Reimbursement FAQs
Some commonly held misunderstandings about reimbursement are clarified.
- By BSTQ Staff
Recently, the Centers for Medicare and Medicaid Services (CMS) assigned a new ICD-9 code for acquired hemophilia.What is the code, and how is it significant for the healthcare community?
The new International Classifications of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for NovoSeven RT (Coagulation Factor VIIa [Recombinant]) to treat acquired hemophilia is 286.52. This code applies to dates of service on or after October 1, 2011.
According to a statement by Novo Nordisk, NovoSeven RT’s manufacturer, “Previously, disorders involving circulating anticoagulants, including acquired hemophilia, were coded with the broad ICD-9-CM code 286.5 or ‘hemorrhagic disorder due to intrinsic circulating anticoagulants.’ This did not allow for the differentiation of the unique condition of acquired hemophilia from the more common lupus anticoagulant (LAC) and hyperheparinization conditions. In mid-2010, Novo Nordisk submitted a request to the National Center for Health Statistics, a division of the Centers for Disease Control and Prevention, to generate unique codes for these three different conditions to facilitate ongoing quality assurance and postmarketing surveillance activities. The resulting ICD-9-CM update is an important step forward for the hemophilia community and further demonstrates Novo Nordisk’s commitment to bringing attention to this sometimes deadly condition of acquired hemophilia.”
For more information, visit the CMS website at www.cdc.gov/nchs/data/icd9/ICD-9-CMINDEXADDENDAfy12.pdf.
Does Medicare reimburse the cost of nursing services when injectables are administered to a patient in his or her home?
Medicare reimbursement for nursing services is determined by the site of care. If a patient is homebound, and there is a medical reason why he or she is unable to self-administer and/or there is not a caregiver to teach him or her to selfadminister, then Medicare will reimburse for those services provided by a Medicare-certified home health agency. Under these circumstances, there may be no cost to the patient. However, if durable medical equipment (DME) is required, a patient will be responsible for a 20 percent co-pay to cover the cost of the DME.
If a patient is not certified homebound and he or she does not have secondary insurance or a Medicare Advantage plan, then having a nurse administer injectables in the home is not covered. However, a patient who is not homebound can go to his or her doctor’s office to have the injection administered, and the doctor will be reimbursed by Medicare. In this case, the doctor’s office will let the patient know if he or she will be subject to a co-pay.
Per Medicare, homebound means 1) leaving the home isn’t recommended because of the patient’s condition, 2) the patient’s condition keeps him or herfrom leaving home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person), or 3)leaving home takes a considerable and taxing effort.
A person deemed homebound may leave home for medical treatment or short, infrequent absences for nonmedical reasons, such as attending religious services. In addition, a homebound patient can still get home healthcare if he or she attends adult daycare, but that patient would get the homecare services in his or her home.
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.