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NEWS & UPDATES
February 1, 2009 - Medical Policy Unit Part A & B Updates
L25820 -
Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
R6 (Effective February 1, 2009): Internal: The following article has been
added: A48420 - Intravenous Iron Sucrose and Iron Dextran. No notice period
required and none given.
Drug Article Corrections
A46089 - Temsirolimus (Torisel ™) – Related to
LCD L25820
Correction (published 01/08/2009): ICD-9-CM code 197.7 has been added to the
ICD-9-CM tables and the description for ICD-9-CM code 197.0 has been
corrected in the "ICD-9-CM codes that are Covered" section of the article.
These were inadvertently missed when the ICD-9-CM codes were added to the
article in October. The year “2009” has been corrected in the first
guideline under the “For claims submitted to the carrier or Part B MAC”
section.
A46095 - Bevacizumab (e.g., Avastin™) - Related
to LCD L25820
Correction (published 01/15/2009): the effective date for ICD-9-CM codes
362.07, 362.16 and 362.83 has been changed to 07/18/2008. The terminology
for ICD-9-CM codes 191.0-191.9 has been corrected.
A46758 - Paclitaxel (e.g., Taxol®/Abraxane ™) -
Related to LCD L25820
Correction (published 01/15/2009): the expanded indication for albumin-bound
paclitaxel has been corrected to include recurrent breast cancer.
A46096 - Zoledronic Acid (e.g., Zometa ®, Reclast®
) – Related to LCD L25820
Correction (published 01/15/2009): ICD-9-CM codes 995.29 and V12.79 have
been removed from the article on the CMS Medicare Coverage Database. These
ICD-9-CM codes should have been removed from the secondary ICD-9 table for
the management of osteoporosis as a consequence of the endocrine (including
aromatase inhibitors) treatment of malignancy with the last revision.
A46754 - Alteplase Recombinant (e.g., Cathflo®
Activase ®) – Related to LCD L25820
Correction (published 01/29/2009): the description for ICD-9-CM code 410.72
has been corrected on the Web site version to match what is listed in the
CMS Medicare Coverage Database.
A47582 - Bortezomib (e.g., Velcade®) – Related to
LCD L25820 - Correction (published 01/29/2009): the description for
ICD-9-CM code 273.3 has been corrected on the Web site version to match what
is listed in the CMS Medicare Coverage Database.
A47586 - Etoposide (Etopophos®, Toposar®, Vepesid®,
VP-16) – Related to LCD L25820 - Correction (published 01/29/2009):
the description for ICD-9-CM codes 183.3 and 183.5 have been corrected on
the Web site version to match what is listed in the CMS Medicare Coverage
Database.
A46103 - Gemcitabine Hydrochloride (e.g., Gemzar®)
– Related to LCD L25820
Correction (published 01/29/2009): the description for ICD-9-CM codes 239.6,
239.8 and 239.9 has been corrected on the Web site version to match what is
listed in the CMS Medicare Coverage Database.
A47579 - Ifosfamide (Ifex) - Related to LCD
L25820 - Correction (published 01/29/2009): the spelling of the
word “brain” has been corrected for ICD-9-CM code 198.3 on the version
published on the Web site.
A47381 - Intravenous Immune Globulin (IVIG) -
Related to LCD L25820
Correction (published 01/29/2009): a duplicate statement in the “ICD-9-CM
Codes that are Covered” section has been removed. The word “Limitations” has
been changed to “Indications” in the following statement: “For ICD-9-CM
codes: 042, 283.0, 283.10, 283.19, 283.9, 287.30, 287.31 and 996.85 please
refer to the “Indications” section for specific age requirements.”
A46105 - for Intravenous Iron Therapy (Sodium
Ferric Gluconate) – Related to LCD L25820 - Correction (published
01/29/2009): HCPCS code J1756 has been removed from the article on the CMS
Medicare Coverage Database. The description for ICD-9-CM codes 280.1 and
V66.2 has been corrected on the Web site version to match what is listed in
the CMS Medicare Coverage Database.
