Revenue Cycle ManagementClosing the Loop on Optimal Financial Performance
Bruce Bradley, PharmDMaxie Friemel, PharmD, MS, BCPS
Agatha Nolen, MS, PhD, FASHP
Disclosure
In accordance with the ACPE’s and ACCME’s Standards for Commercial Support, anyone in a position to control the content of an educational activity is required to disclose their relevant financial relationships. In accordance with these Standards, ASHP is required to resolve potential conflicts of interest and disclose relevant financial relationships of presenters. • In this session:
All planners, presenters, reviewers, and ASHP staff report no financial relationships relevant to this activity.
Disclaimer • Please note that this information may become obsolete with revised
regulations• Please review your current transmittals, program manuals, bulletins,
banner pages or other regulatory publications for updates• Please contact your payer should you have any questions regarding their
interpretation and retain the documentation for your records
23rd Annual ASHP Conference for Pharmacy Leaders Revenue Cycle Management Closing the Loop on Optimal Financial Performance
©2018 American Society of Health-System Pharmacists Page 1 of 7
Learning Objectives
• Describe strategies for evaluating commercial contracts and federal and state coverage determinations to ensure payer requirements are met for payment of drugs and drug administration services to overcome challenges that affect the pharmacy’s bottom line.
• Evaluate formulary decisions for high cost drugs (e.g. biosimilars, CAR‐T therapy, and IPPS new technology add on‐payments).
• Describe key components of claims processing that ensure the integrity of submitted claims.
• Given various scenarios, practice the use of monitoring methods to maintain a robust and contemporary revenue cycle management system in light of evolving reimbursement changes.
• Evaluate key principles for establishing integrity and creating systems to avoid, and effectively appeal denials when they occur.
Revenue Cycle Process Flow
Billing ImpactsPharmacy Clinical Systems
• Medication Data– NDC– Strength– Package size & equivalency– SDV, MDV, PF– Bulk products
• Clinical Data– Dispensing unit– Order – Administration/preparation – Waste– Accumulation
• Automation/Systems– EMR– Automated dispensing cabinets– ED/OR modules– Other 3rd party interfaces
23rd Annual ASHP Conference for Pharmacy Leaders Revenue Cycle Management Closing the Loop on Optimal Financial Performance
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Billing ImpactsCharge Master or Patient Accounting
• Healthcare Common Procedure Coding System (HCPCS)• Procedure codes• Revenue codes• Alternate codes (based on payer)• Modifiers (e.g. JW, TB, JG, UD)• Charge tables• Status indicators (SI)• Other payer tables
Billing ImpactsPatient Care or Clinical Processes
• Registration– Advance Beneficiary Notice (ABN)– Prior authorizations– Local/National Coverage
Determinations (LCD/NCD)• Pharmacy
– Ordering– Preparation– Documentation of waste (when
necessary)
• Providers– Documentation of orders– Signed orders (when necessary)
• Nursing (or other end users)– Documentation administration– Documentation amount pulled from
ADS (when charge on dispense)– Reconciliation of charges
Billing ImpactsInternal Edits and Charge Router Rules
• Age discrepancies with billed HCPCS• Cost center allocations/accounting• High dollar or high billing quantity• Modification to any information placed in the charge master• Modifier check or additions• Medically Unlikely Edits (MUE)• National Correct Coding Initiatives (NCCI) edits
23rd Annual ASHP Conference for Pharmacy Leaders Revenue Cycle Management Closing the Loop on Optimal Financial Performance
©2018 American Society of Health-System Pharmacists Page 3 of 7
Billing ImpactsClaim Processors & Claim Edits
• Validates claim against respective payer rules• May modify claim details (i.e. NDC, HCPCS, revenue code) to meet payer
specifications• MUE• NCCI edits• Modifier checks and additions
Billing ImpactsPayer Edits and Denials
• Invalid or missing NDC• Invalid HCPCS, NDC mismatch • Medical necessity denial• NCD & LCD rejections• Non‐covered services• Line item vs. claim level denial
Billing ImpactsAppeals
• Medical necessity documentation• Medical records sent with appeals• Level of appeals (1 – 5)
23rd Annual ASHP Conference for Pharmacy Leaders Revenue Cycle Management Closing the Loop on Optimal Financial Performance
©2018 American Society of Health-System Pharmacists Page 4 of 7
Billing ImpactsReimbursement
• Validation of appropriate reimbursement based on payer contracts
Billing ImpactsReimbursement
• Validation of appropriate reimbursement based on payer contracts
Common Definitions • Advance Beneficiary Notice (ABN)
– Notice of non‐coverage, issued by all health care providers when Medicare payment is expected to be denied
• Hospital Outpatient Prospective Payment System (HOPPS or OPPS)– Created by CMS, sets the standards for billing, payment rates and other
relevant regulations for Part B services, and some inpatient services billed as Part B, for Medicare beneficiaries
• Inpatient Prospective Payment System (IPPS)– System of payments for acute care hospital inpatient services under Medicare
Part A based on prospectively set rates• Local or National Coverage Determinations (LCD/NCD)
– Decision by the Fiscal Intermediary to cover a particular item or service as a reasonable and necessary
23rd Annual ASHP Conference for Pharmacy Leaders Revenue Cycle Management Closing the Loop on Optimal Financial Performance
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Common Definitions • Status Indicator (SI)
– A letter code that is assigned by CMS that signifies how an individual HCPCS/CPT will be reimbursed and helps determine if policy rules and discounting apply
– SI = G Pass‐Through Drugs and Biologicals: paid under the OPPS and receive separate APC payment
– SI = K Non‐Pass Through Drugs and Biologicals: paid under the OPPS and receive a separate APC payment
– SI = N Packaged Item or Services: paid under the OPPS, payment is packaged into payment for other items or services
– SI = M Items or Services not billable to the Fiscal Intermediary: not paid under the OPPS
Common Definitions
• Medically Unlikely Edit (MUE)– Assigned for most HCPCS/CPT codes, represents the maximum units of service
that a provider would report in most circumstances• New Technology Add‐On Payment:
– Under the IPPS, CMS established a process for identifying and ensuring adequate payment for new medical services and technologies that are inadequately paid under the DRG.
• Target Probe and Educate (TPE):– Service provided by the Medicare Administrative Coordinators (MAC) designed
to help improve billing practices in areas that have a high national or specific providers/suppliers who have high claim error rates
Key Takeaways
1) REVENUE CYCLE COMPLEXITYThere are multiple complex steps, teams and intertwining builds that are essential to understand how a medication is charged, billed, and reimbursement received.
2) CONTINUAL CHANGERegulations are continually changing and there is a higher focus on medications. Teams need to be prepared and nimble to accommodate these changes.
3) INFORMED DECISIONSUtilizing the tools provided, allow you to make informed decisions on high cost formulary decisions, system build, denials, reimbursement and more.
23rd Annual ASHP Conference for Pharmacy Leaders Revenue Cycle Management Closing the Loop on Optimal Financial Performance
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Game Instructions• Object:
– To be the team with the most money at the end of the game.• Set up:
– Each table will be divided into 2 teams of about 5 people per team (10 people per table).
Game Instructions Cont.• Gameplay:
– Flip coin to determine who goes first.– Teams take a turn by rolling a dice and moving their game piece the respective number of
spaces. – The team will draw from one of the 3 piles of cards based on the space in which they
land. Each card consists of a billing question, discussion question or a trivia question. – If a team lands on a jail spot, they will need to pay $100 to the Banker to post bail. If a
team lands on the tourist attraction, they will need to pay $100 parking fee. – The team will have 3 minutes to answer the question. After the question is answered,
there will be 2 minutes to discuss the answer as a group.– The facilitator will serve as the Banker and pay the team up to the amount listed on the
card for a correct answer. The team will lose money up to the amount listed on the card for an incorrect answer.
– Discussion questions are open for the entire group to discuss, but only the team who landed on the space will receive the money value listed on the card.
– If a team goes bankrupt, you will be allowed to continue but will not receive any additional money.
23rd Annual ASHP Conference for Pharmacy Leaders Revenue Cycle Management Closing the Loop on Optimal Financial Performance
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Please note that this information may become obsolete with revised regulations Page | 0
CLOSING THE LOOP ON OPTIMAL
FINANCIAL PERFORMANCE
October 2018
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Table of Contents SECTION I: INTRODUCTION .................................................................................................................... 4
Closing the Loop on Optimal Financial Performance ............................................................................... 5
Objectives ............................................................................................................................................... 5
CONTACT INFORMATION ........................................................................................................................ 6
SECTION II: IMPLEMENTING STRATEGIES FOR MAXIMIZING COMMERCIAL CONTRACTS .................. 8
340B Reimbursement ............................................................................................................................. 9
No Cost Drug ......................................................................................................................................... 11
Influenza/Pneumonia Vaccine ............................................................................................................... 13
Inpatient Carve Outs ............................................................................................................................. 15
LCD Specific ........................................................................................................................................... 17
Discussion Questions (A - C) .................................................................................................................. 19
SECTION III: EVALUATING FORMULARY DECISIONS FOR HIGH COST DRUGS .................................... 20
CAR T-Cell Therapy ................................................................................................................................ 21
Biosimilar .............................................................................................................................................. 23
Specialty Drug ....................................................................................................................................... 27
IPPS New Technology ............................................................................................................................ 29
Hemophilia Products ............................................................................................................................. 33
Discussion Questions (D - F) .................................................................................................................. 35
SECTION IV: ENSURING THE INTEGRITY OF SUBMITTED CLAIMS ....................................................... 36
Bolus from the Bag ................................................................................................................................ 37
Unapproved Drugs ................................................................................................................................ 41
Overpayment ........................................................................................................................................ 43
Underpayment ...................................................................................................................................... 45
Not-Billable Services.............................................................................................................................. 47
Waste.................................................................................................................................................... 49
Discussion Questions (G & H) ................................................................................................................ 51
SECTION V: IMPLEMENTING & MONITORING REVENUE CYCLE MANAGEMENT SYSTEMS ............... 52
Packaged Drug ...................................................................................................................................... 53
Pass-Through vs. Non-Pass-Through Drug ............................................................................................. 55
Self-Administered Drug ......................................................................................................................... 57
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Quarterly Maintenance Process for Billing Information ......................................................................... 59
Discussion Questions (I - L) .................................................................................................................... 63
SECTION VI: EFFECTIVLEY APPEAL DENIALS WHEN THEY OCCUR....................................................... 64
Targeted Probe and Educate ................................................................................................................. 65
MUE ...................................................................................................................................................... 67
MUE/Appeal ......................................................................................................................................... 69
SECTION VII: TEXAS TRIVIA .................................................................................................................. 72
Trivia Questions & Answers ................................................................................................................... 73
SECTION VIII: ADDENDUM ................................................................................................................... 76
Definitions ............................................................................................................................................. 77
Additional Resources............................................................................................................................. 78
Questions & Answers Key...................................................................................................................... 79
Disclaimer ............................................................................................................................................. 80
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SECTION I: INTRODUCTION
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Closing the Loop on Optimal Financial Performance Revenue cycle is a leading strategic imperative for hospital senior executives and pharmacy leaders
due to increasing drug costs and new payment models with declining reimbursement. An integrated
revenue cycle management system that encompasses charge master compliance, formulary
decisions, complex IT systems, payer requirement compliance, and contracting is critical. Pharmacy
leaders must lead the design and maintenance of a comprehensive revenue cycle management
system to keep pace with evolving reimbursement changes. In a creative gaming format, this
workshop will provide practical solutions to manage real-life challenges and provide an opportunity
for attendees to evaluate scenarios and model resolutions to improve revenue cycle management.
