Dietary Supplements: Billing Pitfalls to Avoid
Pharmacy Revenue Cycle Podcast
Release Date: 12/06/2021
The Heavy Hitters for July Quarterly Updates
Pharmacy Revenue Cycle Podcast
July 2023 is here and time to validate another round of quarterly updates from CMS. The JZ modifier, in addition to the JW modifier, is now required to effectively bill for drug waste (JW) and to attest when no drug was discarded (JZ) for all separately payable that are single-dose or single-use containers. Additionally, we have updated the Visante Quarterly Update Tool and the C9399 Tool to help organizations validate that their system is up to date with the recent changes.
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Beat Inflation with a Part B Rebate
Pharmacy Revenue Cycle Podcast
As a part of the Inflation Reduction Act of 2022, CMS is requiring manufacture rebates for certain Medicare Part B drugs in which the cost has exceeded inflation. Beneficiaries out of pocket costs will be reduced to 20% of the inflation-adjusted payment described in the Act.
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Don’t be “SAD”... An Alternative Way to Handle Self-Administered Drugs
Pharmacy Revenue Cycle Podcast
Self-administered drugs (SAD) have been a long-standing controversy when administered in a hospital outpatient setting from the perspectives of a patient, frontline healthcare workers, and billing. “Why does my Tylenol cost $10 per tablet, but the 1,000-count bottle I have at home was purchased for $3?” This question is often difficult to answer and may lead to unintended operational consequences.
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Botulinum toxin PA – Are you exempt?
Pharmacy Revenue Cycle Podcast
The new year brings a new focus on resolutions including prior authorization processes. In July 2020, Medicare implemented a prior authorization process for select services including botulinum toxin. Its time to revisit workflow processes and, if not exempt, confirm with respective teams that a prior authorization is obtained prior to providing the service.
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Designer HCPCS Codes are in the Mainstream Spotlight
Pharmacy Revenue Cycle Podcast
The Pharmacy Revenue Cycle is starting out with a new fashion design for 2023 as there are 36 new brand-specific HCPCS codes. CMS has been reviewing its approach for assigning for drugs that have been approved under the Food, Drug and Cosmetic Act 505(b)(2) New Drug Application (NDA) or the Biologics License Application (BLA) after October 2003. These drugs are not rated therapeutically equivalent to the reference drug listed in the FDA’s Orange Book and therefore are considered single-source products according to section 1847A(c)(6) of the Social Security Act. Each single source product...
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Hospital Outpatient Prospective Payment System (OPPS) Final Rule- CY2023
Pharmacy Revenue Cycle Podcast
The Centers for Medicare & Medicaid Services (CMS) provided the OPPS Final Rule for CY2023 in the Federal Register on Provisions in this rule will be effective for dates of service on or after January 1, 2023. Significant changes for drug reimbursement and coding occur in three areas: 340B-acquired drugs, non-opioid pain management reimbursement in Ambulatory Surgery Centers (ASC) and Hospital Outpatient Departments (HOPD), and new requirements for reporting waste in HOPD. 340B-acquired Drugs In light of the Supreme Court decision in American Hospital Association v. Becerra, 142 S. Ct....
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Drug Waste is Packed with a Punch and a Refund
Pharmacy Revenue Cycle Podcast
Dive into the CY23 CMS Physician Fee Schedule rule as it relates to the new requirements for discarded drugs or drug waste. A JW and JZ modifier are required for all Part B separately payable single-dose or single-use packages. Additionally, manufacturers are required to pay a refund for discarded drugs that exceed 10% of the total charges.
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Payment Increases for Biosimilars
Pharmacy Revenue Cycle Podcast
Payment Increases for Biosimilars On April 16th, 2022, the Inflation Reduction Act of 2022 was signed into law. Section 11403 requires a temporary increase in add-on payment for qualifying biosimilars from 6% to 8% for 5 years. This change was implemented on October 1, 2022, and CMS uploaded pricing files that already include the temporary price increase. Applicable 5-year period This increase began on October 1, 2022, for products for which payment was made by September 30, 2022. For other biosimilar products in which payment was made between October 1, 2022 - December 31, 2027, the 5-year...