A46104 - Micafungin Sodium (e.g., Mycamine™) –
Related to LCD L25820
Correction (published 01/29/2009): the description for ICD-9-CM code V07.8
has been corrected on the Web site version to match what is listed in the
CMS Medicare Coverage Database.
A46088 - Omalizumab (e.g., Xolair®) – Related to
LCD L25820 - Correction (published 01/29/2009): the description for
ICD-9-CM code 995.3 has been corrected on the Web site version to match what
is listed in the CMS Medicare Coverage Database.
A46756 - Oxaliplatin (e.g., Eloxatin®) - Related
to LCD L25820 - Correction (published 01/29/2009): the description
for ICD-9-CM codes 183.3 and 183.5 have been corrected on the Web site
version to match what is listed in the CMS Medicare Coverage Database.
A46738 - Pamidronate Disodium for Injection
(e.g., Aredia®) - Related to LCD L25820
Correction (published 01/29/2009): the description for ICD-9-CM code V58.69
has been corrected on the Web site version to match what is listed in the
CMS Medicare Coverage Database.
Empire Blue Cross Blue
Shield - Empire News - Winter 2008 News
Injectable drug update
The following policy updates will be effective for all claims
processed on or after March 20, 2009, regardless of the date
of service. In addition to current policy the following updates
and processing changes will be applied.
Palonosetron HCl (J2469) — Claims reporting diagnosis V58.12 will be
reviewed for criteria: Diagnoses 995.2 and V66.2 will be considered not
medically appropriate.
Bortezomib (J9041) — Claims reporting diagnoses 200.20-200.28,
202.80 will be reviewed for criteria.
Pemetrexed Disodium (J9305) — Claims reporting diagnosis 162.0 will be
reviewed for criteria.
Rituximab (J9310) — Claims reporting diagnosis 287.4 will be considered
not medically appropriate: 287.4.
Fulvestrant (J9395) — Claims reporting diagnosis 175.0-175.9 will be
reviewed for criteria: 175.0-175.9.
Zoledronic acid (Zometa) (J3487) — Claims reporting diagnoses 200.00-
202.98, 203.10-203.82, 204.00-208.91 will be reviewed for criteria
Full EBCBS Winter 2008 News Update
IMPORTANT make note of Policy Updates on page 15
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National Government Services Medical Policy Revision for: Drugs and
Biologicals, Coverage of, for Label and Off Label Uses
LCD and Coverage Articles Part A & B Effective January 1, 2009
LCD for Drugs and Biologicals, Coverage of,
for Label and Off-Label Uses (L25820)
R5* (effective 01/01/2009); Internal; the LCD has been revised to include
compendia recognized by CMS based on Change Request 6191 (Compendia as
Authoritative Sources for Use in the Determination of a Medically Accepted
Indication of Drugs and Biologicals Used Off-Label in an Anti-Cancer
Chemotherapeutic Regimen. Added Internet Only Manual (IOM) language to the
“Limitations” section. The following articles have been added: A48208 -
Filgrastim, Pegfilgrastim (e.g., Neupogen®, Neulasta TM), A48339 –
Floxuridine, A48211 - Thyrotropin Alfa (Thyrogen®) and A48213 - Vitamin B-12
Injections. The following article has been retired: A46093 – Rituximab (Rituxan®).
Minor changes were made to reflect current template language. Although
revision R5 is effective 01/01/2009, the addition of the compendia based on
Change Request 6191 is effective 11/25/2008. No notice period required and
none given.
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Clarification of NGS’s policy
for coverage of Anti-Emetics effective January 1, 2009.
The following is an excerpt from NGS policy (see link below for full
policy).
This policy is effective January 1, 2009 but will not be implemented until
March 1, 2009.