Objectives
Describe strategies for evaluating commercial contracts and federal and state coverage
determinations to ensure payer requirements are met for payment of drugs and drug
administration services to overcome challenges that affect the pharmacy’s bottom line.
Evaluate formulary decisions for high cost drugs (e.g. biosimilars, CAR-T therapy, and IPPS new
technology add on payments).
Describe key components of claims processing that ensure the integrity of submitted claims.
Given various scenarios, practice the use of monitoring methods to maintain a robust and
contemporary revenue cycle management system in light of evolving reimbursement changes.
Evaluate key principles for establishing integrity and creating systems to avoid, and effectively
appeal denials when they occur.
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CONTACT INFORMATION
Agatha Nolen, B.S.Pharm., Ph.D., M.S, FASHP
Email: [email protected] Agatha Nolen, Ph.D., D.Ph., FASHP Assistant Vice President-Pharmacy
in Ethics and Compliance at the Corporate offices for HCA (Hospital
Corporation of America) in Nashville, TN with responsibility for billing
of pharmacy products and services for 28 million patient encounters
per year in 175 hospitals and 120 ambulatory surgery centers as well as
physician offices and imaging centers. Previously she held Director of
Pharmacy positions at health systems for more than15 years and
practiced as a decentralized pharmacist in ICU/Cardiac Care and OR
Pharmacies. Received B.S. and M.S. degrees from University of
Oklahoma and played Varsity Women’s Golf. She completed a Ph.D. in
Public Administration (Field of Study: U.S. Health Policy) at Tennessee State University. Assistant
Professor for the University of Tennessee and served as a faculty member in the inaugural ASHP
Pharmacy Leadership Academy. Member of the pharmacy department who received the Texas
Innovative and Collaborative Practice Award, served as an ASHP Board Member from 2003-2007
and currently serves on the Hospital Outpatient Payment Panel (HOPP) which advises CMS on
payment rates for outpatient services. Numerous publications and presentations on health policy
and clinical and administrative pharmacy including an analysis of ten years of public policy in
healthcare reform concentrating on improving patient safety with health information technology.
Adrianne (Maxie) Friemel, PharmD, MS, BCPS
Email: [email protected]
Maxie Friemel, PharmD, MS, BCPS, is the Revenue Integrity Specialist
for SCL Health since June 2016. She received her Doctor of Pharmacy
from Texas Tech University Health Science Center in 2011, and went
on to complete a two year PGY1 Pharmacy Practice and
Administration Residency program with master’s degree in healthcare
administration from the University of Wisconsin Hospital and Clinics.
Post residency Dr. Friemel served as the supply chain manager and
home infusion liaison for the University of Wisconsin Hospital and
Clinics for three years. In her current position with SCL Health, she
works closely with the eight hospital systems to develop workflows
for the pharmacy personnel and other clinical providers to ensure
optimal and compliant revenue capture. She is integral in collaborating with the clinical, informatics,
and revenue cycle teams to accomplish goals. Dr. Friemel has been an active member of pharmacy
organizations throughout her career. She currently services as the Vice Chair of the Section Advisory
Group on the Management of the Pharmacy Enterprise as a part of the ASHP Section of Pharmacy
Practice Managers. Dr. Friemel is also engaged with the local Colorado Pharmacist Society –
Academy of Health System Pharmacist has been nominated chair-elect 2018-2019.
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Bradley Bruce, PharmD
Email: [email protected] Dr. Bradley Bruce is a Senior Consultant in Regulatory Compliance
Support (Regs) at Hospital Corporation of America (HCA). Regs
fundamental task is to reduce risk by supporting and educating
hospital sites on proper drug coding and billing. In his role, Dr. Bruce
manages the preservation of the corporate drug chargemaster,
maintains a claims data dashboard (Tableau), and researches drug
billing questions for HCA members. Dr. Bruce develops timely
communications on market shifts in drug reimbursement and
quarterly coding changes. Dr. Bruce servers as the Regs department
lead for HCA’s community outreach group where he lives out HCA’s
mission; “Above all else, we are committed to the care and
improvement of human life”. Dr. Bruce has experience in a variety of different healthcare settings
including midsize urban teaching hospital, large not-for-profit academic medical center, and a
national for profit integrated delivery network (IDN) system. He received his Doctor of Pharmacy
degree from the University of Missouri Kansas City and completed a pharmacy practice (PGY1)
residency at Henry Ford Hospital and was a Corporate Pharmacy Leadership (PGY2) residency at
HealthTrust in Nashville, TN.
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SECTION II: IMPLEMENTING STRATEGIES FOR MAXIMIZING
COMMERCIAL CONTRACTS
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QUESTION 1.
340B Reimbursement
In July 2018, the appellate court dismissed the American Hospital Association case to reverse the
CMS cuts to the 340B Drug Pricing Program. Your hospital is not an excepted site like sole rural
community hospitals, children’s hospitals, or cancer center hospitals. Calculate the reimbursement
impact to your 340B facility and select the correct modifier.
HCPCS, SI* Description Annual Volume ASP + 6% ASP -22.5%
J2350, G Ocrelizumab, 1 mg 90,000 mg $57.17 $41.80
J9310, K Rituximab, 100 mg 600,000 mg $915.30 $669.21
J9263, N Oxaliplatin 0.5 mg 720,000 mg $0.21 $0.15
A. Total loss of ($1,476,540)
a. Ocrelizumab – no additional loss in reimbursement, must apply TB modifier
b. Rituximab loss of ($1,476,540) apply JG modifier
c. Oxaliplatin – no additional loss in reimbursement, apply TB modifier
B. Total loss of ($2,859,840)
a. Ocrelizumab loss of ($1,383,300) apply TB modifier
b. Rituximab loss of ($1,476,540) apply JG modifier
c. Oxaliplatin – no additional loss as it is not separately reimbursable, apply TB modifier
C. Total loss of ($2,946,240)
a. Ocrelizumab loss of ($1,383,300) apply JG modifier
b. Rituximab loss of ($1,476,540) apply JG modifier
c. Oxaliplatin loss of ($86,400) apply JG modifier
D. Total loss of ($2,946,240)
a. Ocrelizumab loss of ($1,383,300) apply TB modifier
b. Rituximab loss of ($1,476,540) apply JG modifier
c. Oxaliplatin loss of ($86,400) no modifier necessary
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ANSWER 1.
340B Reimbursement
Best Answer A
A. Total loss of ($1,476,540)
a. Ocrelizumab – no additional loss in reimbursement, must apply TB modifier
b. Rituximab loss of ($1,476,540) apply JG modifier
c. Oxaliplatin – no additional loss in reimbursement, apply TB modifier
EXPLANATION 1. 340B Reimbursement
Hospitals that are not exempt from the 2018 OPPS Payment Rate for 340B Purchased Drugs
requirements are as follows:
340B purchased drugs with “pass-through” status (G) will continue to be paid at ASP + 6%, a TB
modifier must be applied
340B purchased drugs with “non-pass-through” status (K) will continue to be paid at a reduced
rate of ASP -22.5%, and a JG modifier must be applied
340B purchased drugs with “packaged services” status (N) is not a separately reimbursable item
thus reimbursement is not impacted, no modifier is necessary or apply TB modifier.
Exempted 340B sites continue to receive ASP + 6% reimbursement rates, but a TB modifier must be
applied to all drugs with status indicator of K and G.
Resource:
Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS):
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalOutpatientPPS/Downloads/Billing-340B-Modifiers-under-Hospital-OPPS.pdf
POINTS: $400
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QUESTION 2.
No Cost Drug
You have a Medicare patient who comes to your infusion clinic for an Intravenous Immune Globulin
(IVIG) infusion every six weeks. The physician has followed the patient for years and is convinced
that only one brand of IVIG is safe for the patient and provides an appropriate response for treating
their Guillain-Barré syndrome. However that brand of IVIG is non-formulary at your institution. The
doctor has approached the drug company and they will ship the IVIG directly to the hospital
pharmacy at no cost to the hospital. How is the best way to bill for this encounter?
A. Bill for the drug administration services and place a token charge of $1.00 on the claim for the
IVIG under revenue code 636 and the appropriate HCPCS code of the brand of IVIG
administered.
B. Bill for the drug administration services and a regular charge for the IVIG on the claim based
upon what you would normally charge for the brand of IVIG that your routinely stock. You use
the HCPCS code for your normal IVIG brand in revenue code 636.
C. Don’t bill at all for the encounter as a courtesy to the physician for making arrangements for
the IVIG to be provided at no cost.
D. Don’t bill the encounter to Medicare, but bill the patient’s Medigap insurance for the usual
charge for both the formulary brand of IVIG and the drug administration services.
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ANSWER 2. No Cost Drug
Best Answer A
Bill for the drug administration services and place a token charge of $1.00 on the claim for the IVIG
under revenue code 636 and the appropriate HCPCS code of the brand of IVIG administered.
