D68.32 Won't Get You Paid for Blood Clotting Factor
Medicare Part A claims that include ICD-10-CM diagnosis code D68.32 Hemorrhagic disorder due to extrinsic circulating anticoagulants will be denied after June 30, 2018, when the code is terminated.
Per the Inpatient Hospital Billing Manual, Chapter 3, Section 20.7.3, Payment for Blood Clotting Factor Administered to Hemophilia Inpatients, effective July 1, 2018, payment may be made for blood clotting factors only if one of the following hemophelia diagnosis codes is reported:
D66 Hereditary factor VIII deficiency
D67 Hereditary factor IX deficiency
D68.1 Hereditary factor XI deficiency
D68.2 Hereditary deficiency of other clotting factors
D68.0 Von Willebrand’s disease
D68.311 Acquired hemophilia
D68.312 Antiphospholipid antibody with hemorrhagic disorder
D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
D68.4 Acquired coagulation factor deficiency
Medicare Part A Payment
Prospective payment system (PPS) hospitals receive an additional payment for the costs of administering blood clotting factor to Medicare hemophiliacs who are hospital inpatients. Payment is based on a predetermined price per unit of clotting factor multiplied by the number of units provided.
Physicians and other qualified healthcare providers should bill using the appropriate HCPCS Level II code (J7178-J7209) and accurately reporting the units of service, not to exceed the maximum number of units per day based on the code descriptor, reporting instructions associated with the code, and other local or national payer policy.
HCPCS Level II Code Drug Dosage
J7189 Factor villa 1 mcg
Actual dosage: 13,365 mcg
Note: The process for dealing with one International Unit (IU) is is the same as the process for dealing with one microgram.
Report J7189 and 13,365 in the units field (13,365 mcg divided by 1 mcg equals 13,365 units).
When the dosage amount is greater than the amount indicated for the code, round up to determine units. When the dosage amount is less than the amount indicated for the code, report 1 unit.
Medicare Part B Payment
Blood clotting factors not paid on a cost or PPS basis are priced as a drug/biological under the Medicare Part B Drug Pricing File using the average sales price plus 6 percent. The 2018 Clotting Factor Furnishing Fee, effective Jan. 1, is $0.215 per unit. When the national payment limit for a clotting factor is not included on the ASP Medicare Part B Drug Pricing File or the Not Otherwise Classified Pricing File, payment is made for the clotting factor and the furnishing fee.
CMS, Transmittal 3990, March 1, 2018
CMS, Blood Clotting Factor Furnishing Fee: www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/ClotFactorFurnishFee.html
CMS, 2018 ASP Drug Pricing Files: www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2018ASPFiles.html