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Oncology and Hematology

Noridian follows the CMS Internet Only Manual requirements regarding claim processing and payment of drugs and biologicals, as provided in the resource section of this webpage. Additional information regarding discarded drugs and biological as well as the needed hematocrit or hemoglobin reading is provided below.

CMS provides guidelines regarding Medicare Part B Drug Average Sales Price, Not Otherwise Classified (NOC, and manufacture reporting on their website, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html This link takes you to an external website..

Discarded Drugs and Biologicals

When a physician, hospital or other provider or supplier must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label.Use modifier JW to identify unused drug or biologicals from single use vials or single use packages that are appropriately discarded. This modifier, billed on a separate line than the administered drug, will provide payment for the amount of discarded drug or biological.

However, the JW modifier must not be used on Medicare Part B Drug CAP claims; providers shall not code for wastage for drugs furnished under the CAP. Claims for drugs provided under CAP submitted with the JW modifier will be treated as unprocessable.

Reporting the Hematocrit or Hemoglobin Reading

Claims meeting the following criteria must be submitted to include the most recent hematocrit or hemoglobin reading:

  • All claims billing for the administration of an ESA (HCPCS J0881, J0882, J0885, J0886 and Q4081).
  • All claims for the administration of a Part B anti-anemia drug (other than ESAs) used in the treatment of cancer that are not self-administered.

Alll non-ESRD claims billing HCPCS J0881 and J0885 must be reported with one of the following modifiers:

  • EA: ESA, anemia, chemo-induced
  • EB: ESA, anemia, radio-induced
  • EC: ESA, anemia, non-chemo/radio

The instructions for reporting the test results on professional electronic claims (837P) state to report the hemoglobin or hematocrit readings in Loop 2400 MEA segment. The specifics are:

  • Hemoglobin or Hematocrit readings: Loop 2400 MEA01=TR(Test Results)
    • Hemoglobin: MEA02=R1
    • Hematocrit: MEA02=R2
    • Test results: MEA03 (3 digit plus decimal point numeric test result) Example 2400/MEA/TR/R1/27.5

The most recent numeric test results should always be reported as a three digit/number (0-9) with a decimal point between the second and third number (NN.N or 12.3). It is very important to note here that the decimal point must be submitted as part of the submitted value.

  • If a 3-digit number is being reported (such as 31.2), then 31.2 should be sent
  • If a 2-digit number is being reported (such as 4.5), then 04.5 should be sent
  • If a 2-digit whole number is being reported (such as 28), then 28.0 should be sent
  • If a single decimal position needs to be reported (such as .9), then 00.9 should be sent
  • If a 1-digit whole number is being reported (such as 7), then 07.0 should be sent
  • If a test result is being reported as 2-digits and 2 decimal places (such as 26.25), then 26.2 should be sent

The hemoglobin and hematocrit test result number should always be a 4-byte value (three numbers with a decimal point between the second and third number). These numbers must follow the format of NN.N. If the test result is less than three numbers, then zeroes must be entered in order to ensure the decimal is given in the correct position as is demonstrated in some of the previous examples.

Not Otherwise Classified Drug Codes: QB Field

When a 'not otherwise classified' or 'unlisted' HCPCS procedure code is submitted and there is a specific procedure code for that particular injection, radiopharmaceutical or injectable contrast material, the service will be returned as unprocessable. This is applicable to HCPCS codes J3490, J3590, J9999, A4641, A9699 and A9700. Claims that have been denied as 'unprocessable" must be submitted as new claims.

Resources

Last Updated Jun 15, 2017