Rev Your Engines: Revenue Codes and Drug Reimbursement 6/22/21

The National Uniform Billing Committee (NUBC) was formally organized in May 1975 and develops and maintains the UB-04 (uniform billing) data set used by the institutional health care community. The NUBC is one of four organizations recognized in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for a special consultative role around the development and adoption of administrative transactions for the electronic exchange of health information. 

One of the primary responsibilities of the NUBC is to maintain and update the revenue codes used by institutional providers for billing. Revenue codes are not used on physician claims but are required on institutional claims. 

Typically, the revenue code indicates what department or place a procedure or treatment is performed, such as the emergency room, or operating room. However, drugs can be used in multiple locations, so the revenue codes pertaining to pharmacy (025x, 063x, 089x) describe drugs, biologicals and radiopharmaceuticals independent of where they are administered in the facility.

It should be noted that these revenue codes are used exclusively for products labeled by the FDA as drugs, biologicals or radiopharmaceuticals and are not to be used to bill other products that a pharmacy may provide such as medical devices, supplies, or dietary supplements. It is a facility decision whether or not to bill these items under a non-pharmacy revenue code.

Revenue codes are four-digit codes that begin with a “zero”. Let’s take a closer look at the most common revenue codes used for drug products.

The 089x range is a new range where 0891 represents CAR T-cell therapy and 0892 represents Gene Therapy. The FDA maintains a list of approved cellular and gene therapy products that can be used to identify these products.

In the 063x range, the most commonly used revenue code is 0636– Drugs requiring detailed coding. This revenue code cannot be billed without a valid HPCPS/CPT code. 

Another common revenue code is 0637-self-administrable drugs. The use of this revenue code indicates to CMS that the provider understands that there is no coverage under Part B, but the charges are being reported for information only, or so that CMS acknowledges the coverage status for potential billing to another insurer or the patient.

In the 025x series, the most common pharmacy-related revenue codes are 0250– General and 0253-Take home drugs. 

Revenue code 0253 is used when drugs are given to the patient after a visit for the patient to take at home. This revenue code is also not covered under most circumstances and the charges are billed to a patient as a routine ambulatory prescription.

Revenue code 0250 is used for all other drugs and biologicals when no HCPCS/CPT code is available for billing but where CMS coverage exists. 

Two other revenue codes may be used by pharmacy when setting up billing: 0343 and 0344. These codes are used to identify radiopharmaceuticals with 0343 designating diagnostic radiopharmaceuticals and 0344 designating therapeutic radiopharmaceuticals.

Why are revenue codes important? 

One important aspect is determining whether a charge is covered by a payer. For example, CMS does not cover self-administered drugs, so listing a product on a claim with revenue code 0637 is an indication that the provider doesn’t expect to be paid for the product.

It is important that the Managed Care contract negotiation group understand which products are reported in which revenue code and ensure that contracts are written to capture additional reimbursement for high cost drugs. For example, revenue code 0636 is often referenced in contracts to indicate an additional “drug carve-out” payment on outpatient claims. Failure to list drugs with HCPCS/CPT codes that meet payer criteria can result in lost payment if they appear on the claim in revenue code 0250.

It is also important that medical devices and dietary supplements as well as other supplies not be listed in pharmacy revenue code as the medicare cost report is structured to track the pharmacy-related revenue codes to the primary cost center: Drugs charged to patients. CMS publishes crosswalks for the IPPS and OPPS rule each year. This listing is for the OPPS FY2021 Rule.

SHOUT-OUTS!

1. Pharmacy should be familiar with the pharmacy-related revenue codes to ensure that the chargemaster is correctly coded based upon NUBC requirements.

2. Managed Care contract negotiating group should be familiar with the different product types of drugs, biologicals and radiopharmaceuticals.

3. Pharmacy and Managed Care should collaborate to ensure that contracts reflect appropriate reimbursement terms for drugs, biologicals and radiopharmaceuticals based upon revenue codes and HCPCS/CPT code combinations.