Home Infusion Codes 3 Code Type Code Description PER DIEM SPECIALTY THERAPY SERVICES: HCPCS CODES S9359* HCPCS Home infusion therapy, anti tumor necrosis factor intravenous therapy (eg, infliximab); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem HOME NURSING: CPT CODES 99601* CPT Home infusion/specialty drug administration, per visit (up to 2 hours) 99602* CPT Each additional hour (list separately in addition to code for primary procedure) (use in conjunction with 99601) J1745* HCPCS Injection, infliximab, 10 mg CODES FOR REMICADE NDC REMICADE (infliximab vial, 100 mg) OTHER SUPPLIES J7050* HCPCS Infusion, normal saline solution, 250 cc NDC Sod chl 0.9% 250 ml bag A4216* HCPCS Sterile water, sterile saline and/or dextrose, diluent/flush, 10 ml xxxxxxxxx-xx xxxxxxxxx-xx NDC Sterile water, preservative-free injection, 20 ml vial * If the infusion is performed in an ambulatory infusion suite rather than a patient s home, modifier SS may be appended to the codes. The NDC will vary by product manufacturer. 9

13 Other Coding Considerations When coding and billing for REMICADE (infliximab) and drug administration services, providers may also need to accurately calculate billing units, describe concomitant services or supplies, or account for modification to a service. This section reviews some of those additional considerations. REMICADE Billing Units The HCPCS code for REMICADE is J1745, described as: Injection infliximab, 10 mg. Thus, each 10-mg dose equals one billing unit, or 1/10th of a vial. It is important to understand that when billing for REMICADE, each 100-mg vial of drug represents 10 units of J1745. The following chart illustrates the correlation between vials, milligrams, and billing units. Number of 100-mg vials of infliximab Number of mg Number of billing units based on J1745 (10 mg infliximab per unit) Partial Additional Hours of Infusion Time 4 CMS has a policy for reporting the add-on infusion codes when less than a full hour of service is provided. CPT code (for each additional hour ) is to be used for infusion intervals of greater than thirty minutes beyond one hour increments. If the incremental amount of infusion time is 30 minutes or less the time is not to be billed separately. Document infusion start and stop times in the medical record. Some payers may require reporting the actual number of minutes on claims. Modifiers Modifiers provide a means to report or indicate that a service or procedure has been altered by some specific circumstance but not changed in its definition or code. They add more information and help to eliminate the appearance of duplicate billing and unbundling. Appropriately used, modifiers increase coding and reimbursement accuracy. The following table summarizes modifiers that may be applicable to the provision of REMICADE in physician offices and hospital outpatient departments. 10

14 Table 4: Summary of Code Modifiers 5 Modifier Description Indication and Placement CMS Item 24D UB-04 Locator Box Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service patient requires distinct E/M service in addition to the infusion procedure must be substantiated with relevant documentation append the modifier to the relevant E/M code 52 Reduced Services last additional hour of service is not a full 60 minutes; may require listing actual service minutes local MAC/other payer requirements may vary append the modifier to the infusion code JW Drug amount discarded/not administered to any patient unused drug remains after applicable dose is administered from single-use vial CMS has issued a discarded drug policy; local MAC/other payer requirements may vary append the modifier to the drug code on a line separate from that reporting the administered dose If required by payer If required by payer KX Requirements specified in the medical policy have been met represents awareness of/compliance with payer policies for the use of specific codes payer requirements may vary regarding use with the chemotherapy/complex biologic infusion codes append the modifier to codes as required by the payer If required by payer If required by payer 11

