Health Information Management

Q/A: Provenge® payment problems persist

APCs Insider, March 23, 2012

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Q: We continue to receive no payment for administering the drug Provenge®, CMS had said that it would reimburse for it separately. We realize changes have occurred several times, but should we be receiving separate payments for these infusions?

A: Yes. You should receive separate payment based on the most recent instructions published by CMS. Transmittal 2380, published January 6, had clarified this payment policy.

However, CMS recently announced that “an issue in the Medicare claims processing system … is causing claims for the administration of Provenge® not to be paid separately from Provenge®,” according to WPS Health Insurance, a Medicare contractor, The agency said that CPT® code 96365 is bundled when billed with HCPCS code Q2043 and that Provenge providers might be affected by this situation, according to information on WPS’ website. Refer to CMS Learn Resource 201203-38 and Technical Direction Letter (TDL) 12272, dated March 15 for more information.

CMS will correct this problem by updating the edits to allow separate payment when CPT code 96365 is reported with Q2043. The agency instructed Medicare contractors to adjust claims with dates of service on or after July 1, 2011 brought to their attention. Beginning April 1, providers may ask contractors to adjust claims involving Provenge administration service denials.

Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

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