Hemophilia Clotting Factor Billing

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

  • Factor VIII deficiency (classic hemophilia);
  • Factor IX deficiency (also termed plasma thromboplastin component (PTC) or Christmas factor deficiency); and
  • Von Willebrand's disease

Part B blood clotting factors are priced as a drug/biological under the drug pricing fee schedule. A furnishing fee will be paid for items and services associated with 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 Under 9,999 Units Per Line

CMS-1500 Claim Example

To calculate the correct units to bill per line, divide the number of units given by the Medically Unlikely Edit (MUE) Value. For example, HCPCS J7185 has a MUE Value of 4000 units per line. This is the maximum number of units which can be billed per line (as per MAI). If more than one line needs to be billed, the repeat modifier (76) must be appended to the second and subsequent lines. Refer to the CMS Medicare Unlikely Edits for MUE Values.

HCPCS MUE Value MUE Adjudication Indicator MUE Rationale
J7185 4000 1 Line Edit Clinical: Data

 

  • Patient received 12,000 IU of Factor VIII (J7185)
  • Do not bill a date span on the claim. Indicate date span in narrative of the claim.
  • Enter units given (not to exceed MUE per line) = 4,000
  • Append modifier 76 to any second and subsequent lines

Image of  CMS-1500 Claim Form.  Three lines (Items 24a-24g) are completed as an example. Each line contains J7185 and 4000 units. Modifier 76 has also been appended to the second and third lines.

Electronic Claim Example

The NTE segment is located under the (1) Professional Claim form, (2) Billing Line Items Tab.  Currently, PC-ACE is limited to allow up to 999 UOS per line; however, effective 10/01/17, the UOS per line will increase to 9999.

Image of electronic Professional Claim Form.  Three lines (Items 24a-24g) are completed as an example. Each line contains J7185 and 4000 units. Modifier 76 has also been appended to the second and third lines.

Billing Instructions for MUEs Over 9,999 Units Per Line

Due to claims processing system limitations, if the total MUEs exceed 9,999 per claim line, 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. Do not span the dates on the claim line, but enter the date span in the narrative. 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 IIX 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 IIX is being billed by a pharmacy to replenish the patient's home supply, the date of delivery should be used as the DOS on the claim.

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

 

Last Updated Tue, 31 Dec 2019 12:32:39 +0000