15 CMS Discarded Drug Policies 6 When it is necessary to 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 program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label. When processing claims for drugs and biologicals local contractors may require the use of the modifier JW to identify unused drugs or biologicals from single-use vials or packages. This modifier, billed on a separate line, will provide payment for the amount of discarded drug or biological. For example, a single-use vial that is labeled to contain 100 units of a drug has 95 units administered to the patient and 5 units discarded. The 95-unit dose is billed on one line, while the discarded 5 units may be billed on another line by using the JW modifier. Both line items would be processed for payment. The JW modifier is only applied to the amount of drug or biological that is discarded. Summary: Payment for discarded amounts of drug or biological applies only to single-use vials or packages. Multi-use vials are not subject to payment for discarded amounts of drug or biological. Medicare contractors may choose to require the JW modifier on claims for discarded drug or biological. Check with your local contractor for their specific requirements. Both the administered and discarded drug amounts should be clearly documented in the medical record. Same Day Evaluation and Management Services 7 In may be necessary to provide evaluation and management (E/M) services on the same day as a drug administration procedure. Depending on the payer, E/M services that are medically necessary, separate and distinct from the infusion procedure (CPT codes and in the physician office and HCPCS code G0463 in the hospital outpatient setting), and documented appropriately are generally covered. Please note that CMS has a specific policy regarding use of CPT code (level 1 medical visit for an established patient) in the physician office. The policy states: For services furnished on or after January 1, 2004, do not allow payment for CPT code 99211, with or without modifier 25, if it is billed with a nonchemotherapy drug infusion code or a chemotherapy administration code. This means that a level 1 medical visit for an established patient (99211) cannot be billed on the same day as an office-based infusion of REMICADE (infliximab). 12

16 Payment for REMICADE (infliximab) and Drug Administration Services There is a demonstrated history of paid claims for REMICADE for all payers, including Medicare, Medicaid, and commercial plans. Coverage varies by payer, contracts, treatment setting, and individual patient case. There are comprehensive published Medicare coverage policies specific to REMICADE. Copies of coverage policies are available on your regional Medicare Administrative Contractor (MAC) website, and are also available from the AccessOne website under Billing and Reimbursement: The following section discusses Medicare, Medicaid, and private insurer payment policies that will usually apply to REMICADE. Medicare Payment to Physician Offices In 2015, Medicare Part B reimburses for REMICADE administered in Medicare-participating physician offices based on Average Sales Price plus six percent (ASP+6%). After the patient s deductible is met, Medicare pays 80% of these established rates, and the patient or secondary insurance is responsible for the remaining 20%. CMS updates the ASP+6% reimbursement amount on a quarterly basis. Current drug pricing files are accessible from the CMS website at: Drugs/McrPartBDrugAvgSalesPrice/index.html. Medicare reimburses physicians for drug administration services and procedures associated with REMICADE according to the Physician Fee Schedule (PFS). The Medicare fee schedule for professional services is based on the resource-based relative value scale (RBRVS) methodology, a system in which considerations are made for physician work, practice expense, and malpractice expense relative to each code, then adjusted for differences in costs by geographic location. For geographic-specific rates for any PFS code, please refer to the Physician Fee Schedule Search, available at: Medicare Payment to Hospital Outpatient Departments In 2015, Medicare Part B reimburses for REMICADE administered in Medicare-participating hospital outpatient departments based on Average Sales Price plus six percent (ASP+6%). After the patient s deductible is met, Medicare pays 80% of these established rates, and the patient or secondary insurance is responsible for the remaining 20%. CMS updates the ASP+6% reimbursement amount on a quarterly basis. Current drug pricing files are accessible from the CMS website at: Drugs/McrPartBDrugAvgSalesPrice/index.html. Medicare reimburses hospital outpatient departments for drug administration services and procedures associated with REMICADE (infliximab) according to the Outpatient Prospective Payment System (OPPS). Payment is based on ambulatory payment classifications (APC), a system in which services of similar resource consumption are grouped and paid at the same rate. Adjustments are made for geographic location. Updates are posted quarterly to the OPPS website at: 13

