Reimbursement FAQs

Some patients claim that they are being billed for their subcutaneous immune globulin (SCIG) for a date of service (DOS) other than the date their medication was filled, shipped or received. Is that an accepted practice?

SCIG is reimbursed under Medicare using the durable medical equipment, prosthetic, orthotics and supplies (DMEPOS) benefit. The DOS should be the date the prescription was filled. If the prescription was not filled via mail order, the DOS should be the day the medication was received by the beneficiary. Additionally, because Medicare may be a primary or secondary payer, providers servicing private pay patients are expected to follow Medicare standards when billing for SCIG.

Medicare claims review and adjudication procedures, section 4105.3, specifically states:

“Generally, for DMEPOS that is not mail order, the supplier’s date of service (DOS) is the date of delivery to a beneficiary’s home.… Generally, for mail order DMEPOS, the DOS on the claim is the shipping date. However, for mail order DMEPOS provided immediately subsequent to a hospital inpatient stay and/or DME immediately following a nursing home stay, the DOS is the later of the shipping date or the date of discharge.”¹

I have patients who have been using Gamunex subcutaneously off label for several years. Now that Gamunex-C has been FDA-approved for subcutaneous administration in primary immunodeficient patients, are there new codes to use for reimbursement?

Yes, there are new codes for GamunexC. Specifically, using Gamunex-C for subcutaneous administration requires the use of a HCPCS code modifier to distinguish the route of administration. Using the modifier code is especially important when billing Medicare.

The HCPCS code that is to be used for intravenous administration of Gamunex-C remains J1561. Billing for the subcutaneous route of administration of Gamunex-C requires the use of an additional modifier code. That HCPCS code is J1561-JB.

Keep in mind that if the patient has a preauthorization specifically for Gamunex, you may need to seek a new authorization request before you can bill using the new codes. Failure to do so could result in a denial of claim.

NDC numbers also are different for Gamunex-C:

For a comprehensive list of all codes needed to bill for Gamunex-C, go to www.gamunex-c.com/media/Gamunex-C_Coding_Guide_GX172-1110.pdf.

Is it true that Medicare will start denying claims for subcutaneous immune globulin (SCIG) as medically unnecessary if the provider bills for a pump that is not the least costly alternative (LCA)?

In June 2007, the Centers for Medicare and Medicaid Services (CMS) issued a statement that said the Freedom 60 infusion pump is the only allowable pump for the administration of SCIG therapy. Providers that choose to upgrade the pump to a more expensive option can do so and still attain partial payment that is no greater than the allowable amount for the Freedom 60 pump.

Then, on Dec. 16, 2010, CMS instructed CMS Durable Medical Equipment Medicare Administrative Contractors (DMEMAC) to no longer make partial payments for such claims as of Feb. 4, 2011, unless the item submitted for reimbursement is the LCA. Furthermore, if a provider bills for an item other than the LCA, the entire claim (including the drug) will be denied as medically unnecessary. This change will apply to all claims in which the DOS for the initial rental month is on or after Feb. 4, 2011. Subsequent claims with a determination LCA prior to that date will continue to be adjudicated using the LCA determination of that rental period.²

Are there other products with new reimbursement codes from CMS for 2011?

Yes, there are many new codes that were effective Jan.1,2011. Some of these include:

• J0597: Injection, c-1 esterase inhibitor (human), berinert, 10 units, manufactured by CSL Behring.
• J1559: Injection, immune globulin (Hizentra), 100 mg otherwise specified, 500 mg, subcutaneous immune globulin product manufactured by CSL Behring.
• J1599: Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified, 500 mg. To be used for Gammaplex, manufactured by Bio Products Laboratory.
• J7184: Injection, von Willebrand factor complex (human), wilate, per 100 IU VWF:RCo, manufactured by Octapharma.

Flu vaccine in multi-dose vials that previously were payable for Medicare with CPT code 90658 are now billed with Q codes:

• Q2035: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria), manufactured by Merck.
• Q2036: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval), manufactured by GlaxoSmithKline.
• Q2037: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin), manufactured by Novartis Vaccines.
• Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone), manufactured by Sanofi Pasteur.
• Q2039: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified).

For a complete list of changes in HCPCS codes, go to www.cms.gov/ HCPCSReleaseCodeSets/ANHCPCS/list.asp.

What has changed regarding certification of homebound patients?

As of Jan. 1, 2011, the Centers for Medicare and Medicaid Services (CMS) mandated that as a condition of payment, a physician or non-physician practitioner (NPP) must have a face-to-face encounter with the patient. Documentation of that encounter must be presented on the certification of eligibility for patients with a start of care on or after Jan. 1, 2011. For more details about the new requirements, go to www.cms.gov/center/hha.asp.

Editor’s Note: The content of this article isintended to provide a general guide to the subject matter. Specialist advice should be sought about yourspecific circumstances.