EXPLANATION 2. No Cost Drug
As of June 29, 2018, CMS requires that a “no-cost” drug be billed on an outpatient claim with a
token charge and the appropriate HCPCS code in revenue code 636.
Other answers:
B. You cannot charge for a drug when you do not incur a cost.
C. You cannot “give away” services to a physician or patient as a courtesy as this may invoke
Stark Law violations for beneficiary or physician inducement.
D. When Medicare is primary and a Medigap policy is secondary, Medicare must be billed first
as the primary payer. It would not be appropriate to bill for one drug when dispensing a
different one when the HCPCS codes are different for the two products.
Resource: CMS Transmittal R4013- March 30, 2018: Institutional Billing of No Cost Items https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4013CP.pdf
POINTS: $400
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QUESTION 3.
Influenza/Pneumonia Vaccine
Your Clinical Manager has read studies that pneumococcal infections in adults 65 years of older can
be deadly: pneumococcal pneumonia kills about 1 out of 20 who get it, pneumococcal bacteremia
kills about 1 out of 5 who get it, and pneumococcal meningitis kills about 1 out of 5 who get it. He
has just reviewed data from last year’s flu season that shows that only 15% of patients over 65 who
were outpatients and inpatients in your institution received a flu vaccine and pneumonia vaccine.
However, when reviewing the costs of the two pneumococcal vaccines (PCV13 (pneumococcal
conjugate vaccine) and PPSV23 (pneumococcal polysaccharide vaccine), you are concerned about
the impact on your budget. In response to your Clinical Manager’s request to set a goal that 90% of
patients over 65 who are eligible get a pneumococcal vaccine starting with the next flu season, you
suggest that he:
A. Set up the computer system so that only outpatients will receive the flu and pneumonia
vaccines
B. Set up the computer system so that patients are identified and receive an Advance
Beneficiary Notice (ABN) notifying them that they will get a separate bill from the hospital
for their flu and pneumonia shots and the estimated amount of the bill
C. Set up the computer system to screen all patients over 65 years of age and prepare to
administer the vaccines to all eligible inpatients and outpatients
D. Set up the computer system so that patients are identified and you administer the flu
vaccine, but you provide them with discharge instructions to go to their physician’s office
to receive their pneumonia vaccine
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ANSWER 3.
Influenza/Pneumonia Vaccine
Best Answer C
Set up the computer system to screen all patients over 65 years of age and prepare to administer
the vaccines to all eligible inpatients and outpatients
EXPLANATION 3. Influenza/Pneumonia Vaccine
Medicare pays for both inpatients and outpatients to receive influenza vaccines each year and
pneumococcal vaccines when they are eligible without any co-pay. Accounts for inpatients are split
so that flu and pneumonia vaccines are billed on an outpatient claim and paid separately.
Why are these answers incorrect?
A. It is difficult to distinguish whether a claim may be billed as an inpatient or outpatient at the
time of service and most States require that hospitals report the percentage of all patients
vaccinated for the flu and pneumonia, not just outpatients.
B. An ABN is only issued to a Medicare inpatient when a service is non-covered. Since flu and
pneumonia shots are covered, an ABN would not be appropriate
D. Although answer “d” may lower your drug costs, the CDC recommends that eligible patients
receive both a flu and pneumonia vaccinations from all providers as appropriate. It would
inconvenient for the patient to receive a flu vaccine in the hospital and they might not schedule
an office visit just for a pneumonia vaccine, or the office visit will be delayed putting them at
risk when non-vaccinated.
Ensuring the Integrity of Submitted Claims
Resources: CMS Transmittal 202: December 31, 2014 Modifications to Medicare Part B
Coverage of Pneumococcal Vaccinations https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R202BP.pdf
Resources: CMS Transmittal 3159: December 31, 2014 Modifications to Medicare Part B
Coverage of Pneumococcal Vaccinations https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3159CP.pdf
POINTS: $300
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QUESTION 4.
Inpatient Carve Outs
Your managed care team negotiated new contract terms with commercial payers to pay separately
for higher cost medications used while patients were admitted to the hospital for an inpatient stay.
To accomplish this, you must bill the medications using the unique HCPCS code and under revenue
code 636. The managed care team wants to be proactive and ensure everyone knows about the
sweet carve out deal. Who do you plan to communicate and what changes need to be made?
A. By definition pharmaceuticals requiring detailed coding must use revenue code 636. No
communication or changes are necessary.
B. By definition pharmaceuticals requiring detailed coding must use revenue code 636.
Communicate to the pharmacy & finance team letting them know of the additional revenue
stream.
C. According to the UB billing manual all pharmacy charges for inpatient claims roll to revenue
code 250 in a single line without detailed coding. This change is not possible on the inpatient
claim and communicate to managed care to renegotiate a separate agreement that the billing
team is able to operationalize.
D. According to the UB billing manual all pharmacy charges for inpatient claims roll to revenue
code 250 in a single line without detailed coding. This change requires communication to the
charge master team, billing team, charge capture, and pharmacy teams to ensure claims logic
is in place to accommodate billing a pharmaceutical with detailed coding under revenue code
636.
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ANSWER 4.
Inpatient Carve Outs
Best Answer D
According to the UB billing manual all pharmacy charges for inpatient claims roll to revenue code
250 in a single line without detailed coding. This change requires communication to the charge
master team, billing team, charge capture, and pharmacy teams to ensure claims logic is in place to
accommodate billing a pharmaceutical with detailed coding under revenue code 636.
EXPLANATION 4.
Inpatient Carve Outs
The National Uniform Billing (UB) explains the standards for billing. The State and National Uniform
Billing Committees consisting of members from CMS, BCBSA, HIAA, Tricare, etc. determine the date
elements and design of the billing formats. Revenue code 636 is an extension of the pharmacy codes
that require more detailed coding.
Answer A & B are incorrect as not all payers require revenue code 636 for inpatient claims billed on
the UB-04. Majority of inpatient claims are reimbursed by DRG or per diem; thus, detailed coding is
not required.
Answer C is incorrect as the system may be modified through claims logic to allow charges to roll to
Revenue code 250. This may typically be the system default, but it is important to work with the
appropriate stake holders to ensure the logic is correct for any carve outs.
POINTS: $300
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QUESTION 5.
LCD Specific
A patient is being seeing in your infusion center for prevention of skeletal-related events related to
bone metastases from a solid tumor. They have been prescribed Xgeva (denosumab) 120 mg syringe
starting their first dose today. You notice that you do not have any Xgeva on your shelf, but you do
have a couple syringes of Prolia (denosumab) 60 mg syringe. What is your best course of action to
serve this patient today?
HCPCS J0897, denosumab 1 mg
Please select the answer that is MOST correct:
A. Initiate a loan/borrow from the nearest health-system to provide the patient with Xgeva
B. Reschedule the patient for an alternative day and order in Xgeva
C. Both brand names consist of the same drug moiety and same HCPCS, denosumab, so it is safe
to administer 2 injections of Prolia
D. Administer 2 injections of Prolia, but change the NDC to Xgeva when billing.
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ANSWER 5.
LCD Specific
Best Answer A
Initiate a loan/borrow from the nearest health-system to provide the patient with Xgeva
EXPLANATION 5.
LCD Specific
Prior authorizations are not required when billing for Medicare beneficiaries. Patients must meet
medical necessity in which the drugs administered must be used for an FDA approved indication.
Xgeva is in FDA indicated for skeletal-related events in patients with bone metastases from solid
tumors. Prolia is indicated in patients with osteoporosis and at high risk for fractures. Billing the
Prolia NDC non FDA approved indications will result in a medical necessity denial.
Answer B is not the best answer as you could attempt to service the patient today through
loan/borrow. If your organization does not support loan/borrow or it is not feasible, then B may be
an alternative option.
Answer C is incorrect as it does not matter in this case if the HCPCS is the same for both brand
names, the claim will deny based on the billed NDC (see answer explanation for A)
Answer D is incorrect and it is a standard that the NDC used on the patient should be the NDC that
is billed to the patient.
Resource: Medicare Coverage Database: National and Local Coverage Documents
https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
POINTS: $200
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Discussion Questions (A - C)
Discussion A
Of the following, discuss what is the greatest need for better reimbursement for drugs on outpatients? 1. Education of pharmacists on billing requirements 2. System ability to report National Drug Codes (NDC) 3. Pharmacist on negotiating team for commercial contracts 4. Analysis of rules and transmittals from federal government
Discussion B
Medicare has started Targeted Probe and Education (TP&E) audits which are designed to provide
education to the providers on NCD/LCD interpretation and appropriate documentation. Some of
the TP&E topics from the MAC deal with drugs on outpatients. Describe your current involvement
in TP&E, and discuss what you believe is the pharmacy’s role in TP&E audits and education to
prevent pre-payment reviews and disrupted cash flow.
Discussion C
You have a patient that has been coming to your clinic for 10 years receiving rituximab for his rheumatoid arthritis. He is very disgruntled and states that he received a letter stating his insurance is no longer going to cover his infusions unless he seeks care at a an alternative free standing infusion center or receives care in home. What are some of the driving factors to letters similar to these and what are some next steps?
POINTS: $100
Please note that this information may become obsolete with revised regulations Page | 20
SECTION III: EVALUATING FORMULARY DECISIONS FOR HIGH COST
DRUGS
Page | 21 Please note that this information may become obsolete with revised regulations
QUESTION 6.
CAR T-Cell Therapy
Your facility is part of a large health-system network with entities in multiple states. You are known as a leader in cancer diagnosis and treatment and have had a bone marrow transplant service for over 15 years and participate in hundreds of clinical trials. Although you did not participate in any clinical trials for CAR T-Cell therapy products, your VP of Cancer Care has requested that you prepare to order and dispense two new drug products, KYMRIAH and YESCARTA for adult patients. You have determined that the cost to the hospital for either product for adults will be ~$375,000 for one dose as it is an engineered product made from the patient’s own blood cells retrieved during leukapheresis. Because of the newness of the therapy, the VP of Cancer Care indicates that at least the first 30 patients will be admitted as inpatients and remain hospitalized during the infusion and for at least 7 days thereafter due to the high incidence of cytokine release syndrome and the need for immediate treatment. In working with your CFO, you determine that the products have been assigned HCPCS codes Q2040 and Q2041 with the following payment rates listed on Addendum B for July 1, 2018: Q2040- Tisagenlecleucel, up to 250 million CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per infusion [Kymriah] (payment rate: $500,915.367) Q2041- Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR T cells, including leukapheresis and dose preparation procedures, per infusion [Yescarta] (payment rate: $395,380.000) Because of the high cost of these drugs, you prepare a formulary monograph for presentation at the next P&T Committee for their approval and note that neither drug company is willing to sign a contract for pricing. What is your recommendation based upon the financial reimbursement for inpatients?