17 Medicare Policy for Other Healthcare Providers Medicare coverage policies limit provision of drugs to certain treatment settings. Under current rules, Medicare will not reimburse home health companies, ambulatory surgical centers, or durable medical equipment companies for REMICADE (infliximab). If patients have secondary or supplemental insurance (eg, through a spouse s employer-sponsored plan or post-retirement health benefits), there may be coverage and reimbursement that goes beyond what is provided by Medicare. Also, Medicare does not provide additional payment to rural health clinics for infused drugs like REMICADE. Medicaid Payment Policies Medicaid programs generally provide reimbursement for REMICADE in one or more ambulatory treatment settings, but the Medicaid payment policies may vary because each state administers its own program. Not all Medicaid fee-for-service programs use the same payment formula to reimburse for REMICADE provided in physician offices. Providers can check with the state agency for the current reimbursement method. States will typically use a fee schedule to reimburse for office-based infusion services. Most Medicaid programs require prior authorization for office infusions, and some may have specific coverage policies for infused therapies. Some state Medicaid programs may allow REMICADE to be billed through pharmacies. In a few states, Medicaid programs may require REMICADE to be dispensed to the physician s office then billed through the pharmacy benefit. In these cases, the drug is delivered to the treatment setting and the office or clinic may only bill for the infusion service. In some cases, state Medicaid programs also may permit REMICADE to be provided in the home setting by a qualified home infusion company. Medicaid reimbursement for drugs provided in hospital outpatient departments is most commonly determined by an ASP-based formula and may be influenced by whether the facility is located in an urban or rural area or whether it is a specialty (eg, children s or rehabilitation hospital) or teaching facility. If you need assistance understanding Medicaid policies in your area, AccessOne is available to help you at 1 (888) ACCESS-1 ( ). In addition, you may contact your local payer. Commercial Payers Private payers will generally provide reimbursement for REMICADE (infliximab). Some payers may require drug acquisition through a specialty pharmacy, in which case the provider may only bill for the administration service (please refer to Coding for Drugs Purchased From Other Than the Administering Provider, Appendix D). Payment for REMICADE provided in the office setting is commonly based on an ASP-based formula. However, there will be some cases in which the cost of the drug is included in some type of capitated rate. Although such rates are often assumed to cover the cost of the therapy, physician offices and clinics can sometimes obtain separate payment by calling the plan and explaining the medical necessity and specific circumstances. To the degree that providers are offered capitated or risk contracts, they should consider attempting to negotiate a separately payable status for drugs like REMICADE. 14

18 Private insurance payments for hospital outpatient department services will typically be based on charges, fee schedules, or outpatient per-diem rates. However, this will vary by plan, the contracts between plans and hospitals, and by the specific insurance products offered by any given payer (eg, HMO, PPO, etc.). If you need assistance understanding plan payment policies, contact AccessOne or your local payer. Home Infusion Reimbursement Ambulatory infusion providers are licensed pharmacies that provide a wide range of services ranging from home infusion and nutritional therapies, to care management services and biologics, including REMICADE. Reimbursement for REMICADE (infliximab) provided through a home infusion pharmacy depends strictly on individual private payer and state Medicaid policies. It is especially important to note that Medicare does not currently pay for REMICADE when provided by a home infusion provider although other payers may allow or even require this setting. Drug administration services may be provided in either the patient s place of residence or within an Ambulatory Infusion Suite (AIS) operated by the home infusion provider. Medicare Part D REMICADE is covered under Medicare Part B, however some Part D formularies also list REMICADE. In circumstances where the physician and patient conclude that obtaining REMICADE through Part D (eg, Part D retail pharmacy provider, or Part D participating specialty pharmacy) is clinically preferred for the patient, this option is available. Under these circumstances physicians may not bill Part B for the drug, only the services they supply for drug administration. 15

19 References 1 American Medical Association. Code Manager Online. International Classification of Disease, 9th edition, Clinical Modification. Accessed November 18, American Medical Association. Code Manager Online: Current Procedural Terminology. Accessed November 18, National Home Infusion Association. NHIA national coding standard for home infusion claims under HIPAA, version a. 4 CMS. Pub Medicare Claims Processing Manual, Chap. 12, Section 30.5(E). 5 American Medical Association. Code Manager Online: Current Procedural Terminology: Appendix A - Modifiers. Accessed November 18, American Medical Association. Code Manager Online: Medicare Rules Legend. Accessed November 18, CMS Pub Medicare Claims Processing Manual, Chapter 17, Section CMS Pub Medicare Claims Processing Manual, Chapter 12, Section 30.5(F). 16

