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Jan. 4, '04
Vol. 2, No. 1
Weekly news and analysis
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| EXEC CORNER |
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Sales price changes
New sales prices may impact provider decisions
First quarter payment rates are different for more than 30 drugs and biologicals. See the full list of changes under the "Drug Payment Reform" section. Pharmaceutical and biotech companies reported new average sales prices for the third quarter of 2004, prompting the new rates. As with all changes, follow Medicare Reform Advisor for updates and how the payment changes affect providers and their treatment decisions. Make sure you renew your subscription to receive this information. See renewal instructions below.
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| HOW TO RENEW YOUR SUBSCRIPTION |
| If you'd like to continue receiving Medicare Reform Advisor in 2005 at the current rate, you have three options for renewing your subscription: call HCPro customer service at 800-650-6787, fax your name and contact information to 800-639-8511, or e-mail ( customerservice@hcpro.com ) our staff.
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| DATEBOOK |
| January 5--The much anticipated drug formulary guidelines that will determine the number of drug classes for 2006 will be discussed at a telebriefing Tuesday, January 5. Medicare Reform Advisor will have indepth coverage in next week's issue.
January 27--The California Healthcare Foundation hosts a two-day conference in Washington, DC on Medicare Modernization in a Polarized Environment. On January 27-28, speakers will address the drug benefit, the Medicare Advantage program, and the impact of health savings accounts. Call 202-452-8097 for details. |
© 2004 HCPro, Inc. |
Medicare releases final drug formulary
The United States Pharmacopeia (USP) released the final Medicare drug formulary guidelines Monday afternoon. They will serve as a tool to help prescription drug plans create their formularies and to give CMS information on the drug types it should look for in a plan's formulary. Drug companies will be looking for avenues to challenge formulary determinations now that plans can limit the number of drugs by class to just two drugs-a reform-law provision that could cripple drug firms. "This is a tremendous sword in the hands of Part D plans," according to William Sarraille, JD, an attorney with Sidney, Austin, Brown & Wood in Washington, DC. He says drug plans in the new Part D that rolls out in 2006 may want to cover no more than two drugs in a therapeutic class to lower their risk-and they have that option, under the law. USP says that CMS can check a plan's formulary for at least one item in each formulary drug type-requesting justification if a formulary excludes any of these items. This will allow CMS to help ensure that a formulary is comprehensive and will not substantially discourage enrollment of eligible beneficiaries. The USP Final Draft Model Guidelines will be available shortly at www.usp.org and contain the following totals: 41 therapeutic categories; 32 with associated drug classes; 9 with no associated drug classes; 137 pharmacologic classes. There are a total of 146 unique therapeutic categories and pharmacologic classes. See this week's "Datebook" for more information.
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- Generic drug sales: Elan Pharmaceutical's Natalizumab, the generic injection to reduce relapsing forms of multiple sclerosis, has its own billing code, according to a CMS announcement Monday. The code is C9126 for Injection, natalizumab per 5 mg. CMS had been paying for the drug under the unclassified drug code C9399, which the reform law mandates as an interim payment code for newly FDA approved drugs. The payment for the MS treatment is currently set at 95% of average wholesale price with a copay of $6.03. The FDA approved the drug in November 2004. For claims submitted prior to implementation of the January 2005 outpatient prospective payment system rates, hospitals may bill for natalizumab injections using HCPCS code C9399, known as the unclassified drug code. For claims submitted on or after implementation of the January 2005 OPPS rule, hospitals should bill for natalizumab injections using the product-specific HCPCS code, C9126.
- Lower sales: Praecis Pharmaceuticals projects lower fourth quarter sales of Plenaxis, its palliative injection drug used to treat prostate cancer, due in large measure to changing Medicare reimbursement. Physicians' concerns over obtaining reimbursement coverage for Plenaxis during the initial launch phase were compounded recently by the uncertainty over the impact of Medicare's reforms, the company said in a statement. Praecis now expects sales to decrease from the third to the fourth quarter of 2004.
- Credit extension: In a move to keep beneficiaries until the big 2006 drug benefit, some pharmaceutical companies told Medicare Reform Advisor that they are offering free or low-cost drugs to people after their discount card credit runs out. The credit was $600 last year and is $600 in 2005, under reform law restrictions.
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Drug sale prices change Medicare allowable rates
The following is a breakdown of the new payment rates for 31 drugs and biologicals for the first three months of 2005, according to changes reported Monday in the average sales price of drugs. We've provided the healthcare common procedural code, then the description, followed by the Medicare allowable payment rate for the first quarter of 2005 (January 1 through March 31), and then the updated copayment for this period. For a comparison to the 2004 fourth quarter rates, click here and also stay tuned to Medicare Reform Advisor this month for interviews with specialists on the impact of the new rates.
