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Economic Considerations
Lynn Webster M.D.Lifetree Clinical Research and Pain Clinic
Salt Lake City, Utah
Economic Factors
• Site of Service – Hospital Inpatient, Hospital Outpatient, ASC,
Office
• Management Cost– Cost of drugs, refill kits and office overhead
• Management Reimbursement – Drugs– Cognitive skills
Payment by Site of Service: Trial
Code Description Facility Pymt
MD Pymt w/Fix
MD Pymt w/o Fix
62319 Injection, including catheter placement, cont infusion
$485 $92 $71
Total $485 $92 $71
Description DRG Facility Pymt MD Pymt w/Fix
MD Pymt w/o Fix
Medical back problems w/MCC
552 $4487 $92 $71
Total $4487 $92 $71
Inpatient Hospital Trial
Outpatient Hospital Trial
The drug used for the trial is included in the DRG for Inpatient Trials. For outpatient hospital trials, Lioresal and Prialt are reimbursed separately, Infumorph is packaged in the APC payment.
CPT Copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Changes to the Hospital Outpatient Prospective Payment System and FY 2010 Payment Rates. Federal Register Display Date: October 30, 2009
Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2010. Federal Register Display Date: October 30, 2009
Payment by Site of Service: Implant
Code Description Facility Pymt MD Pymt w/Fix
MD Pymt w/o Fix
62350 Catheter Implant*multiple surg reduction is reflected
$1443 $184 $146
62362 Programmable Pump Implant
$13305 $385 $306
Total $14748 $569 $452
Description DRG Facility Pymt MD Pymt w/Fix
MD Pymt w/o Fix
Peripheral/Cranial and Other Nervous System W/CC or Peripheral Neurostimulator
41 $11967 $184$385
$146$306
Total $11967 $569 $452
Inpatient Hospital Implant
Outpatient Hospital Implant
The DRG assignment varies depending on diagnoses and severity of illness (MCC or CC). For illustration above a pain disorder diagnoses was used.
CPT Copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Changes to the Hospital Outpatient Prospective Payment System and FY 2010 Payment Rates. Federal Register Display Date: October 30, 2009
Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2010. Federal Register Display Date: October 30, 2009
Payment by Site of ServiceRefill Programming and Analysis
Code Description Facility Pymt
MD Pymt w/Fix
MD Pymt w/o Fix
62368 Pump Programming and Analysis
$171 $37 $28
95990 Refill – Non-Phys
NA $64 $56
95991 Refill – Physician
$127 $37 $28
J2275 Morphine, 10 mg
N/A
Total $298 $74 $56
Code Description MD Pymt w/Fix
MD Pymt w/o Fix
62368 Pump Programming and Analysis
$54 $43
95990* Refill – Non-Phys $75 $56
95991 Refill – Physician $93 $79
J2275 Morphine, 10 mg $14
Total $161 $136
Physician Office RefillOutpatient Hospital Refill
•Fee not established for 95990 in facilityTotals calcuated using MD RefillFor illustration, Infumorph 50 mg used for calculating payment http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01a1_2009aspfiles.asp
Refill kits are used in both sites of services and are included in the payment reflected aboveCPT Copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Changes to the Hospital Outpatient Prospective Payment System and FY 2010 Payment Rates. Federal Register Display Date: October 30, 2009
Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2010. Federal Register Display Date: October 30, 2009
Medicare Administrative Contractor (MAC) Drug Reimbursement
• All contractors instructed to utilize ASP pricing for commercially prepared drugs used in infusion pumps
– http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01a19_2010aspfiles.asp
• Because of some confusion, a couple MACs still paying at 95% of Average Wholesale Price (AWP)
• Compounded Drugs are Paid at MAC discretion– Payment Varies– Coding/reporting requirements vary
Current ASP* Payment Amounts
Physician Office Reimbursement
= ASP + 6%
Facility Reimbursement
= ASP + 5%
Difference
HCPCs Code
Drug Dosage Cost 10/1/2010 10/1/2010
J0475 Baclofen 10 MG injection
10 MG $203.93 $200.08 $3.85
J0476 Baclofen intrathecal trial
50 MCG $73.15 $71.77 $1.37
J2275 Morphine sulfate injection
10 MG $2.42 $2.37 $0.05
J2278 Ziconotide injection 1 MCG $6.61 $6.48 0.3
*Average Sales Price
Current AWP* Amounts
• Baclofen 10 mg $215.18• Baclofen 50 mcg $ 79.80• Morphine Sulfate 10mg $4.39 approx• Ziconitide only priced at ASP
*Average Wholesale Price
IT Reimbursement• Industrial Claims
– Each state’s Industrial Commission sets the fee schedule
• Some states pay at invoice plus ~15%
• Private Payers– Most use the Medicare ASP + 6% fee schedule
• Noridian Medicare– J3490 code – Pay from invoice with no additional payment allowed
IT Therapy Costs
LOW HIGH
IT Prialt •Average dose 4 mcg/day in 20-mL Medtronic pump•ASP + 6% = $6.51/mcg
IT Morphine•Average dose 6 mcg/day in 20-mL Medtronic pump•ASP + 6% = $2.83/10 mg
$ $ $ $ $ $ $ $ $
Oral Therapy Costs
LOW HIGH
Oxycontin® 80 mg TIDPercocet® 10/325 mg 8x day
Lyrica® 150 mg BIDCymbalta® 60 mg QDKlonopin® 1 mg BID
Ambien® CR 12.5 mg QHS
Methadone® 10 mg QIDOxycodone® 15mg QID
Gabapentin® 400 mg QIDDesipramine® 10mg TIDTrazodone® 50mg QHS
$ $ $ $ $ $ $ $ $
Cost Comparison of 2 Intrathecal Medications to an Oral Brand Name Medication Regimen and an Oral
Generic Medication Regimen
Deer and Smith, et al. Manuscript in Progress
Economic Considerations• IT therapy can be less expensive than using
oral medications• Reimbursement depends on payer and site of
service• Drug invoice pricing may not provide payment
for handling and acquisition
Economic Considerations
• The Neuromodulation Therapy Access Foundation (NTAC) is working with multiple organizations to provide appropriate payment for all aspects of pump therapy– Palmetto GBA recently implemented fee schedule that
replaces invoice only methodology (California, Nevada, Hawaii)
– Allows for fee schedule to cover drug and separate compounding fee
• Thanks to Drs Schwachmann, Helm and William Stuart PharmD