How do you bill an outpatient monoclonal antibody used in a hospitalized Covid-19 patient in which the facility incurs a cost?
This seems to be one of many riddles to solve as we continue to fight the Covid-19 pandemic. Tocilizumab under the EUA is approved for hospitalized patients > 2 years of age receiving corticosteroids and requiring supplemental oxygen. CMS issued its separate HCPCS, Q0249, from that of the original HCPCS, J3262 used when given for FDA approved indications. Similar to the vaccines, there are two separate HCPCS codes for the 1st administration (M0249) and 2nd administration (M0250). However, unlike the other monoclonal antibodies used for treatment of Covid-19, tocilizumab is provided in an inpatient setting. The tocilizumab should be billed on a 12X type of bill (inpatient Part B hospital claim) which must be separated from the type of bill 11x inpatient claim. Each MAC may have its own variation of how claims should be billed. Novitas outlines using 1 mg per billed unit (i.e. 200 units per dose) and billing only one line of Q0249 per day. Administration charges should be billed under a revenue code 771 with the condition code 91. Unlike remdesivir, they are not eligible for the New Covid-19 Technology Add on Payment (NCTAP). Q0249 should be paid at reasonable cost similar to billing influenza vaccine in the hospital setting.
You may encounter additional scenarios where inpatients receive tocilizumab, but not for CVOD-19. Two examples would be for an inpatient who receives tocilizumab for rheumatoid arthritis and is due for another dose, or a CAR T-cell therapy patient who develops cytokine release syndrome. These scenarios are billed differently, with different anticipated reimbursements.
A summary table for billing of tocilizumab in a hospital setting:
Pharmacy and Coding/HIM teams should collaborate on an appropriate workflow to ensure that the administration codes for tocilizumab are billed on the inpatient treated for Covid-19.
Billing and Informatic teams should validate inpatient hospital claims and display the HCPCS codes Q0249, M0249, and M0250 on the claim and are not rolled into a single line under the respective revenue codes.
Billing team should set up a process similar to the influenza vaccines that separates the tocilizumab onto a type of bill 12x inpatient Part B claim versus billing out on the type of bill 11x inpatient claim.
Pharmacy or Revenue Integrity teams should conduct an audit to validate the coding, revenue codes and claims were billed correctly.
CMS website with instructions on monoclonal antibody infusions is here.