Hemophilia Clotting Factor Billing

Medicare Part B covers administration of blood clotting factors and related items used for hemophilia patients able to use such factors without medical supervision. Hemophilia encompasses the following conditions:

  • Factor VIII deficiency (classic hemophilia); hemophilia A-J7185, J7186, J7190, J7192);
  • Factor IX deficiency (hemophilia B, plasma thromboplastin component (PTC) or Christmas factor deficiency (J7193, J7194, J7195, J7200-J7203); and
  • Von Willebrand's disease (J7192)
  • Additional HCPCS: J7170, J7175, J7179-J7183, J7187-J7189, J7198, J7204-J7205, J7207-J7213
  • 2023 HCPCS:
    • J7177 (Injection, human fibrinogen concentrate (fibryga), 1 mg )
    • J7178 (Injection, human fibrinogen concentrate, not otherwise specified, 1 mg)
    • J7214 (Injection, factor viii/von willebrand factor complex, recombinant {altuviiio}, per factor viii i.u.)

Part B blood clotting factors are priced as a drug and biological under the drug pricing fee schedule. A furnishing fee will be paid for items and services associated with the clotting factor.

Note: The electronic claim examples below are for PC-ACE users. Providers not using PC-ACE should contact their software vendor for claim completion assistance.

Billing Instructions for MUEs Over 9,999 Units Per Claim

Due to claims processing system limitations, if the total MUEs exceed 9,999 per claim, divide claim lines up to the allowable MUEs per claim line (9,999). For example, J7182 has a per line MUE of 22,000. Due to the system limitations, each claim line is split up to the 9,999 MUE limitation; with excess billed on a third line (2002).

Do not span the dates on the claim line, but enter the date span in the narrative with total units (22,000). Append modifier 76 to any second and subsequent lines.

CMS-1500 Claim Example

Image of CMS-1500 Claim Form. Three lines (Items 24s-24g) are completed as an example. All lines contain J7182. Lines one and two contain 9999 units and the third line contains 2002 units. Modifier 76 has also been appended to the second and third lines.

Electronic Claim Example

Image of Professional Claim Form. Three lines (Items 24s-24g) are completed as an example. All lines contain J7182. Lines one and two contain 9999 units and the third line contains 2002 units. Modifier 76 has also been appended to the second and third lines.

Snapshot of electronic claim line notes

Billing Instructions for Not Otherwise Classified Codes

For Not Otherwise Classified HCPCS codes (NOC), enter the drug name, dosage and NDC in Loop 2400, SV101-7 segment (preferred) or Loop 2400, NTE02 for electronic claims. Loop 2400, segment SV104 (quantity billed) must be entered as "one" (1). Paper claim submitters must enter the number of units per line in Item 19 of the CMS-1500 claim form and the quantity billed as "one" (1).

CMS-1500 Claim Example

Snapshot of Item 19 - 24J on electronic claim form. Item 19 lists drug name, NDC, dosge, month supply, and UOS

Electronic Claim Example

Snapshot of electronic claim form, line 24a-24j

Dollar Amount Exceeds $99,999.99

If providing a month supply and the total billed amount exceeds $99,999.99, two claims must be submitted.

Additional Important Claim Information

  • If required information is not submitted, claims will be denied as unprocessable. When codes are denied as unprocessable, provider must correct claim error and resubmit it
  • If claim denies due to number of units exceeds acceptable maximum (for example N362), verify MUEs and number of allowable units. MUEs denied have appeal rights. Medical documentation must support services rendered

Date of Service

If the Factor VIII is administered within a facility or "incident to" a physician service, the actual date the drug was administered should be used as the DOS. If the Factor VIII is billed by a pharmacy, to replenish the patient's home supply, the date of delivery must be the DOS billed.

Documentation

The amount of clotting factors determined to be necessary to have on hand and thus covered under this provision will be based on the historical utilization pattern or profile developed by the carrier for each patient. Changes in a patient's medical needs over a period of time may require adjustments in the profile. It is expected that the treating source, e.g., a family physician or Comprehensive Hemophilia Diagnostic and Treatment Center, will have such information.
For hemophilia factors, we would expect:

  • The diagnosis on a claim must be one of the hemophilia diagnosis codes
  • Provider's prescription must include:
    • Name of drug
    • Concentration (if applicable)
    • Dosage to include initiation date, frequency of administration, duration of infusion (if applicable), signature, date and any other individual state requirements
  • Record from the physician's office must include evidence of medical necessity
  • Copy of this medical record must be provided on request

Resource

 

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