20 Appendix A: Sample Claim Forms The Form CMS-1500 is the basic form prescribed by CMS for the Medicare and Medicaid programs for claims from suppliers and non-institutional providers that qualify for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. It has also been adopted by the TRICARE Program. For detailed guidance on completing the CMS-1500 items, please see the Medicare Claims Processing Manual, Pub , Chap 26, available at: The 837P (Professional) is the standard format used by healthcare professionals and suppliers to transmit healthcare claims electronically. The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837P (Professional) Version 5010A1 is the current electronic claim version. Data elements in the CMS uniform electronic billing specifications are consistent with the hard copy data set to the extent that one processing system can handle both. For more information on electronic claims, please see the ASC website at: To view a crosswalk between the electronic and hard copy claim form, please see: The Form CMS-1450, also known as the UB-04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. It is the basic form prescribed by CMS for the Medicare and Medicaid programs for claims from hospitals, including hospital outpatient departments. Because it serves many payers, a particular payer may not need some data elements. For detailed guidance on completing the CMS-1450 items, please see the Medicare Claims Processing Manual, Pub , Chap 25, available at: Please see Checklist for Clean Claims on page

21 2015 Physician Office Sample Claim Form: CMS Item 19 Some payers may ask providers to specify REMICADE (infliximab) dosage and NDC, or insert patient on concomitant methotrexate therapy for RA. Do not abbreviate methotrexate. NOTE: Some payers require alternate product codes (eg, Medicaid claims). Please consult with your local payers or contact AccessOne at ACCESS-1 ( ) to confirm payerspecific coding requirements. 2 Item 21 Indicate diagnosis/diagnoses using appropriate ICD-9-CM codes. Please note that on October 1, 2015, the ICD-9 code sets used to report medical diagnoses will be replaced by ICD-10 code sets. 3 Item 24D Indicate appropriate CPT and HCPCS codes and modifiers if required. Be sure to enter the correct CPT codes by payer Medicare claims for REMICADE administration will use codes and NOTE: Individual payer (eg, private, Medicaid) policies may vary regarding the use of codes and or and Consult local payers for coding policy. Medicaid coding for REMICADE may vary. Please consult with your local payer or contact AccessOne at ACCESS-1 ( ) to confirm payer requirements. 4 Use of evaluation and management codes requires documentation of medically appropriate services performed on the same day as the infusion. Medicare requires the use of modifier 25 when reporting a significant, separately identifiable E/M service by the same physician, on the same day of the infusion procedure. 5 Item 24E Refer to the diagnosis for this service (see box 21). Enter only one diagnosis pointer per line. 6 Item 24G 10-mg units (10 units of J1745 = a single 100-mg vial of infliximab). 18

22 X Doe, John B X Doe, John B Spruce Street X 3914 Spruce Street Anytown AS Anytown AS Medicare 1 2 Dr. Jones A A J1745 A A PLEASE PRINT OR TYPE Dr. Jones 4231 Center Road Anytown, AS APPROVED OMB FORM 1500 (02-12) 19

23 2015 HOPD Sample Claim Form: UB-04 1 Locator Box 42 List revenue codes in ascending order. 2 Locator Box 43 Describe procedure (eg, IV therapy, clinic visit). 3 Use of E/M codes requires documentation of medically appropriate services performed on the same day as the infusion. In 2015, Medicare requires that HCPCS code G0463 be used to represent all hospital outpatient clinic visits (formerly coded with CPT codes and ). 4 Locator Box 44 Indicate appropriate CPT and HCPCS codes and modifiers if required. Be sure to enter the correct CPT codes by payer Medicare claims for REMICADE (infliximab) administration will use codes and NOTE: Individual payer (eg, private, Medicaid) policies for codes to describe IV therapy may vary. Consult local payers or contact AccessOne at ACCESS-1 ( ) for coding policy regarding use of and or and Locator Box mg units (10 units of J1745 = a single 100-mg vial of infliximab). 6 Locator Box 47 Indicate total charges. 7 Locator Box 67 Indicate diagnosis using appropriate ICD-9-CM codes. Please note that on October 1, 2015, the ICD-9 code sets used to report medical diagnoses will be replaced by ICD-10 code sets. 20