…not only does the indication for the use of the drug need to meet medical
necessity requirements, but the route of administration is also subject to
medical necessity criteria. Contractors must continue to apply the policy
that not only the drug is medically reasonable and necessary for any
individual claim, but also that the route of administration is medically
reasonable and necessary. That is, if a drug is available in both oral and
injectable forms, the injectable form of the drug must be medically
reasonable and necessary as compared to using the oral form .(Pub 100-02,
Medicare Benefit Policy Manual, Chapter 15, Section 50.2 - Determining
Self-Administration of Drug or Biological (Rev. 91; Issued: 06-20-08;
Effective/Implementation Date: 07-21-08)). Medication
given by injection (parenterally) is not covered if standard medical
practice indicates that the administration of the medication by mouth
(orally) is effective and is an accepted or preferred method of
administration. (Pub 100-02, Medicare Benefit Policy Manual,
Chapter 15, Section 50.4.3) Specifically, for anti-emetic medication, CMS
states: It is recognized that a limited number of patients will fail on oral
anti-emetic drugs. Intravenous anti-emetics may be covered (subject to the
rules of medical necessity) when furnished to patients who fail on oral
anti-emetic therapy. (Pub 100-02, Medicare Benefit Policy Manual, Chapter
15, Section 50.5.4)
Link to full policy:
http://www.ngsmedicare.com/NGSMedicare/lcd/L25820_active_lcd.htm
NYSSMOH News Update
Re: IV anti-emetics
As of March 1, 2009, CMS will
not cover any IV anti-emetic if an oral formulation of the drug is
available unless there is a medical reason the patient must receive the IV
rather than the oral form. Palonosetron (Aloxi) given IV has been found to
have superior efficacy in several published studies. Although the FDA has
approved oral palonosetron, it is not available and has not even been
manufactured. We have been advised that in the absence of an available
oral form, CMS will cover IV palonosetron.
Please note the use of palonosetron
must be medically necessary and documented in chart notes.
NGS
Drugs and Biologicals, Coverage of, for Label and Off-Label Uses -
Supplemental Instructions Article
Article # A44930
Claims for drug administration services must be submitted on the same claim
as that for the drug.
When the drug is purchased by the beneficiary, or when the drug was supplied
without charge by the manufacturer, it should NOT be billed to Medicare by
the provider, even with a submitted charge of $0.00. However, the name and
dosage of the drug may be listed in the narrative record of the claim, to
avoid requests for additional information on the claim.
When billing for an IV drug which has an available oral form, please also
report one of the following ICD-9 codes (whichever is appropriate).
579.3 OTHER AND UNSPECIFIED POSTSURGICAL NONABSORPTION
579.9 UNSPECIFIED INTESTINAL MALABSORPTION
995.29 UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL
SUBSTANCE
V12.79 PERSONAL HISTORY OF OTHER SPECIFIED DIGESTIVE SYSTEM DISEASES
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J-Codes Assigned
| J-Code |
Drug |
Fee |
|
J9330 |
Torisel (Temsirolimus)
1mg |
$47.91 |
| J9207 |
Ixempra (Ixabepilone) 1mg |
$63.74 |
|
J1453 |
Emend (Fosaprepitant
injection)
1mg |
$1.57 |
| J9181 |
Etoposide 10
mg |
$ .48 |
| |
J9182
Etoposide 100mg DELETED |
|
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Empire Blue Cross Blue Shield
Injectable drug update
The following policy updates will be effective for all claims processed on
or after March 20, 2009, regardless of the date of service. In addition to
current policy the following updates and processing changes will be applied.
Palonosetron HCl (J2469) — Claims reporting diagnosis V58.12 will be
reviewed for criteria: Diagnoses 995.2 and V66.2 will be considered not
medically appropriate.
Bortezomib (J9041) — Claims reporting diagnoses 200.20-200.28, 202.80 will
be reviewed for criteria.
Pemetrexed Disodium (J9305) — Claims reporting diagnosis 162.0 will be
reviewed for criteria.
Rituximab (J9310) — Claims reporting diagnosis 287.4 will be considered not
medically appropriate: 287.4.
Fulvestrant (J9395) — Claims reporting diagnosis 175.0-175.9 will be
reviewed for criteria: 175.0-175.9.
Zoledronic acid (Zometa) (J3487) — Claims reporting diagnoses 200.00-202.98,
203.10-203.82, 204.00-208.91 will be reviewed for criteria.