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Car T-cell Therapy: Coverage and Billing-Outpatient (Updated – October 1, 2022)
Pharmacy Revenue Cycle Podcast
Chimeric Antigen Receptor (CAR) T-cell therapy is an example of a rapidly emerging immunotherapy approach called adoptive cell transfer (ACT) where patients’ own immune cells are collected and used to treat their cancer. This newsletter details coverage and billing instructions when the products are used on an outpatient basis and has been updated to reflect HCPCS codes current as of October 1, 2022. The Center for Biologics Evaluation and Research (CBER) of the Food and Drug Administration (FDA) regulates cellular therapy products, human gene therapy products, and certain devices related to...
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Vacating the 340B Payment Reduction Policy
Pharmacy Revenue Cycle Podcast
On September 28, 2022, the US District Court issued a that states the Department of Health and Human Services (HHS) is required to vacate the prospective portion of the 340B reimbursement rate outlined in the 2022 Outpatient Prospective Payment System (OPPS) Rule. In other words, payment rates must revert to the default of ASP + 6% rather than the reduced rate for select drugs of ASP - 22.5%. The decision was determined to not cause substantial disruption; thereby, requiring HHS to begin immediately. This was in response to American Hospital Association v. Becerra, 142 S. Ct. 1896 (2022), in...
info_outlineHospital pharmacies often carry and dispense dietary supplements and herbal products in order to maintain a patient on their home regimens.
Pharmacies may determine which dietary supplements and herbal products they carry based upon patient needs and internal policies, but they can’t be billed as a drug. What does that mean?
Just like medical devices, dietary supplements and herbal products may be supplied by the pharmacy, but it is important that they NOT be billed as a drug as only drugs and biologicals are billed with revenue codes 25x (250-259) and 63x (631-637).
It is important that these products NOT be set up in chargemasters under a 259 or 637 revenue code as these revenue codes are reserved for “self-administered drugs”. Since dietary supplements are not drugs, they can’t be billed as a self-administered drug and billed to a Medicare outpatient.
Typically, facilities choose one of two options for billing and coding of dietary supplements and herbal products:
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Consider them as “supplies” and bill them with revenue code 27x, or
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Consider them as “nutritional supplements” including the cost in other services such as room and board on inpatients or within procedure charges for outpatients. A separate charge is not generated for this option.
As we mentioned in our previous newsletter on medical devices, revenue codes are established by the National Uniform Billing Committee (NUBC) and they provide instructions on how they are to be used. All providers must follow the applicable rules from NUBC in billing for healthcare services.
How can I tell if a product is a dietary supplement?
There isn’t a comprehensive database like there is with drugs and the FDA NDC Directory. The easiest way is to look at the package (or Google an image) as these products must be clearly labelled as “dietary supplements”. Dietary supplements are prohibited from having an NDC number, so any 10- or 11-digit number on the package is for tracking only, and is not an NDC number.
SHOUT-OUTS!
1. Pharmacy and Chargemaster Managers should review chargemaster entries to ensure that dietary supplements and herbal products are not billed with “pharmacy” revenue codes (i.e. 259 or 637)
2. Pharmacy should confirm that the set-up process for a new product includes checking to see if the product is a prescription or O-T-C drug, a medical device, a dietary supplement, or an herbal product. Only drugs and biologicals can be billed with pharmacy revenue codes such as 25x and 63x.
3. Pharmacy and Finance should determine if the facility will bill separately for non-drug products under a supply revenue code, 27x, or if they will not be billed separately and the cost will be included in charges for room and board or other procedures. Dietary supplements and herbal products are not drugs, and therefore cannot be billed to the patient as a self-administered drug with revenue code 259 or 637.
Our goal is simple; we’re taking complex information and making it practical.
Until our next edition, this is Maxie Friemel and Agatha Nolen providing you with tips for increasing your Pharmacy Revenue.