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25 Checklist for Clean Claims To proactively prevent denials and underpayments, it may be helpful to perform a pre-billing review prior to submitting any claim to a payer. The following may be considered: Has insurance been verified? Is this a covered service? Were the specific payer requirements followed? If applicable, is the referral authorized? Is medical necessity documented? Is all of the required information included on the claim? Are the correct codes (diagnosis, CPT, and HCPCS) reported? Are the billed units accurate and consistent with the J code descriptor? If reporting any discarded drug, was it properly documented? If a separate and distinct E/M service was provided, is it identified with modifier 25? Appendix B: Medical Necessity Medical necessity refers to a decision by a health plan that a treatment, test, or procedure is necessary for health or to treat a diagnosed medical problem. Health insurance companies provide coverage only for health-related services that they define or determine to be medically necessary. Medicare National Coverage Determinations (NCDs) and Medicare Administrative Contractors (MACs) Local Coverage Determinations (LCDs) define medical necessity requirements. Within these documents covered diagnoses, documentation requirements, and limitations of coverage for specific services provide guidance for establishing medical necessity. You can check your regional MAC website for coverage policies for REMICADE (infliximab) or go to to access state-specific billing and reimbursement guidelines for Medicare Administrative Contractors. This website also contains information on state-specific Commercial Payer and Medicare Part D prior authorization. For a sample template for a letter of medical necessity, please contact AccessOne at: 1 (888) ACCESS-1 ( ), Monday through Friday, 8 AM to 8 PM, ET. Appendix C: Appeals The most common reasons for denials or underpayment of claims include: Omission of any information that clarifies medical necessity (eg, relevant diagnosis codes) Inaccurately reporting the billable units of drug; note that REMICADE (infliximab) is reported in 10-mg units Use of incorrect CPT or HCPCS codes Lack of proper and complete documentation Omission of a physician letter/statement of medical necessity Omission of special coding requirements (eg, the NDC number or required modifiers) Failure to follow payer-specific requirements for providing this therapy 22

26 Different payers provide different appeals rights depending upon the level of appeal for the denied claim (eg, first appeal, second appeal). In the event of a claim denial, be sure to resubmit your claim. Most well-documented follow-up submissions are successful. Additional resources for appealing Medicare claims may be found at: orgmedffsappeals/. You may also want to encourage your patients to contact their employer s benefits office. Many companies are willing to intervene on behalf of employees when prescribed therapies are challenged. For additional information regarding coding, coverage, and reimbursement policies or claim denials for REMICADE (infliximab), see: For additional assistance, call AccessOne at: 1 (888) ACCESS-1 ( ), Monday through Friday, 8 AM to 8 PM, ET. Appendix D: Working With Specialty Pharmacy Some patients may obtain REMICADE through Medicare Part D or another prescription drug benefit, and thus acquire the drug through a retail or specialty pharmacy. The drug is then brought or sent to the administering site of care. Providers that do not buy and supply the drug may not bill for the drug itself, but only for the services associated with drug administration. Management Tools Providers that obtain drugs outside the buy-and-bill model for both commercial and Medicare patients (ie, via some type of pharmacy delivery option) generally find it helpful to develop systems to help manage this method of drug acquisition and service delivery. Please contact AccessOne at 1 (888) ACCESS-1 ( ) for tools that may assist you with tracking and coordinating drugs acquired through specialty pharmacy channels. Coding for Drugs Purchased From Other Than the Administering Provider If the drug is brought to the provider by the patient or delivered to the provider by a specialty pharmacy, the provider may only bill for the administration service. In order to identify and reimburse for the appropriate administration service, most payers require that the name and dosage of the drug be documented on the claim. Commonly payers require that the drug be reported in 24D and billed with a charge of $0.00.* Billing systems that do not permit a $0.00 charge entry may require entering $0.01. Please check with your software vendor. Because payer policies can vary widely regarding the entry of charges and where the drug detail should be reported on the claim form, please contact the payer to clarify the billing policies for drugs that are provider-administered but not provider-purchased. AccessOne is also available to help research payer-specific policies for documenting non-charged drugs. * Data on file with Janssen Biotech, Inc. 23