Stay Current with April 2008 Medicare Physician Fee Schedule Updates

by Jean Acevedo, LHRM, CPC, CHC

Just when you thought you’d understood and implemented the Medicare Physician Fee Schedule (MPFS) and HCPCS Level II updates from late last year, they’ve changed again.

These updates occur each year as the Centers for Medicare and Medicaid Services (CMS) issues technical directives to its contractors to ensure contractors implement the appropriate logic for the current year’s changes, as it clarifies the payment rules and creates new HCPCS Level II codes. These “technical directives” usually publish in the first half of the year. The April change request updates some payment files and includes new and revised codes for the Physician Quality Reporting Initiative (PQRI). While the change request is published in April, the effective date for some of the changes is retroactive to Jan. 1 according to CMS Manual System, Pub. 100-04 Medicare Claims Processing, Transmittal 1482.

Administration of Part D-Covered Drugs/Vaccines

Since Medicare Part D (the prescription drug program) pays for certain vaccines, CMS created a HCPCS Level II code (G0377) for physicians to bill Part B for vaccine administration covered under Part D. The ability to bill Part B for a Part D covered drug no longer exists, so CMS deleted G0377 from the database effective Dec. 31. In the Tax Relief and Health Care Act of 2006, Congress modified the definition of a Part D “drug” to include its administration. CMS interpreted the act to mean the negotiated price for a Part D covered drug included the cost of administering the drug. CMS believes both the drug and its administration should be billed on one claim as a way to prevent fraudulent claims of drug administration that was never given.

The May 14, 2007, CMS Memorandum from the Medicare Drug Benefit Group states “…if a vaccine is administered out-of-network in a physician’s office, the physician would provide the vaccine and its administration and then bill the beneficiary for the entire charge, including all components. The beneficiary would, in turn, submit a paper claim to the Part D sponsor for reimbursement for both the vaccine ingredient cost and administration fee.” If a patient comes to the doctor’s office for Zostavax (a shingles vaccine), it’s expected the patient will pay out-of-pocket for both the vaccine and its administration. The practice should provide the Medicare beneficiary with a 1500 form showing charges for both the Zostavax (CPT® 90736 Zoster (shingles) vaccine, live, for subcutaneous injection) and its administration (CPT® 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)) for submission to the beneficiary’s Part D drug plan. There will be instances where the physician does not stock the vaccine and the patient picks the drug up from a pharmacy, or the pharmacy delivers the vaccine, for administration in the doctor’s office. Again, the patient is financially responsible for the physician’s vaccine administration and a 1500 form should be submitted to his or her Part D plan for reimbursement.

PQRI and Other Changes

Almost 30 new performance measurement codes are included, and some existing PQRI code descriptions were revised. The added measures expand the practitioner’s program participation, potentially earning a 1.5 percent bonus based on the practitioner’s total Medicare allowed payments during the reporting

period by including measures for back pain, mammography, and others. A number of other CPT® and HCPCS Level II codes were modified to reflect revised bilateral indicators, relative value unit (RVU) revisions, or procedure status changes retroactive to Jan. 1. A number of J Codes (J7611–J7614) were reinstated and the reinstated codes were effective for dates of service on or after April 1.

April HCPCS Level II Code Update

CMS has also published an update to the 2008 HCPCS Level II codes, MLN Matters number: MM5981. CMS updates the HCPCS Level II codes on a quarterly basis. The April update is particularly important if your practice or organization provides inhalation therapy with Albuterol or IVIG administration.

Effective for claims with dates of service on or after April 1the following HCPCS Level II codes will no longer be payable for Medicare: J7602 Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per 1 mg (Albuterol) or per 0.5 mg (Levalbuterol) and J7603 Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, per 1 mg (Albuterol) or per 0.5 mg (Levalbuterol), J1751 Injection, iron dextran 165, 50 mg and J1752 Injection, iron dextran 267, 50 mg.

In their places are the following HCPCS Level II codes:

  • J7611 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg
  • J7612 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 0.5 mg
  • J7613 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg
  • J7614 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg
  • Q4098 Injection, iron dextran, 50 mg

IVIG Administration

Along with a new HCPCS Level II code for intravenous immunoglobulin IVIG (Q4097 Injection IVIG Privigen, 500 mg), the April update includes revised billing instructions drawn from Change Request (CR) 5981 to ensure payment for G0332 Services for intravenous infusion of immunoglobulin prior to administration (this service is to be billed in conjunction with administration of immunoglobulin) to pay for additional pre-administration-related services where there may be potential market issues when using Q4097.

Effective April 1, the following codes are affected:

  • J1561 Injection, immune globulin, (Gamunex), intravenous, non-lyophilized (e.g. liquid), 500 mg
  • J1566 Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg
  • J1568 Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg
  • J1569 Injection, immune globulin, (Gammagard liquid), intravenous, non-lyophilized, (e.g. liquid), 500 mg
  • J1572 Injection, immune globulin, (Flebogamma), intravenous, non-lyophilized (e.g. liquid), 500 mg

Medicare contractors will only pay a claim for pre-administration-related services (G0332) associated with IVIG administration if G0332, the drug (IVIG, HCPCS codes: J1561, J1566, J1568, J1569, J1572 and/or Q4097), and the drug administration service are all billed on the same claim for the same date of service;

Returned institutional claims for G0332 to the provider if: J1561, J1566, J1568, J1569, J1572 and/or Q4097 and a drug administration service are not also billed for the same date of service on the same claim

Rejected professional claims as unprocessable for G0332 if: J1561, J1566, J1568, J1569, J1572 and/or Q4097 and a drug administration service are not billed for the same date of service on the same claim

If you don’t follow these billing rules the claim is denied with a message such as M67 “Missing other procedure codes” or 16 “Claim/service lacks information.” The reason explanation of benefits codes often merely state something for claims adjudication was missing but don’t tell you what. In the case of IVIG billing, you should check to see if guidelines noted were followed. If not, then the specific information prompting either of these reason codes will be apparent.

For more changes, check out  Change Request (CR) 5980, issued to your carrier, FI, and A/B MAC which may be viewed at www.cms.hhs.gov/Transmittals/downloads/R1482CP.pdf on the CMS website. And, the April HCPCS update is found at www.cms.hhs.gov/transmittals/downloads/R1492CP.pdf.

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