A. Recommend that only KYMRIAH be stocked since the inpatient payment rate is higher than for the YESCARTA.
B. Recommend that only patients with private insurance be allowed to be scheduled and treated with KYMRIAH or YESCARTA.
C. Recommend that both products be designated as non-formulary and not permitted at the facility since the therapy is so new and so expensive.
D. Recommend that both products be available based upon physician preference since the payment rate is the same when dispensed for Medicare inpatients.
Please note that this information may become obsolete with revised regulations Page | 22
ANSWER 6.
CAR T-Cell Therapy
Best answer: D.
Recommend that both products be available based upon physician preference since the payment
rate is the same when dispensed for Medicare inpatients
EXPLANATION 6. CAR T-Cell Therapy
CMS considered the products to be essentially similar during FY2019 IPPS rulemaking based upon
the new technology applications submitted by the company. The rate of reimbursement is the same
for Medicare inpatients independent of which product is used.
Other answers:
A. Addendum B is only used to determine payment rates for outpatient claims.
B. It would not be appropriate to offer a therapy to private patients only if the facility has signed
an agreement to be a Medicare provider and must adhere to the Medicare Conditions of
Participation.
C. Although this may be a good financial decision, it is unlikely that this recommendation would
be a physician satisfier if the facility is known for cancer treatment and has been performing
bone marrow transplants for a considerable period of time.
Resources:
1. CMS July 2018 Addendum B: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates-Items/2018-July-
Addendum-B.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
2. FY19 IPPS Final Rule: https://www.gpo.gov/fdsys/pkg/FR-2018-08-17/pdf/2018-16766.pdf
POINTS: $400
Page | 23 Please note that this information may become obsolete with revised regulations
QUESTION 7.
Biosimilar
What can we estimate the reimbursement to be for a Medicare patient who receives Inflectra for
Crohn’s disease who had an inadequate response to conventional therapy? Please note that this
patient received a dose in the ER on 4/1/2018 and the claim is being billed as an outpatient type
claim (Part B coverage). Your facility is currently NOT purchasing drugs under 340B.
Please select the answer that is MOST correct:
A. Items and services are all packaged (SI: N) in the ER setting. No additional reimbursement at
this time
B. Inflectra is considered pass-through (SI: G) and will be reimbursed at 95% of AWP
C. Inflectra is considered Non-pass-through (SI: K) and will be reimbursed at ASP of biosimilar
minus 22.5% ASP of reference product
D. Inflectra is considered pass-through (SI: G) and will be reimbursed at ASP of biosimilar plus
6% ASP of reference product
E. All above are incorrect
Please note that this information may become obsolete with revised regulations Page | 24
ANSWER 7.
Biosimilar
Best answer: D.
D. Inflectra is considered pass-through (SI: G) and will be reimbursed at ASP of biosimilar plus 6%
ASP of reference product
EXPLANATION 7. Biosimilar
Drug and biologics with pass through status get reimbursed at a rate of ASP plus 6%. Drugs and
biologics in different status indictors may get different reimbursement rates. 340 B products
currently get reimbursed at ASP – 22.5%. HCPCS code Q5103 (INJECTION, INFLIXIMAB-DYYB,
BIOSIMILAR, (INFLECTRA), 10MG) currently has a Status indictor of “G” or pass-through status.
Based upon the Proposed OPPS Rule FY2019, the reimbursement will change for biosimilars to ASP
+ 6% (not of the reference product but the actual product.
A. Not all items or services in the ER setting are considered packaged (SI: N). The status indicator
determines the packaging for each product in the ER.
B. Inflectra is consider pass-through (SI: G) and but it gets reimbursed at ASP of biosimilar plus 6%
ASP of reference product.
C. Inflectra is not consider Non-pass-through (SI: K).
POINTS: $300
Page | 25 Please note that this information may become obsolete with revised regulations
QUESTION 8. Biosimilar
You are the newly appointed pharmacist on the local P&T committee and the physician chair asks
you which infliximab biosimilars makes the most financial sense to add to formulary. Which item(s)
or activity would you want to explore?
Please select the answer that is MOST correct:
A. Work with finance department to determine the major drug payers at your facility
B. Determine if there is a payer drug policy that excludes certain biosimilars or indications
C. Determine what the contract cost is for each biosimilar product per patient dose
D. All of the above
E. None of the above
Please note that this information may become obsolete with revised regulations Page | 26
ANSWER 8. Biosimilar
Best Answer: D
A. Work with finance department to determine the major drug payers at your facility
B. Determine if there is a payer drug policy that excludes certain biosimilars or indications
C. Determine what the contract cost is for each biosimilar product per patient dose
EXPLANATION 8. Biosimilar
All of these items are good to understand when making a well-informed formulary decision.
Understanding the output of drug contract costs and input of drug reimbursement can help shape
the full picture of the financial performance of each biosimilar product.
POINTS: $200
Page | 27 Please note that this information may become obsolete with revised regulations
QUESTION 9.
Specialty Drug
You are asked by the Chief Financial officer (CFO) of the hospital what is considered a specialty drug.
What would be the best answer you can give him/ her?
Please select the answer that is MOST correct:
A. Everyone defines specialty drug differently
B. Specialty drug are often biologics products
C. Drugs that are really expensive are considered specialty
D. Drugs that require special handling are considered specialty
E. None of the above
Please note that this information may become obsolete with revised regulations Page | 28
ANSWER 9. Specialty Drug
Best Answer: A
Everyone defines specialty drug differently
EXPLANATION 9. Specialty Drug
The definition of specialty drugs can vary from the person or perspective that you are talking about.
Specialty drugs can be a part of answers B, C, or D but the best answer is A.
POINTS: $200
Page | 29 Please note that this information may become obsolete with revised regulations
QUESTION 10.
IPPS New Technology
You are speaking with someone in revenue integrity at your health system about MS-DRG payments
and reimbursement for drug products and they ask you a questions about CMS’s New Technology
Add-on inpatient payment. What is the time frame a drug product can receive add-on inpatient
payment?
Please select the answer that is MOST correct:
A. Add-on inpatient payments are for 1-2 years
B. Add-on inpatient payments are for 2-3 years
C. Add-on inpatient payments are for 3-4 years
D. A time frame is not defined
Please note that this information may become obsolete with revised regulations Page | 30
ANSWER 10.
IPPS New Technology Best Answer: B
Add-on inpatient payments are for 2-3 years
EXPLANATION 10. IPPS New Technology
For IPPS new technology add-on payments, the time frame can be a maximum of 3 years and a
minimum of 2 year from the date of the application. In order to quality for this payment, the product
must be consider new under CMS regulations.
Resource: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/AcuteInpatientPPS/newtech.html
POINTS: $200
Page | 31 Please note that this information may become obsolete with revised regulations
QUESTION 11.
IPPS New Technology
The revenue Integrity person asks you how the reimbursement is calculated for these products are
designated to receive inpatient new technology add-on payments.
A. Payment is the lesser of 25% of the average cost of the technology or 25% of the excess cost
over MS-DRG payment
B. Payment is the lesser of 50% of the average cost of the technology or 50% of the excess cost
over MS-DRG payment
C. Payment is the lesser of 75% of the average cost of the technology or 75% of the excess cost
over MS-DRG payment
D. Payment is the lesser of full amount of the average cost of the technology
Please note that this information may become obsolete with revised regulations Page | 32
ANSWER 11.
IPPS New Technology Best Answer: B
Payment is the lesser of 50% of the average cost of the technology or 50% of the excess cost over
MS-DRG payment
EXPLANATION 11. IPPS New Technology
For IPPS new technology add-on payments, payment is the lesser of 50% of the average cost of the
technology or 50% of the excess cost over MS-DRG payment. Areas may vary from the amount of
reimbursement they receive due to differences in cost of living. In order to quality for this payment,
the product must be considered new under CMS regulations
Resource: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/AcuteInpatientPPS/newtech.html
POINTS: $200
Page | 33 Please note that this information may become obsolete with revised regulations
QUESTION 12.
Hemophilia Products You have been asked to review 5 accounts for Medicare hemophilia patients who received Wilate injection (Von Willebrand Factor/Coagulations Factor VIII Complex (Human) within the past 3 months. The HCPCS Code is J7183 Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco. You note according to the package insert that the ratio of VWF to RCO is 1:1. For each of the 5 accounts you review the medical record and provide the following summary:
Patient #
Patient Type
Physician Ordered in
VEF:RCO Units
Amount Administered
Billed Units of J7183 for each Date of
Service
#1 Inpatient 2100 units every
12 hours 2376 units @
0900 and 2100 5000
#2 Inpatient 2600 units every
24 hours 2500 units @
0900 3000
#3 Outpatient 1997 units x 1 2000 units @
1500 2000
#4 Outpatient 4400 units x 1 4347 units @
1000 5000
#5 Outpatient 2500 units x 1 2337 units @1200 2500
Based upon your medical record review you authorize rebilling for:
A. None of the claims need to be rebilled because they are all single dose vials
B. All of the claims need to be rebilled
C. Only the outpatient claims need to be rebilled as inpatient claims are paid under a fixed payment of the MS-DRG
D. Only patients #1, #2 and #4 need to be rebilled
Please note that this information may become obsolete with revised regulations Page | 34
ANSWER 12.
Hemophilia Products Best Answer: B
All of the claims need to be rebilled
EXPLANATION 12. Hemophilia Products
All the claims need to be rebilled as the lot-specific factors are billed per unit that is stamped on the top of each vial. Only the amount ordered by the physician or administered to the patient can be billed. When there is a discrepancy between what was ordered and what was administered, only the lower of the two can be billed. Hemophilia products are reimbursed separately on both inpatients and outpatients so all claims need to be rebilled as they all resulted in an overpayment. The indicator on the ASP quarterly file from CMS shows if a blood clotting factor is eligible for separate reimbursement on hemophilia patients.
