Reimbursement FAQs

Which billing codes would a home infusion provider use to seek reimbursement for Hizentra, including supplies, pump and nursing, for a primary immunodeficiency disease?

The Healthcare Common Procedure Coding System (HCPCS) is the national standard coding that defines and often combines medically necessary items billed by a provider. Coding of the supplies and pump are different for Medicare compared with other commercial insurance carriers. Under Medicare, Hizentra 20% liquid (immune globulin subcutaneous) is covered by the External Infusion Pump LCD (local coverage determination) policy for Part B Medicare patients who have one of the following diagnoses: 279.04 (congenital hypogammaglobulinemia), 279.05 (immune deficiency with increased IgM), 279.06 (common variable immune deficiency), 279.12 (Wiskott-Aldrich syndrome) or 279.2 (combined immunity deficiency). The therapy must be administered with a Freedom 60 Pump (the only pump that Medicare will consider) with an HCPCS code of E0779.

The drug Hizentra is billed with a J1559 (injection, immune globulin [Hizentra] 100 mg) (HCPCS Level II, 2011). To calculate the number of units billed, a provider would convert the number of grams to milligrams (mg) (1 gram=1,000 mg) and then divide by 100. For example, for a patient who infuses 7 grams per week or 28 grams per month, a provider would bill for a total quantity of 280 mg for the month. In addition to the pump and drug, a provider would bill Medicare for supplies dispensed with a kit code (K0552: supplies for external drug infusion pump, syringe type cartridge, sterile, each) and a code for infusion sets and all other supplies (A4221: one per week).

If a patient meets all criteria, Medicare will pay 80 percent of the fee schedule, and the patient or secondary/supplemental insurance will be responsible for the remaining 20 percent. Nursing would be covered only if a patient meets the homebound status. If a patient meets this status, a Medicare Certified Nursing Agency would provide nursing services and bill Medicare Part A, which would cover 100 percent of the cost.

Under commercial insurance carriers, providers have found that each carrier and/or plan may use different criteria when it comes to its medical guidelines for subcutaneous immune globulin (SCIG). Carriers often will publish these guidelines on their websites, making it convenient for providers to obtain this information and compare it with the medical documentation obtained from the referring physician.

When billing commercial insurance carriers, the methodology is slightly different from what it is with Medicare. Most companies recognize the national standard coding and utilize the per-diem codes. For SCIG, the most appropriate per-diem code is S9338. The HCPCS definition of this code is “home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, drugs and nursing visits coded separately, per-diem” (HCPCS Level II, 2011). This per-diem code can be billed for each day a patient infuses unless otherwise noted in a provider’s contract with a payer. The average reimbursement for per diems for SCIG can range from $30 to $75 a day. For instance, if a patient infuses 7 grams of Hizentra per week, the total number of per diems billed within the month would be four.

As described in the per-diem definition, all supplies, pharmacy services, delivery and coordination are included within this code. Nursing should be billed separately. Standard nursing codes for home infusion consist of 99601 (home infusion/specialty drug administration, per visit, up to 2 hours) and 99602 (each additional hour) (Current Procedural Coding Expert, 2011). For example, if a nursing visit is for three hours, a provider would bill for one 99601 code and one 99602 code. Common practice today is for a patient to be taught to infuse on their own within two to three teaching visits by a registered nurse.

For additional help with coding or reimbursement questions, physicians and providers can call the IGIQ Resource Center at (877) 355-IGIQ (4447).

What is the new clotting factor furnishing fee reimbursement rate for 2013?

The Social Security Act, added by the Medicare Modernization Act Section 303(e)(1), required, beginning Jan. 1, 2005, that a clotting factor furnishing fee be paid separately when furnishing clotting factor unless the costs associated with furnishing the clotting factor are paid through another payment system. The Centers for Medicare and Medicaid Services includes the clotting factor furnishing fee in the published national payment limits for clotting factor billing codes. When the national payment limit for a clotting factor is not included on the average sales price (ASP) Medicare Part B drug pricing file or the not otherwise classified (NOC) drug pricing file, the carrier, fiscal intermediary, regional home health intermediary or A/B Medicare administrative contractor must make payment for the clotting factor, as for the furnishing fee.

According to change request 8049, for the calendar year 2013, the clotting factor furnishing fee of $0.188 per unit is included in the published payment limit for clotting factors. For dates of service in 2013, the clotting factor furnishing fee of $0.188 per unit is added to the payment when no payment limit for the clotting factor is included in the ASP or NOC drug pricing files.

The official change request 8049 can be viewed at www.cms.gov/Regulationsand-Guidance/Guidance/Transmittals/Downloads/R2554CP.pdf.

What are the updated payment allowances for seasonal influenza virus vaccines?

The Centers for Medicare and Medicaid Services provides payment allowances for seasonal influenza virus vaccines when payment is based on 95 percent of the average wholesale price (AWP) (except when payment is based on reasonable cost where the vaccine is furnished in a hospital outpatient department, a rural health clinic or a federally qualified health center). According to change order 8047, payment allowances have been updated effective Aug. 1, 2012.

Payment allowances are provided for the following current procedural terminology (CPT) codes: 90654 ($18.981), 90655 ($16.456), 90656 ($12.298), 90657 ($6.023), 90660 ($23.456) and 90662 ($30.923). Payment for CPT codes 90654 (flu vaccine, intradermal, preservative free [Fluzone ID]), 90660 (FluMist, a nasal influenza vaccine) or 90662 (Fluzone High-Dose) may be made only if the local claims processing contractor determines its use is medically reasonable and necessary for the beneficiary.

Payment allowances also are provided for the following Healthcare Common Procedure Coding System (HCPCS) codes: Q2034 (Agriflu), Q2035 (Afluria, $11.543), Q2036 (Flulaval, $9.833), Q2037 (Fluvirin, $14.051), Q2038 (Fluzone, $12.046) and Q2039 (flu vaccine adult, not otherwise classified). The payment allowance for Q2034 and Q2039 will be determined by the local claims processing contractor.

Payment allowances for pneumococcal vaccines are updated on a quarterly basis via the quarterly average sales price drug pricing files.

For all payment allowances, annual Part B deductible and co-insurance amounts do not apply. All physicians, nonphysician practitioners and suppliers who administer the influenza virus vaccines and pneumococcal vaccines must take assignment on the claim for the vaccine. In addition, Medicare contractors will not search their files to either retract payment for claims already paid or to retroactively pay claims. However, contractors will adjust claims brought to their attention.

The official change request 8047 instruction can be viewed at www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2555CP.pdf. 

Editor’s Note: The content of this column is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.