New Year’s Resolution: Get Control of your Pharmacy Revenue Cycle 1/4/21

As we all ring in the New Year, let’s make the Pharmacy Revenue Cycle a priority for the New Year. This letter brings you a compilation of the top information to set your Pharmacy Revenue Cycle information on the right foot with updates on the MFN Model Interim Final Rule, CY2021 OPPS Final Rule and updated tools for C9399 and Hemophilia Factor reporting. 

Most Favored Nation (MFN) Update

On December 28, 2020, the US District Court for the Northern District of California issued a preliminary injunction that will prevent implementation of the MFN Payment Model Interim Final Rule at least until the completion of the notice and comment period on January 26, 2021. 

Notably, the M1145- MFN drug add-on, per dose has been published in CMS Addendum B effective January 1, 2021 with a payment status indicator of E1. CMS defines E1 as an item, code or services that are not covered by Medicare in Addendum D1. The I/OCE has not been published as of 1/4/2021; however, when posted in should be located here.

2021 HOPPS Final Rule

A few items to call out within the Medicare Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems for 2021. The list is not designed to be all inclusive, but means to draw your attention to a few updates.

• Pass-through payment status expired for 29 drugs and biologicals at the end of December 2020 and another 25 that will end in CY2021. 

• Payment methodology is unchanged from CY2020. The packaging per day cost threshold remains at $130 and the 340B payment discount continues at ASP- 22.5%. 

Pharmacy Revenue Cycle Tool Updates

• Drugs eligible for billing C9399 was updated as of January 1, 2021. Please reference our previous newsletter for more information regarding billing C9399. 

  • New FDA approved drugs added to the list include: setmelanotide, naxitamab-gqqk, rituximab-arrx, and ansuvimab-zykl.

  • Drugs removed from the list as they have a unique HCPCS assignment include: daratumumab and hyaluronidase (J9144) and Mitomycin instillation (J9281).

• Payment Allowance Limits for Medicare Part B Drugs with Clotting Factor Designation. This list represents the CMS defined clotting factors and the payment allowance for both inpatient and outpatient hospital claims. 

Shout Outs!

1. Pharmacy & Revenue Cycle Teams should have a dialogue on how to best proceed with managing the MFN claims. Due to the uncertainty of the rule implementation, a decision could be made to apply the M1145 to the claim now but strip the charge and code due to the E1 status indicator, or wait to apply the code and determine if rebilling is appropriate when the implementation status of the MFN Model Interim Final Rule becomes clear. 

2. Chargemaster and/or Informatics: Review the changes in HCPCS, status indicator and payment for the Hospital Outpatient Departments and ASC. Ensure the changes are reflected in the EMR for proper billing including the application of the TB vs. JG modifier for 340B eligible purchases.

3. Chargemaster and/or Informatics: Review the list of drugs eligible for billing with a C9399 or listed as a hemophilia clotting factor. Changes may be required to ensure that you populate the final claims with the correct information.