A. Lot-specific factors have the actual lot stamped on top of each vial and only that amount can be
billed. It is recommended that a physician order be obtained to cover the full amount on hand due to the high cost of the products.
C. For this HCPCS code, there is a blood clotting factor additional payment which applies to both inpatients and outpatients.
D. Patient #3 needs to be rebilled since the physician ordered 1997 units and only that amount can be billed. Patient #5 needs to be rebilled because the pharmacy adjusted the dose to what was “on hand” in the pharmacy, 2337 units. Since 2337 units were administered, only 2337 units can be billed.
Resources: CMS ASP Pricing File, 2018- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2018ASPFiles.html
POINTS: $200
Page | 35 Please note that this information may become obsolete with revised regulations
Discussion Questions (D - F) Discussion D
When making formulary decisions, how often do you take into consideration the reimbursement
impact in addition to the cost of the product? When you take reimbursement into consideration,
do you typically calculate based upon Medicare only, or do you consider major commercial
contracts?
Discussion E
Certain drugs have additional reimbursement on inpatients such as TPA for stroke and drugs eligible
for new technology add-on payments. However, the additional reimbursement is generated when
ICD-10-PCS codes are added to the claim, not for a HCPCS code related to the drug. Describe your
process for having inpatient claims correctly coded to generate the additional reimbursement.
Discussion F
Blood clotting factors used to prevent and treat certain congenital and acquired hemophilia
conditions are reimbursed separately on inpatient claims. Since each blood clotting factor has a
separate HCPCS code and payment, it is necessary to add the HCPCS codes back onto eligible
inpatient claims since individual HCPCS codes are not reported on inpatient claims only revenue
codes. Describe your process for having HCPCS codes added to inpatient claims for
hemophilia/blood clotting products that are eligible for additional reimbursement.
POINTS: $100
Please note that this information may become obsolete with revised regulations Page | 36
SECTION IV: ENSURING THE INTEGRITY OF SUBMITTED CLAIMS
Page | 37 Please note that this information may become obsolete with revised regulations
QUESTION 13.
Bolus from the Bag
Your system just went live with a new workflow to document alteplase on the MAR. About a month
later, your 340B coordinator notices your 340B accumulations are significantly higher than your
purchases. You reviewed the workflow and realized the bolus dose and infusion dose are
documented using two separate orders. This facilitates the clinical workflow well, but the infusion
dose is set to drop a charge for the entire bag when a portion of this was used for the bolus dose
from the same bag.
Please assess the issues with this situation
A. The bolus dose amount is overcharged/billed to the patient creating an over accumulation in 340B
B. The bolus dose amount is overcharged/billed and may result in a direct overpayment by Medicare.
C. The bolus order and infusion order may incorrectly represent the total dose of alteplase given to the patient.
D. All of the above
Please note that this information may become obsolete with revised regulations Page | 38
ANSWER 13.
Bolus from the Bag
Best Answer: D
All of the claims need to be rebilled
EXPLANATION 13. Bolus from the Bag
This question highlights the importance of communication between clinical team builds and how they
may impact billing. It is important to assess and test front to back end workflow to ensure you do not
create a situation of overcharging or overbilling of the medication.
POINTS: $300
Page | 39 Please note that this information may become obsolete with revised regulations
QUESTION 14.
Drug Shortage & Compounding
You find out from the pharmacy buyer that your pharmacy is going to be getting Hydromorphone
0.5 mg/ 1 ml from RJ’s Compounding Pharmacy (503-B) starting today. Which HCPCS code(s) would
be the best code to use in this scenario?
Please select the answer that is MOST correct:
A. HCPCS code J1170 (INJECTION, HYDROMORPHONE, UP TO 4 MG) is the best
B. HCPCS code J7999 (COMPOUNDED DRUG, NOT OTHERWISE CLASSIFIED) is the best
C. HCPCS code J3490 (UNCLASSIFIED DRUGS) is the best
D. None of the above
Please note that this information may become obsolete with revised regulations Page | 40
ANSWER 14.
Drug Shortage & Compounding
Best Answer: B
HCPCS code J7999 (COMPOUNDED DRUG, NOT OTHERWISE CLASSIFIED) is the best
EXPLANATION 14. Drug Shortage & Compounding
HCPCS code J7999 should be used with truly compounded items. Compounding can vary by payer
or site. Since the case above states that it is purchased from a 503(B) compounding pharmacy, the
J7999 HCPCS code is the most appropriate.
POINTS: $300
Page | 41 Please note that this information may become obsolete with revised regulations
QUESTION 15.
Unapproved Drugs
You recently received an email from the informatics pharmacist asking you how you would setup
and charge for the following drug product. What would the best response be?
Please add 14.6% sodium chloride NDC # 63323-0139-40 in both a 1 ml and 40 ml doses.
Please select the answer that is MOST correct: A. You would add this product in your clinical system and attach HCPCS code J7999
(COMPOUNDED DRUG, NOT OTHERWISE CLASSIFIED).
B. You would add this product in your clinical system and attach HCPCS code J3490 (UNCLASSIFIED
DRUGS).
C. You would add this product to your clinical system but set the system not to charge.
Please note that this information may become obsolete with revised regulations Page | 42
ANSWER 15.
Unapproved Drugs Best Answer: C
You would add this product to your clinical system but set the system not to charge
EXPLANATION 15. Unapproved Drugs
This NDC number (63323-0139-40) is listed by the FDA as an unapproved drug, therefore shouldn’t
be billed to payers unless they supply specific instructions.
Incorrect A: This drug product is manufactured by a Pharmaceutical company and therefore isn’t
considered a compounded product.
Incorrect B: Since this product is unapproved, you wouldn’t bill this product to payers unless they
supply specific instructions.
POINTS: $300
Page | 43 Please note that this information may become obsolete with revised regulations
QUESTION 16.
Overpayment You are notified on June 11, 2018 that the billed units for two different antibiotics are double charged on a patient claim. Researching the account, you notice that the charges are for a Medicare outpatient (Part B coverage). You verify that the reported information is correct and proceed to the next step.
HPCPCS Code Manual Description Status Indicator Reimbursement
J0878 Injection, Daptomycin, 1 MG K $$$$
J3370 Injection, Vancomycin HCL 500 MG N SS
What should be the next you next steps? Please select the answer that is MOST correct A. You need to ensure that any overpayment received is reported and returned within 30 days of
June 11, 2018.
B. You need to ensure that any overpayment received is reported and returned within 60 days of
June 11, 2018.
C. You need to ensure that any overpayment received is reported and returned within 90 days of
June 11, 2018.
D. Wait until someone at Medicare contacts you with instructions.
Please note that this information may become obsolete with revised regulations Page | 44
ANSWER 16.
Overpayment
Best Answer: B
You need to ensure that any overpayment received is reported and returned within 60 days of
June 11, 2018.
EXPLANATION 16. Overpayment
It requires providers and suppliers receiving funds under the Medicare program to report and return
overpayments by the later of the date that is 60 days after the date on which the overpayment was
identified; or the date any corresponding cost report is due, if applicable.
Section 1128J (d) of the Social Security Act (the Act)
Resource: https://www.ssa.gov/OP_Home/ssact/title11/1128J.htm
POINTS: $200
Page | 45 Please note that this information may become obsolete with revised regulations
QUESTION 17.
Underpayment
Your Finance Department has been comparing purchase history records of drugs purchased and drugs billed for the past 3 months. They’ve sent you a report with discrepancies that have a difference of more than 20% showing that more drug was purchased than what has been billed. They send you a sample of claims for HCPCS code J0885 (Injection, epoetin alfa, (for non-esrd use), 1000 units) and note that they did not have any claims billed under Q4081 (Injection, epoetin alfa (for esrd on dialysis), 100 units). You retrieve a list of patients that received epoetin in the past 3 months and review the medical record and the claim for each account. You discover that patients who were on one outpatient unit of the hospital all received 20,000 units of epoetin but the billing reflects only 1 unit of J0885 (1000 units) with the patient charge for 1000 units of $178.00. Upon further investigation, you discover that the unit-based cabinet interface is not calculating the conversion correctly. When the nurse removes a 20,000 unit multi-dose vial, the quantity transmitting to Patient Account is 1 unit of J0885. You do an additional search and it appears that this discrepancy has been going on for at least 2 years. You contact the IT&S department to request that the interface programming be reviewed, but for the claims that you have researched for the past 2 years you recommend:
A. Review the revenue loss with your CFO to make them aware of the underbilling so they can
book a journal entry to account for the discrepancy in previous financial periods. B. Request that all outpatient Medicare claims with a date of service within the past year be
rebilled with the correct quantity of “20” and review other payer contracts for rebilling guidance.
C. Request that all outpatient Medicare claims with a HCPCS code of J0885 be rebilled if the dates of service were within the past 2 years and review other payer contracts for rebilling guidance.
D. Correct the billing manually in the clinical pharmacy system so that the charges on the claim will
be corrected.
Please note that this information may become obsolete with revised regulations Page | 46
ANSWER 17.
Underpayment
Best Answer: B
Request that all outpatient claims with a date of service within the past year be rebilled with the
correct quantity of “20”
EXPLANATION 17. Underpayment
This was an outpatient unit only and appears to be isolated to one area. Medicare and most
commercial payers have a rebilling limit for underbilling of 12 months although some payers like
Medicaid may be as short as 90 days.
Other Answers:
A. Although it would be good to review the event with your CFO it is unlikely that they will book
a journal entry for a previous year as this may have impacts on the cost reports that have already
been filed.
C. Medicare has timely filing limits of 12 months for underbilling. For overpayments, providers
are expected to rebill for 6 years and within 60 days of discovery of the overpayment.
D. Correcting the billing in the pharmacy system for charges more than 3-4 days, typically results
in late charges that may or may not be posted, even if the system allows changes. Charge
corrections also require “rebilling” of the claim which is not automated and must be requested
when there is significant time from the date of the provision of the service and the correction.
