Visante 
This edition of Pharmacy Revenue Cycle News is a compilation of all quarterly resource files that detail code changes pertinent to drug billing effective October 1, 2020. Here’s a listing of the files and a short description of what each one contains. We recommend that pharmacy, finance, and revenue integrity review all files for changes pertinent to drugs in use at the facility, and update their IT systems to reflect the current information. We have three shoutouts; two pertain to reviewing previous claims for potential rebilling, and also an evaluation of formulary status for drugs with status indicator changes regarding separate payment.
Revised update posted on September 24 with HCPCS code changes (Section 8, page 5 of pdf file)
- MLN Matters: OPPS Update
Educational materials for health care professionals on CMS programs, policies, and initiatives - Outpatient Code Editor (OCE) Release Files
Summary of code changes used to edit Medicare outpatient claims - Addenda A and B
Provide payment rates for all services under OPPS (Hospital Outpatient and Ambulatory Surgery Centers - October 2020 Restated Payment Rates
Corrected payment rates for two HCPCS codes (Q5107-Mvasi and J1557-Gammaplex) - Medically Unlikely Edits (MUE)
Maximum units of service expected for a single beneficiary on a single date of service per HCPCS code - October 2020 ASP Drug Pricing Files
ASP Pricing File– Payment rates for drugs with Column J indicating new additions, “Added October 2020”
NOC Pricing File– Payment rates for select drugs which have not been assigned a HCPCS code - October 2020 Drug NDC-HCPCS Crosswalks
ASP NDC-HCPCS Crosswalk– all drugs with assigned HCPCS codes that are used in HOPD, ASC, and physician offices
OPPS NDC-HCPCS Crosswalk– for assigned codes used only in HOPD and Ambulatory Surgery Centers (ASC)
NOC NDC-HCPCS Crosswalk– for Not Otherwise Classified (NOC) codes
AWP NDC-HCPCS Crosswalk– for flu, pneumonia, hepatitis B and albumin when paid on an AWP basis - CMS Medicaid Drug Rebate File (most recent file is for 2ndQU 2020)
Listing of National Drug Codes (NDC) covered under State Medicaid Programs - AMA- CPT Codes for Vaccines
New codes are published in January and July, therefore no update in October - AMA- Annual CPT code release
New codes are released in January, therefore no update in October - FY2021 ICD-10-CM and ICD-10-PCS codes
Annual code release for diagnosis, and inpatient procedure codes
Shout-outs!
1. The Finance Team will want to review previous claims with retroactively revised status indicators. For this quarter, the status indicator for HCPCS code Q5121 (Injection, infliximab-axxq, biosimilar, (avsola), 10 mg) for the period of July 6, 2020 through September 30, 2020 will be changed retroactively from status indicator =”E2” to status indicator = “K” indicating that it will now be separately paid from its FDA approval data of July 6. Facilities who administered Avsola during the 3rd quarter should review outpatient claims to determine if they received payment, and if not, consider rebilling claims to recoup the additional payment. This may impact Medicare, Medicaid, TRICARE, and commercial payers with rate schedules similar to Medicare.
2. The Finance Team will want to review previous claims with two HCPCS codes that have restated payment rates. For October 2020, two drug HCPCS codes are listed with restated payment rates (Q5107-Mvasi and J1557-Gammaplex). Depending upon the significance of the difference and usage volumes, a facility could choose to rebill previously submitted claims to receive any additional payment. For J1557, payment rates have been adjusted back to April 1, 2020. For Q5107, the payment rate has been adjusted to July 1, 2019.
3. Pharmacy and P&T Committee should review the OPPS Update and Addendum B to identify any drugs which will now receive separate payment and those with separate payment expiring to determine if the formulary status of these drugs should be re-evaluated. (Section 8, page 5 of the pdf file).