C9123, Transcyte, per 247 sq cm, $706.16, $141.23
C9205 9205 Oxaliplatin $82.41 $16.48
C9212 9212 Inj, alefacept, IM $399.75 $79.95
C9218 9218 Injection, azacitidine $4.19 $0.84
C9220 9220 Sodium hyaluronate $215.72 $43.14
J0128 9216 Abarelix injection $68.62 $13.72
J0135 1083 Adalimumab injection $288.78 $57.76
J0180 9208 Agalsidase beta injection $121.12 $24.22
J0256 0901 Alpha 1 proteinase inhibitor $3.28 $0.66
J0595 0703 Butorphanol tartrate 1 mg $4.74 $0.95
J1457 1085 Gallium nitrate injection $1.25 $0.25
J2185 0729 Meropenem $3.40 $0.68
J2280 1046 Inj, moxifloxacin 100 mg $3.77 $0.75
J2357 9300 Omalizumab injection $15.32 $3.06
J2469 9210 Palonosetron HCl $18.22 $3.64
J2783 0738 Rasburicase $107.01 $21.40
J2794 9125 Risperidone, long acting $4.60 $0.92
J3240 9108 Thyrotropin injection $699.60 $139.92
J3411 1049 Thiamine hcl 100 mg $0.58 $0.12
J3415 1050 Pyridoxine hcl 100 mg $2.36 $0.47
J3465 1052 Injection, voriconazole $4.55 $0.91
J3486 9204 Ziprasidone mesylate $18.74 $3.75
J7308 7308 Aminolevulinic acid hcl top $87.65 $17.53
J7518 9219 Mycophenolic acid $2.42 $0.48
J7674 0867 Methacholine chloride, neb $0.41 $0.08
J9035 9214 Bevacizumab injection $57.08 $11.42
J9041 9207 Bortezomib injection $28.38 $5.68
J9055 9215 Cetuximab injection $49.64 $9.93
J9216 0838 Interferon gamma 1-b inj $265.67 $53.13
J9300 9004 Gemtuzumab ozogamicin $2,203.67 $440.73
Q4076 1070 Dopamine hcl, 40 mg $0.72 $0.14
Source: CMS.
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Data to help plans, providers estimate drug utilization
CMS, which is required by law to share information about beneficiary drug utilization habits, has opened a new Web site page featuring data to help prospective prescription drug plans estimate the eligible Medicare beneficiary population's use of prescription drugs. Click here for the data. Scroll down to the bold heading, Interim Drug Plan Bidder Data Sets, and follow the instructions.
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New codes for brachytherapy sources
CMS has created three new codes hospitals may bill this year separately when using brachytherapy devices consisting of a seed or seeds or radioactive sources, according to new rules established in section 621 of the Medicare-reform law. All three codes below can be used for dates of service starting January 1, 2005.
- HCPCS code C2634: Brachytherapy source, high activity, iodine-125, per source
- HCPCS code C2635: Brachytherapy source, high activity, paladium-103, per source
- HCPCS code C2636: Brachytherapy linear source, paladium-103, per 1 mm
Source: Transmittal 419.
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CMS to assess pain management in chemo project
Billing instructions released Monday for office-based practices
CMS released billing requirements yesterday for a one-year project that will pay practitioners who administer chemotherapy in their offices $130 per encounter for reporting data on their management of pain, minimization of nausea and vomiting, and reduction of fatigue. Contact Jim Menas for coding and payment policy questions (410) 786-4507 (Jmenas@cms.hhs.gov). See the December 14 issue of Medicare Reform Advisor for background. The rules take effect January 17. The following is a short list of billing rules. See below for instructions on how to receive the full demonstration information.
- Contractors will accept codes G9021--G9032 for 2005.
- Contractors will pay for codes G9021--G9032 if providers do the following:
--Report and submit charges for one code from each of the following symptom assessment categories: assessment of nausea /vomiting (e.g the G9021 to G9024 range); assessment of pain (e.g. the G9025 to G9028 range); and assessment for lack of energy (e.g. the G9029 to G9032 range)
- Report three symptom assessment codes (one from each category) for the same date of service on the same claim for which he/she bills for a chemotherapy infusion (G0359) or chemotherapy push (G0357)
- Show that the date of service is after 12/31/2004 and before 1/1/2006
- Report a diagnosis code and reference it for cancer
- Report the place of service setting as office (11) for codes G9021 to G9032 and G0357 and G0359
- Contractors will reject the claim if one or more but fewer than three symptom codes (one from each category) are billed on a single claim
15 tips: If more than one symptom assessment code from the same category for the same date of service is billed on the same claim (e.g., the provider submits a claim for G9021, G9022, G9028 and G9032 for the same date of service), carriers will allow the higher intensity service billed and deny the less intensive service as a duplicate.
Instructions: For the 14 remaining payment tips, contact the editor by email. Request "Chemo Demonstration Tips."
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Take note of new dosage descriptors and codes
For 2005, several drug and biological codes have changed descriptions and codes (see below). Hospitals are strongly encouraged to report charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged. Hospitals billing for these products must make certain that the reported unit of service is consistent with the quantity of a drug, biological, or radiopharmaceutical that was actually administered to the patient. Hospitals must bill for units of service consistent with the dosages contained in the new long descriptors. Below, we've provided the old code first, then the old description, followed by the new code and new description for 2005:
- C9109 (old code): Injection, tirofiban hydrochloride (old description), 6.25 mg; J3246 (new code): Injection, tirofiban CL, 0.25mg
- C9125: Injection, risperidone, per 12.5 mg; J2794: Injection, risperidone, long acting, 0.5mg
- C9207: Injection, bortezomib, per 3.5 mg; J9041: Injection, bortezomib, 0.1 mg
- C9209: Injection, laronidase, per 2.9 mg; J1931: Injection, laronidase, 0.1 mg
- C9210: Injection, palonosetron hydrochloride, per 250 mcg; J2469: Injection, palonosetron HCL, 25 mcg
- J3245: Injection, tirofiban hydrochloride, 12.5 mg; J3246: Injection, tirofiban HCL, 0.25 mg
- J3395: Injection, verteporfin, 15 mg; J3396: Injection, verteporfin, 0.1 mg
Radiopharmaceutical agents will be treated as drugs effective January 1, 2005; therefore, these agents will no longer be eligible for outlier payments under the outpatient prospective payment system.
Source: Transmittal 419.
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NEED TO CONTACT US?
Bryan Cote
Executive Editor
860-232-6367
E-mail address: bcote@hcpro.com |