Resource: CMS Transmittal 2140: Changes to the Time Limits for Filing Medicare Fee-For-Service Claims- January 21, 2011: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2140CP.pdf
POINTS: $400
Page | 47 Please note that this information may become obsolete with revised regulations
QUESTION 18.
Not-Billable Services The CDC is recommending all healthy adults over the age of 50 receive two doses of Shingrix (recombinant zoster vaccine) over one dose of Zostavax (live zoster vaccine). The two doses of Shingrix will cost an additional $60 per person vaccinated.
Organization’s population statistics:
Adults Age Total Volume Volume by Payer
0-18 years 24% Commercial – 16%
Medicaid – 8%
19-50 years 39% Commercial – 26%
Medicaid – 12% Medicare – 1%
51-60 years 14% Commercial – 6%
Medicaid – 5% Medicare – 3%
61+ years 23% Commercial – 3%
Medicaid – 1% Medicare – 19%
Shingrix
HCPCS 90750
Status Indicator: M
MUE: Facility = 1, Professional = 1
What is your recommendation to maximize revenue for the Shingrix vaccine?
A. Mandate a questionnaire for all newly admitted inpatients and ensure the vaccine is administered to all eligible adult greater than 50 years of age prior to discharge. Ensure documentation is acquired and bill the vaccine on the inpatient UB-04 claim.
B. Mandate a questionnaire for all newly admitted inpatients and ensure the vaccine is administered to all eligible adult greater than 50 years of age prior to discharge. Enroll in roster billing thereby splitting the Shingrix off the inpatient claim and submitting to Medicare Part B outpatient claim.
C. Encourage patients to follow up in an outpatient facility/clinic to receive the Shingrix vaccine. Ensure appropriate documentation and bill on the outpatient UB claim.
D. Encourage patients to follow up in a retail pharmacy and have a pharmacist administer the vaccine billing to the patient under Part D or other pharmacy benefit.
Please note that this information may become obsolete with revised regulations Page | 48
ANSWER 18.
Not-Billable Services
Best Answer: D
Encourage patients to follow up in a retail pharmacy and have a pharmacist administer the vaccine
billing to the patient under Part D or other pharmacy benefit.
EXPLANATION 18. Not-Billable Services
Governmental payers, Medicaid & Medicare, classify this medication with a status indicator of “M”
which is defined as “Items and Services Not Billable to the MAC”. Therefore, it is not appropriate to
bill for this medication on an outpatient claim will result in $0 revenue. Part D and other pharmacy
benefits managers do reimburse for the vaccine.
Answer A is incorrect as inpatient claims are subject to DRG or per diem rates. No additional revenue
will be made on the administration of the Shingrix.
Answer B is incorrect as only pneumococcal and influenza vaccines are eligible for roster billing.
Additionally, governmental payers will not reimburse for the status indicator of M.
Answer C is incorrect due the assignment of the status indicator of M. Status indicators are indicated
for OPPS billing; however, free standing clinics or other clinics that follow the physician fee schedule
rules also classify this as a non-billable service and will result in $0 payment.
Resources:
CDC Shingles Vaccination:
https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html
CMS Addendum B:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-
Updates.html?DLSort=2&DLEntries=10&DLPage=1&DLSortDir=descending
CMS Addendum D1:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalOutpatientPPS/downloads/CMS1506FC_Addendum_D1.pdf
POINTS: $400
Page | 49 Please note that this information may become obsolete with revised regulations
QUESTION 19.
Waste Your finance department notices a large variance between purchases vs. charges of rituximab. After further research, patients on average received only 750 mg and the rest is wasted but not charged. What is the potential added revenue you could achieve if you started billing for waste on these patients?
Available formulations o Rituximab 100 mg/10 mL o Rituximab 500 mg/50 mL
Billing quantity = 100 mg
ASP + 6% = $884
A. Dose = 750 mg (billing qty = 8), Waste = 250 mg (billing qty = 3) Added revenue for waste = $884 x 3 = $2,652
B. Dose = 750 mg (billing qty = 8), Waste = 50 mg (billing qty = 0) Added revenue for waste = $884 x 0 = $0
C. Dose = 750 mg (billing qty = 8), Waste = 50 mg (billing qty = 1) Added revenue for waste = $884 x 1 = $884
Please note that this information may become obsolete with revised regulations Page | 50
ANSWER 19.
Waste
Best Answer: B
Dose = 750 mg (billing qty = 8), Waste = 50 mg (billing qty = 0) Added revenue for waste = $884 x 0 = $0
EXPLANATION 19. Waste
Medicare requires the smallest vial size to be used when preparing medications to minimize waste.
To prepare 750 mg, you may use a combination of 1 x 500 mg vial plus 3 x 100 mg vial or 8 x 100 mg
vials. Thus, only 50 mg of waste can be billed. The billing quantity is equal to 100 mg and you cannot
bill more than the volume contained in the vial. A quantity of 8 = 800 mg billed which is rounded up
(no decimals allowed).
Answer A in incorrect as it assumes you used 2 x 500 mg vials. In this case, you could have used the
smaller 100 mg vial to prepare the dose.
Answer C is incorrect because the total bill quantity is 9 but only a total of 8 billing units are
contained in the vials to prepare a 750 mg dose. This would be considered an overpayment.
What is your action step to resolve you purchases vs. charges variance?
Evaluate your preparation practices and ensure each preparation is being prepared using the
smallest vial size available to minimize the waste.
Other information regarding waste.
Waste is a valuable method to recoup payment. Requirements for billing waste:
• Only allowed for single dose vials
• Documentation of the waste must be contained in the medical record
• Each charge line must include a JW modifier
• The billed quantity must not exceed the amount in the vial
Resource:
CMS Waste FAQ updated August 26, 2016
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf
POINTS: $300
Page | 51 Please note that this information may become obsolete with revised regulations
Discussion Questions (G & H)
Discussion G
Describe your current process for determining if a drug is “compounded” for billing purposes and
when the use of HCPCS code J7999-compounded drug, not otherwise classified is the most
appropriate HCPCS code to bill on a claim.
Discussion H
Describe your process when a billing error has occurred that resulted in an overpayment to a federal
payer (e.g. Medicare, TRICARE) and how you participate in ensuring that the overpayment is
refunded.
POINTS: $100
Please note that this information may become obsolete with revised regulations Page | 52
SECTION V: IMPLEMENTING & MONITORING REVENUE CYCLE
MANAGEMENT SYSTEMS
Page | 53 Please note that this information may become obsolete with revised regulations
QUESTION 20.
Packaged Drug Your organization is in the process of reviewing procedural areas’ (i.e. GI, imaging, etc.) documentation and charging practices to improve safety and charging. Your team is implementing medication barcode scanning; therefore, will be dropping charges upon administration on the MAR. The procedural departments are pushing back and do not want to barcode scan heparin flushes or contrast. They state they should not have to document these as they are “not drugs” and should not have to bill for these items as they are included in the procedure charge (example: MRI with contrast). What is your best approach to overcome this hurdle? A. Contrast and heparin flushes are included in Level II HCPCS coding system. It is best practice to
bill out each code separately as the data is used to formulate long term decisions by Medicare to establish procedure payment rates.
B. The procedure code example, MRI with contrast, is the explanation of the procedure being performed. The contrast product has a separate code that should be used to bill along with the procedure “MRI with contrast”.
C. Some Heparin flush products and contrast products contain NDCs and have been approved by the FDA as a drug; therefore, may be billed as a packaged drug.
D. All of the above are true statements
Please note that this information may become obsolete with revised regulations Page | 54
ANSWER 20.
Packaged Drug Best Answer: D
All of the above are true statements
EXPLANATION 20. Packaged Drug
Each organization may vary in how items are billed and may interpret regulations differently. The Level II HCPCS system is a comprehensive standardized dataset used to identify products, supplies, and services not included in the CPT code. This data is used to formulate payment thresholds for rendered services among other things. The more detailed information provided will allow CMS to understand the additional services that are required for particular procedures/diagnoses. Some Heparin flushes and contrast (majority) are FDA approved drugs that are considered “packaged”. Packaged, identified by the CMS status indicator of N, is any drug that is less than an average of $120 per day (CMS calculation). These drugs are separately billable to Medicare, but are not separately payable.
POINTS: $200
Page | 55 Please note that this information may become obsolete with revised regulations
QUESTION 21.
Pass-Through vs. Non-Pass-Through Drug
Your clinical coordinator is interested in adding a new antibiotic, IV delafloxacin, to the hospital
formulary. After speaking with the finance department, a difference is noted in the reimbursement
rates (see information below from Addendum B - OPPS Payment by HCPCS Code for CY 2018) when
comparing to IV levofloxacin, another injectable antibiotic in the same drug class. Of note, these
drugs were not purchased under a 340B account.
HCPCS Code Short Descriptor Status
Indicator (SI) Payment Rate
C9462 Injection,
delafloxacin G $0.47 per 1 mg
J1956 Injection,
levofloxacin N $0
After further review, the difference in reimbursement was noted due to the difference in the OPPS
status indicators. Which of the following descriptions defines the OPPS status indicator for IV
delafloxacin?
A. Items, codes, and services that are not paid under OPPS or any other Medicare payment system
B. Pass-through drugs and biologicals, paid under OPPS as a separate APC payment
C. Non-pass-through drugs and non-implantable biologicals, including therapeutic
radiopharmaceuticals, paid under OPPS as a separate APC payment
D. Items and services packaged into ambulatory payment classification (APC) rates, paid under
OPPS, no separate APC payment due to packaging
Please note that this information may become obsolete with revised regulations Page | 56
ANSWER 21.
Pass-Through vs. Non-Pass-Through Drug
Best Answer: B
Pass-through drugs and biologicals, paid under OPPS as a separate APC payment
EXPLANATION 21. Pass-Through vs. Non-Pass-Through Drug
IV delafloxacin is classified as OPPS status indicator G under pass-through drugs and biologicals.
Pass-through drug status was established to incentivize use of innovative medical drugs, biologics,
and devices. Other examples include orphan drugs or certain cancer biologics.
Answer A is incorrect since it is the description of status indicator E1, with examples being certain
vaccines or oral buprenorphine.
Answer C is incorrect since it is the description of status indicator K, with an example being
infliximab.
Answer D is incorrect since it is the description of status indicator N. IV levofloxacin would be
classified as OPPS status indicator N.
