School Is Out for the Holidays—But Cancer Programs Still Have Coding Homework

Posted in ACCC News, Cancer Care, In and Around Washington, DC by ACCCBuzz on December 20, 2013

by Bonnie Kirschenbaum, MS, FASHP, FCSHP

checklistThis year, due to the federal government shutdown, the final Outpatient Prospective Payment System (OPPS) rule was released at the end of November—so cancer programs have less time than usual to prepare for changes that will go into effect on Jan. 1, 2014. Last week, ACCC held a conference call for members with analysis of the final 2014 OPPS and Physician Fee Schedule (PFS) rules. And it’s clear from the call that cancer programs have plenty of homework to do.

Here are 5 things to do for 2014, organized by OPPS payment category.

1. New drugs not yet assigned unique Healthcare Common Procedure Coding System (HCPCS) codes. When an injectable drug first comes to market and has pass-through status, it may not yet have a HCPCS code assigned to it. Instead, it will be paid for at 95% of average wholesale price (AWP) using code C9399, unclassified drugs or biologics, along with the National Drug Code (NDC) number of the drug.  Homework: This coding procedure and payment rate remains for 2014, but you must report the NDC to identify the drug.

2. New pass-through drugs with HCPCS codes. If a new drug is assigned a HCPCS code at or after FDA approval, it must be used. No payment will be made if the miscellaneous unclassified code persists in your system. Homework: Scour your files to remove and replace miscellaneous codes.

3. Specified covered outpatient drugs (SCODs) costing more than $90 per day. This reimbursement “basket” is where the majority of drug payment lies and where most drugs land once their pass-through status expires. Accurate billing is critical for these drugs. Homework: Make sure HCPCS codes, billing unit assignments, and conversions from actual dose given to billing units submitted are faultless!

4. Lower-cost packaged products costing less than $90 per day. There is no separate reimbursement for these products; payment for them is included in the bundled payment for the specific procedure or visit for which they were used. However, they must be billed as separate line items to ensure adequate payment for the bundle and, if they were administered as infusions, to ensure payment for drug administration (which is available separately from the bundle). Homework: Keep on documenting and billing for these drugs!

5. Drugs with pass-through status. The usual annual reworking of pass-through drugs resulted in 14 drugs and biologicals losing their pass-through status effective Dec. 31, 2013. Interestingly, only 9 of these products will be separately paid for in 2014, and 5 no longer will be separately reimbursed (see Table 32 in the final OPPS rule). Drugs and biologicals keeping or newly assigned pass-through status (see the list of 26 in Table 33 in the final OPPS rule) will have their pass-through payment rates reviewed on a quarterly basis with payment adjustment as needed. HomeworkSeveral 2014 HCPCS codes have changed, as well as the status indicators which will indicate whether or not there is separate payment in 2014. Ensure that these HCPCS code changes are part of your IT systems.

Of course payments will be reduced by approximately 2% for as long as sequestration remains in effect. Counteract this by ensuring accuracy in the areas discussed above!

ACCC members can access an archived conference call and analysis of the 2014 Medicare rules here. Look for an in-depth discussion of the rules in your January/February Oncology Issues.

Bonnie Kirschenbaum, MS, FASHP, FCSHP, is a healthcare consultant and columnist, and serves on the editorial board for ACCC’s Oncology Drug Reference Guide.

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