Fee schedules are available
If you need a copy of your fee schedule, you can fax a request to the
attention of Provider Network Management at 718-312-6240. You can also
obtain fee schedule information on our Physician Online Services at
empireblue.com.
Click on the “Physicians” tab and then register or log in. From your
homepage, select “Searches” then “Fee Schedules.”You can view fees by CPT
code and modifier.
MediBlueSM news
Annual benefits changes for Medicare Advantage plan members will be
effective January 1, 2009. The changes apply to members enrolled in Empire’s
MediBlue HMO, MediBlue PPO and MediBlue Total Solutions plans.
Offices are encouraged to perform insurance verifications on all MediBlue
patients to clarify prescription benefits, coinsurance and out of pocket
changes.
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Coding for Drugs and Biologicals
Information for General Infusion Information, Chemotherapy Infusions and
Unlisted Drug Coding
Sections:
-
General Infusion Information
-
Chemotherapy
Drugs, Monoclonal Antibodies, and Biological Response Modifiers
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Unlisted Drug Code Use
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General Infusion Information
There are CPT codes for several different types of infusions and
injections for drugs and biologicals. These include codes for chemotherapy
infusions and injections, therapeutic, prophylactic and diagnostic
infusions, and injections and hydration.
The CPT Manual published by the American Medical Association
(2008) describes chemotherapy drugs and biologicals infusions and
injections as requiring “physician work and/or clinical staff monitoring
well beyond that of therapeutic drug agents (90760-90779) because the
incidence of severe adverse patient reactions are typically greater.”
(p424) These codes are paid at a higher rate to reflect the greater
physician work and other resources required to safely administer these
substances.
For the therapeutic, prophylactic and diagnostic infusions and injections
codes (90760-90779), the CPT states that: “if performed to facilitate the
infusion or injection, the following services are included and are not
reported separately:
-
use of local anesthesia;
-
IV start;
-
access to indwelling IV, subcutaneous catheter or
port;
-
flush at conclusion of infusion;
-
standard tubing, syringes, and supplies.” (p.383)
The CPT defines hydration as “pre-packaged fluid and electrolytes… not the
infusion of drugs or other substances.” “Typically, such infusions require
little special handling to prepare or dispose of, and staff that
administer these do not typically require advanced practice training.
After initial set up, infusion typically entails little patient risk and
thus little monitoring.” (p.384)
For additional information on these services, and the rules for billing
the initial and subsequent hours, please consult the CPT manual.
Documentation for Infusions
Start and stop times must be evident in the documentation in order to bill
units for hours infused. If no start or stop time or total hours infused
can be determined from the documentation, the best course is to query the
clinician. If, in the circumstance that NO times are evident, an IV push
code may be appropriate for billing since no infusion is supported beyond
15 minutes. Upon medical review, these services may be denied for
insufficient documentation if billed as hours of infusion.
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Chemotherapy
General Information
-
Chemotherapy drugs are defined by the HCPCS Level II
as drugs occurring in the range of J9000 through J9999.
-
Drugs in this range are assumed to require the
complex drug administration services and physician supervision
requirements inherent in CPT codes 96401-96417. The use these codes
depends upon the drug administered, not the patient’s diagnosis, since
many anti-neoplastic medications are used for treatment of illnesses
besides neoplasm.
-
In addition to non-radionuclide anti-neoplastic
drugs, HCPCS Level II codes J9000-J9999 also include biologic response
modifiers (BRMs), monoclonal antibodies (MAs), and hormonal anti-neoplastics
(HANs), the administration of which may be billed with chemotherapy
administration codes.
Biological Response Modifiers
|
J0215 |
Alefacept 0.5 mg |
|
J7516 |
Cyclosporin Parenteral 250 mg |
|
J7525 |
Tacrolimus 5 mg |
|
Q3025 |
Interferon beta 1-a 11 mcg IM |
The anti-anemia or anti-emetic drugs used in cancer care do not warrant
use of the chemotherapy administration and injection codes. Neupogen,
Neulasta, Darbepoetin, Aranesp, Epogen and other similar drugs are not
considered biological response modifiers for the purpose of coding drug
administration and infusions and should be billed with the appropriate
therapeutic injection codes.