POINTS: $300
Page | 57 Please note that this information may become obsolete with revised regulations
QUESTION 22.
Self-Administered Drug
The Director of Nursing has read an article in the New York Times about patients receiving a separate
bill for their home medications at inflated charges after an outpatient encounter. She sends you an
email asking you to endorse having all patients bring their home meds to the hospital and take them
so that they won’t get a separate bill. You set up a meeting with her to discuss her idea. From a
financial standpoint, what is your best recommendation?
A. Do not allow Medicare patients to take their own medications, but patients who have private
insurance can bring in their own medications
B. You explain that “self-administered drugs” apply only to Medicare and Medicare Advantage
patients, but the hospital is no longer obligated to bill them to the patient
C. No patients are allowed to ever bring any of their own medications into the hospital
D. All patients are mandated to bring in their own maintenance medications to the hospital and
take them themselves as self-medication
Please note that this information may become obsolete with revised regulations Page | 58
ANSWER 22. Self-Administered Drug
Best Answer: B
You explain that “self-administered drugs” apply only to Medicare and Medicare Advantage
patients, but the hospital is no longer obligated to bill them to the patient
EXPLANATION 22. Self-Administered Drug
Self-administered drugs apply only to Medicare patients who are billed on a claim as an outpatient.
In October 2015, the Office of Inspector General (OIG) issued a policy statement that hospitals may
fully discount self-administered drugs and not bill the patient separately for them.
The other answers:
A. Typically, the insurance status of a patient is not known to the pharmacists and nurse managers
so it would be difficult to treat one type of insurance differently than another for an issue that is so
broad.
C. There may be items that are non-formulary or restricted specialty drugs that can’t be ordered by
the hospital pharmacy. Investigational drugs that are issued to a patient at a different location
would also need to be supplied by the patient. This would be a very broad policy that would be
difficult to enforce.
D. With required medication identification and potential barcoding for BCMA systems, this would
be an operational challenge. In addition, even if requested, some patients would not bring their
medications to the hospital which would be confusing to providers who dispense and administer
the medications.
Resources:
OIG Policy Statement: https://oig.hhs.gov/compliance/alerts/guidance/policy-10302015.pdf
How Medicare Covers Self-Administered Drugs Given in Hospital Outpatient Settings:
https://www.medicare.gov/pubs/pdf/11333-How-Medicare-Covers-Self-Administered-Drugs-in-
Hospital-Outpatient.pdf
Medicare Claims Processing Manual- 100-04 Chapter 17, Section 80.5: Self-Administered Drugs:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c17.pdf
POINTS: $400
Page | 59 Please note that this information may become obsolete with revised regulations
QUESTION 23.
Quarterly Maintenance Process for Billing Information
Which of the following is correct in regards to the frequency that CMS publishes maintenance files?
Please select the answer that is MOST correct: A. The Alpha Numeric HCPCS file and Addendum B are updated every quarter.
B. The Alpha Numeric HCPCS file is updated every quarter
C. Addendum B is updated yearly
D. The Alpha Numeric HCPCS file is updated yearly
E. None of the above are correct
Please note that this information may become obsolete with revised regulations Page | 60
ANSWER 23.
Quarterly Maintenance Process for Billing Information
Best Answer: D
The Alpha Numeric HCPCS file is updated yearly
EXPLANATION 23.
Quarterly Maintenance Process for Billing Information
The Alpha Numeric file is published once yearly usually in the beginning of December for the
following year. The Addendum B can be published every quarter.
Alpha-Numeric HCPCS
https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html
Addendum B
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html
POINTS: $200
Page | 61 Please note that this information may become obsolete with revised regulations
QUESTION 24.
Quarterly Maintenance Process for Billing Information
How often does CMS release a new HCPCS code?
Please select the answer that is MOST correct: A. CMS can release a new HCPCS code once a week
B. CMS can release a new HCPCS code once a month
C. CMS can release a new HCPCS code once a quarter
D. CMS can release a new HCPCS code once a year
E. There is no set schedule
Please note that this information may become obsolete with revised regulations Page | 62
ANSWER 24.
Quarterly Maintenance Process for Billing Information
Best Answer: C
CMS can release a new HCPCS code once a quarter
EXPLANATION 24.
Quarterly Maintenance Process for Billing Information
CMS can release HCPCS code once a quarter and will be reflective in the Addendum B file that
quarter and the Alpha Numeric file the next year.
Alpha-Numeric HCPCS
https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html
Addendum B
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html
POINTS: $200
Page | 63 Please note that this information may become obsolete with revised regulations
Discussion Questions (I - L)
Discussion I Of the following which is the greatest barrier to getting paid for drug products? Choose one and
identify one way that you have overcome this barrier. drug chargemaster setups
preauthorization
clinical requirements
documentation requirements
NDC reporting
Discussion J The requirement to report wasted drug on a separate charge line from single dose vials that are
separately payable was mandated by Medicare effective January 1, 2017 and includes the reporting
of the wasted amount on a separate charge line with a JW modifier and a statement in the medical
record that the amount was wasted. Health systems have taken different approaches to meeting
this requirement, including the following. Discuss how your health system is meeting this
requirement.
Only Billing what was administered to the patient from single dose vials even if the remainder
is wasted
Billing for waste for only targeted, very expensive drugs
Billing for all discarded waste to fully meet the regulatory requirements and maximize drug
reimbursement
Discussion K Describe your current process for self-administered drugs on outpatients. Do you allow patients to
bring in their own medications? If so, how do you verify integrity and document administration? If
not and you supply the drugs, do you bill the patients for the drugs directly, bill the insurance
company only, or discount the drugs so that the Medicare patients do not receive a bill.
Discussion L Your state Medicaid agency completed an audit of drugs billed from Jan 2015 through December 2017
and has provided you with a list of 215 patients that they are stating the NDC was invalid for the date
of service. The compliance department is very concerned that an invalid NDC has been billed. How do
you assess your organization and ensure the correct (administered) NDC is billed?
Review ADS machines for charge on dispense mechanisms
Validate default NDC are represented of current NDC
Ensure barcode scanning of each drug is in place wherever feasible
Validate new NDC purchased are updated in EMR prior to being dispensed
POINTS: $100
Please note that this information may become obsolete with revised regulations Page | 64
SECTION VI: EFFECTIVLEY APPEAL DENIALS WHEN THEY OCCUR
Page | 65 Please note that this information may become obsolete with revised regulations
QUESTION 25.
Targeted Probe and Educate
Your facility has just been notified by Novitas (your Medicare Administrative Contractor (MAC)) that you have received the results for a Round 1 Targeted Probe and Educate audit on Denosumab injection and your compliance rate is 30%. You review the TP&E criteria and determine that the largest deficiency in the records is in the documentation of medical necessity. An educational call is scheduled for next Thursday. How do you respond to this request for assistance?
A. The TP&E program from Medicare doesn’t impact pharmacy since they are only reviewing
medical records which is the responsibility of the Health Information Management (HIM) department.
B. Decline to participate in the educational call since there are no fees or penalties associated with the audit.
C. Recommend that an order form be jointly developed between Pharmacy and the Oncology Physicians to ensure that all required information including previous history, indication for the drug, risk of fracture or bone metastases, and bone density scan results are provided when the drug is ordered through a paper order sheet or electronic order entry.
D. Suggest that you will only stock Xgeva in the future since it appears that only the Prolia product
is subject to the TP&E audit.
Please note that this information may become obsolete with revised regulations Page | 66
ANSWER 25.
Targeted Probe and Educate
Best Answer: C
Recommend that an order form be jointly developed between Pharmacy and the Oncology
Physicians to ensure that all required information including previous history, indication for the drug,
risk of fracture or bone metastases, and bone density scan results are provided when the drug is
ordered through a paper order sheet or electronic order entry.
EXPLANATION 25. Targeted Probe and Educate
Pharmacy should assist in obtaining complete documentation from the physician when drugs are
ordered to ensure that they are used appropriately and that all payer documentation requirements
are met.
Other answers:
A. Although TP&E audits are based upon a review of the medical record, all disciplines with
input into the appropriate care of the patient should participate in the TP&E process since
non-compliance in future Rounds can result in further actions by CMS including pre-
payment reviews, extrapolation for additional refunds, referral to Recovery Audit
Contractor (RAC) or other actions.
B. The TP&E educational call is provided to educate providers on where care or documentation
is insufficient. Pharmacies can assist with ensuring that the drugs are appropriately ordered
and administered and that the medical record supports what was billed on the claim (i.e.
physician order and complete documentation of administration)
D. Although the “Prolia” product is named in the Novitas checklist, CMS pulls records based
upon the HCPCS code on the claim. Since both Prolia and Xgeva are billed with the same
HCPCS code (J0897), both drugs are subject to the TP&E audit.
CMS Website: Targeted Probe and Educate:
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-
Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html
Consider adding the link to the Novitas TPE on denosumab:https://www.novitas-
solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00184116&_afrLoop=8667406
34047517#!%40%40%3F_afrLoop%3D866740634047517%26centerWidth%3D100%2525%26conte
ntId%3D00184116%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse
%26showHeader%3Dfalse%26_adf.ctrl-state%3Dbpiq5iugx_33
POINTS: $400
Page | 67 Please note that this information may become obsolete with revised regulations
QUESTION 26.
MUE
Background
Medicare OP claim was rejected for a published MUE (Medically Unlikely Edit)
Rejected HCPCS code is J1650- Injection, enoxaparin sodium, 10 mg
MUE limit for J1650 is “30” as a Date of Service Edit and the rationale is Clinical: Data
FDA labelling for enoxaparin dosing is: In outpatient treatment, patients with acute deep vein thrombosis without pulmonary embolism who can be treated at home, the recommended dose of Enoxaparin Sodium Injection is 1 mg/kg every 12 hours administered SC.
The patient weighs 275 lbs (124.738 kg)
Case
A review of the medical record documentation shows the following administrations for enoxaparin
documented by barcode medication administration (BCMA) for the date of service in question.
Dose ordered: 1 mg/kg every 12 hours
Administered at: 0939
Dose: 120 mg using one 120 mg/ml 0.8 ml syringe sc
Record filed at: 0944
NDC captured in record: 0703861021
Administered at: 0943
Dose: 124.738 mg using two 100 mg/ml 1 ml syringes sc
Record filed at: 0944
NDC captured in record: 0703858021
(both doses administered by the same nurse)
The patient was discharged to home before the evening dose was due.
