Health Information Management

Q&A: Our payments for some separately reportable drugs change

APCs Insider, July 18, 2014

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Q: Why do the payments for some separately payable drugs change? One week we get paid a certain amount and the next week it may be different, but the units and HCPCS code are the same. We tend to see this at the first of each quarter. 

A: For the last several years, CMS has been updating the payment rates for separately payable drugs based on the average sales price (ASP). As new information becomes available, the ASP may rise or fall, and CMS adjusts the payment rate accordingly with each new quarter’s OPPS files. The new information is included in the quarterly OPPS Pricer files that are loaded into the claims processing system.

One example is HCPCS J0129 (abatacept injection, 10 mg). This code is assigned status indicator K (nonpass-through drugs and nonimplantable biologicals, including therapeutic radiopharmaceuticals) and receives separate payment for CY 2014. In the January Addendum B, the national unadjusted price for each 10 mg unit was $23.43. Because of changes in the average sales price data, for July 2014 the payment rate per 10 mg is $32.21. 

CMS has also updated pricing for some drugs and biologicals from previous quarters. The payment rate for J2788 (Rho d immune globulin 50 mcg) has been updated for the time period October 1, 2013, through December 31, 2013. The payment rate for J0775 (Injection, collagenase, clostridium histolyticum, 0.01 mg) has been updated for the time period January 1 through March 31, 2014. CMS instructs contractors to adjust claims brought to their attention.

More information can be found in Transmittal 2971. Addendum B includes a column that contains an asterisk (*) to indicate a change has been made to a specific line item. 

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


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