Monoclonal Antibodies
-
Monoclonal antibodies are frequently identified with
generic drug names ending in “mab,” such as rituximab (J9310),
trastuzumab (J9355), bevacizumab (J3095), etc. All MAs are appropriate
for use with the chemotherapy administration codes.
Hormonal Anti-Neoplastic Drugs
|
J0128 |
Aberelix 10 mg |
|
J0970 |
Estradiol valerate up to 40 mg |
|
J1000 |
Depo-estradiol cypionate up to 5 mg |
|
J1380 |
Estradiol valerate 10 mg |
|
J1390 |
Estradiol valerate 20 mg |
|
J1410 |
Estrogen conjugate 25 mg |
|
J1435 |
Estrone 1 mg |
|
J3315 |
Triptorelin pamoate 3.75 mg |
Note: the lists of drugs and biologicals in this article
are subject to change as new drugs are reviewed and evaluated.
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Unlisted Codes for Drugs and
Biologicals (J3490, J3590, J9999, and C9399)
Unlisted codes should only be applied when no other code adequately
describes the service.
Unlisted codes are commonly used when the:
-
drug/biological does not have a specific HCPCS code;
-
drug/biological is administered by a route other than
stated in the code;
-
amount of drug or biological is less than the amount,
or of a different concentration, than specified in the HCPCS descriptor.
For example, a 25 mg injection of Demerol is administered from a 25 mg
vial. There is currently no HCPCS code for a 25 mg vial of Demerol. It
would be appropriate to use J3490 in this instance. The only HCPCS code
available for Demerol is J2175; for a 100 mg vial. If a 25mg injection of
Demerol is administered from a 100 mg vial, then J2175 should be used with
waste reported and documented in the medical record.
Unlisted codes J3490, J3590, and J9999 billed to the
Part A fiscal intermediary or MAC under the hospital OPPS are paid at a
lesser rate or are packaged into the payment for other services on the
claim. For non-OPPS facilities such as critical access hospitals (CAHs)
and dialysis facilities, the claim is suspended for these codes and drugs
are priced according to the remarks on the claim.
Facilities under the hospital OPPS may use code C9399, billed as one unit,
when the drug is FDA approved, but does not have an assigned HCPCS or the
assigned HCPCS is not yet effective. Claims with C9399 are suspended and
the drug is manually priced according to the remarks on the claim.
Unlisted codes J3490, J3590, and J9999 billed to the Part B carrier or MAC
are priced manually. For billing these unlisted codes the claim must
include in Item 19 of the CMS-1500 or electronic equivalent:
-
Unit of service (= 1);
-
Name of the drug;
-
Dose administered (mg, cc, etc.);
-
Amount wasted (if any);
-
Route; and
-
NDC number (National Drug Code Number).
Claims billed to the carrier with C9399 will be rejected.
References:
Current Procedural Terminology 2008, American Medical Association
CMS Publication 100-4, Claims Processing Manual, Chapter 12,
Section 30.5
CMS Publication 100-2, Benefit Policy Manual, Chapter 15, Section
50
Posted 12/11/08 on the NGS website
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Transcript Now Available – ICD-10-CM/PCS National Provider Conference Call
for Other Part A and Part B Providers
The transcript of the Centers for Medicare &
Medicaid Services’ ICD-10-CM/PCS National Provider Conference Call for Other
Part A and Part B Providers that was held on November 12, 2008
is now available at
http://www.cms.hhs.gov/ContractorLearningResources/Downloads/November12calltranscript.pdf
Additional information can be found on CMS
web site:
http://www.cms.hhs.gov/ICD10/01_Overview.asp#TopOfPage
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2009 Physicians Fees Schedules
Area 01 Physician Fee Schedule
Area 02 Physician Fee
Schedule
Area 03 Physician Fee
Schedule
Area 04 Physician Fee Schedule
2009 ASP Drug Pricing Files
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Link to CMS e-prescribing incentive program:
http://www.cms.hhs.gov/PQRI/03_EPrescribingIncentiveProgram.asp#TopOfPage
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NGS Medical Policy Info
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