The claim shows that 32 units were billed but rejected by Medicare due to the MUE.
What is the best solution to process the claim?
A. Lower the billed units to 30 to match the published MUE without a medical record review
B. Lower the billed units to 12 and remove 20 units
C. Call the nurse on duty to ask what she administered
D. Prepare a paper claim with 32 billed units and request an appeal of the MUE due to the patient’s weight
Please note that this information may become obsolete with revised regulations Page | 68
ANSWER 26.
MUE Best Answer: B
Lower the billed units to 12 and remove 20 units
EXPLANATION 26. MUE
It is most likely based upon the physician order and the sequencing of the documentation that the
nurse only administered the 1 x 120 mg dose since both records were filed at the exact same time.
It appears that the clinical system calculated based upon the patient’s weight, but the caregiver
rounded the dose down from 124.738 to 120 mg and administered only 1x120 mg dose.
Other explanations:
A. It would never be appropriate to just match the published MUE without a medical record
review.
C. MUE are only active in the Outpatient Code Editor (OCE). Since the after discharge there are
usually 3-4 days of claims corrections and late charges, the claim would not be sent to the OCE
grouper until at least 4 days. The same nurse would not be on duty and even if you were able
to reach her, she may not remember exactly what occurred after a span of days or weeks as the
claim is being processed.
D. For a patient weighing 124 kg and with a physician order of 1 mg/kg every 12 hours, billed units
of 32 equal a dose of 320 mg which would be unlikely for a morning dose. The patient was
discharged before an evening dose was due, so only one dose should appear on the claim.
Resources:
1. CMS Published MUEs (updated quarterly): General Information:
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html
2. CMS Published MUEs (Current and Previous Quarter):
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes.html
POINTS: $400
Page | 69 Please note that this information may become obsolete with revised regulations
QUESTION 27.
MUE/Appeal In March 2018, the FDA approved a new 4 week dosing regimen for nivolumab (Opdivo). This 480 mg dosing regimen has been proven just as efficacious as the previous 2 week at 240 mg, and now offers patients the convenience and flexibility to meet their needs. Your physicians jumped on board and switched 83% of their patients to the new dosing regimen. 3 months later your denial team approached you and stated the Opdivo is denied and is not being reimbursed by Medicare. You notice the MUE has been exceeded, what is your next step to recoup your loss? HCPCS: J9299, nivolumab 1 mg MUE: 440 MAI: 3 ASP + 6%: $27.15
A. Talk to your physicians and state they must convert the dose back to 240 mg to stay under
the MUE limit
B. Instruct the billing staff they should only bill up to the MUE limit as required by Medicare
C. Bill for the full 480 billing units and work with your denial management team to write a letter to Medicare and appeal the denial
D. Instruct patients to find an alternative facility to receive their nivolumab infusion
Please note that this information may become obsolete with revised regulations Page | 70
ANSWER 27.
MUE/Appeal Best Answer: C
Bill for the full 480 billing units and work with your denial management team to write a letter to
Medicare and appeal the denial
EXPLANATION 27. MUE/Appeal
An MAI indicator of 3 means, Medicare has set the MUE based upon clinical benchmarks. This means
when a claim is denied it may be appealed with appropriate documentation to support the excess
billed services.
Answer A is not the best answer in this case. Converting back to the original dosing will stay under
the MUE limit and allow the claim to process without denial. However, this regimen may not be the
preference of the patient or provider when there is another clinically appropriate option available.
Writing the appeal will provide feedback back to Medicare and in turn provide more support for
changing the MUE value.
Answer B is incorrect as it will generate a loss of 40 mg or $1,086 each time a dose is given at 480
mg.
Resource:
CMS MLN Matters: MM8853
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/downloads/MM8853.pdf
POINTS: $300
Page | 71 Please note that this information may become obsolete with revised regulations
Please note that this information may become obsolete with revised regulations Page | 72
SECTION VII: TEXAS TRIVIA
Page | 73 Please note that this information may become obsolete with revised regulations
Trivia Questions & Answers
1. Which major Gas Station Company was created/founded in Dallas?
A. Twice Daily
B. 711 C. Shell
D. Mobil
E. Speedway
2. Which professional sports team is NOT currently located in Texas?
A. Cowboys
B. Mavericks
C. Stars
D. Thunder E. Astros
F. Comets
G. Rockets
H. Spurs
I. Rangers
3. Dallas is the ___ largest city by population in the United States (2014).
A. 12th
B. 9th
C. 3rd
D. 5th E. 7th
4. What time zone is Dallas located in?
A. AT
B. CT C. MT
D. ET
5. How many golf courses does Dallas have?
A. 0-99
B. 100-199
C. 200-299 D. 300+
6. How big is Dallas’s Fort Worth international airport?
A. 13 square miles
B. 19 square miles
C. 27 square miles D. 31 square miles
Please note that this information may become obsolete with revised regulations Page | 74
7. What percentage of America’s paper bills are printed in Dallas?
A. 25%
B. 35%
C. 48%
D. 60%
8. Sam Houston, arguably the most famous Texan, was born in which state?
A. South Carolina
B. Virginia C. Tennessee
D. Texas
E. Missouri
9. How tall is the Big Tex statue?
A. 59 feet
B. 68 feet
C. 43 feet
D. 52 feet
10. Texas is the only state to have the flags of six different nations fly over it. Which nation is
NOT one of these six?
A. Spain
B. France
C. Mexico
D. Republic of Texas
E. Confederate States
F. England G. All answers are correct
11. Texas is popularly known as the __________ State?
A. Show Me
B. Lone Star
C. Natural
D. Golden
E. First
12. Which City in Texas is the Alamo located?
A. Dallas
B. Houston
C. Austin
D. Fort Worth
E. San Antonio
POINTS: $100
Page | 75 Please note that this information may become obsolete with revised regulations
Please note that this information may become obsolete with revised regulations Page | 76
SECTION VIII: ADDENDUM
Page | 77 Please note that this information may become obsolete with revised regulations
Definitions
Advance Beneficiary Notice (ABN)
Notice of non-coverage, issued by all health care providers when Medicare payment is expected
to be denied
Hospital Outpatient Prospective Payment System (HOPPS or OPPS)
Created by CMS, sets the standards for billing, payment rates and other relevant regulations for
Part B services, and some inpatient services billed as Part B, for Medicare beneficiaries
Inpatient Prospective Payment System (IPPS)
System of payments for acute care hospital inpatient services under Medicare Part A based on
prospectively set rates
Local or National Coverage Determinations (LCD/NCD)
Decision by the Fiscal Intermediary to cover a particular item or service as a reasonable and
necessary
Status Indicator (SI)
A letter code that is assigned by CMS that signifies how an individual HCPCS/CPT will be
reimbursed and helps determine if policy rules and discounting apply
SI = G Pass-Through Drugs and Biologicals: paid under the OPPS and receive separate APC
payment
SI = K Non-Pass Through Drugs and Biologicals: paid under the OPPS and receive a separate APC
payment
SI = N Packaged Item or Services: paid under the OPPS, payment is packaged into payment for
other items or services
SI = M Items or Services not billable to the Fiscal Intermediary: not paid under the OPPS
Medically Unlikely Edit (MUE)
Assigned for most HCPCS/CPT codes, represents the maximum units of service that a provider
would report in most circumstances
New Technology Add-On Payment
Under the IPPS, CMS established a process for identifying and ensuring adequate payment for
new medical services and technologies that are inadequately paid under the DRG.
Target Probe and Educate (TPE):
Service provided by the Medicare Administrative Coordinators (MAC) designed to help improve
billing practices in areas that have a high national or specific providers/suppliers who have high
claim error rates
Please note that this information may become obsolete with revised regulations Page | 78
Additional Resources
Acute Inpatient Prospective Payment System (IPPS):
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/AcuteInpatientPPS/index.html
CMS Addendums & Crosswalks
o A and B: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html
o D1: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalOutpatientPPS/downloads/CMS1506FC_Addendum_D1.pdf
o ASP Drug Pricing Files: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-
B-Drugs/McrPartBDrugAvgSalesPrice/2018ASPFiles.html
Federal Register, Physician Fee Schedule, Proposed Rule CY 2019:
https://www.federalregister.gov/documents/2018/07/27/2018-14985/medicare-program-
revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions
Federal Register, Hospital Outpatient Prospective Payment System, Proposed Rule CY
2019
https://www.federalregister.gov/documents/2018/07/31/2018-15958/medicare-program-
proposed-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical
Federal Register, Hospital Inpatient Prospective Payment Systems, Final Rule CY 2019
https://www.federalregister.gov/documents/2018/08/17/2018-16766/medicare-program-
hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the
Hospital Outpatient Prospective Payment System (last updated December 2017)
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/downloads/HospitalOutpaysysfctsht.pdf
Medically Unlikely Edits (last updated August 2018)
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html
Medicare Advance Written Notices of Noncoverage (last updated September 2017)
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf
Page | 79 Please note that this information may become obsolete with revised regulations
Questions & Answers Key
Question 1. Answer: A
Question 2. Answer: A
Question 3. Answer: C
Question 4. Answer: D
Question 5. Answer: A
Question 6. Answer: D
Question 7. Answer: D
Question 8. Answer: D
Question 9. Answer: A
Question 10. Answer: B
Question 11. Answer: B
Question 12. Answer: B
Question 13. Answer: D
Question 14. Answer: B
Question 15. Answer: C
Question 16. Answer: B
Question 17. Answer: B
Question 18. Answer: D
Question 19. Answer: B
Question 20. Answer: D
Question 21. Answer: B
Question 22. Answer: B
Question 23. Answer: D
Question 24. Answer: C
Question 25. Answer: C
Question 26. Answer: B
Question 27. Answer: C
Please note that this information may become obsolete with revised regulations Page | 80
Disclaimer
Please note that this information may become obsolete with revised regulations
Please review your current transmittals, program manuals, bulletins, banner pages or other
regulatory publications for updates
Please contact your payer should you have any questions regarding their interpretation and
retain the documentation for your records
Page | 81 Please note that this information may become obsolete with revised regulations