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Bonnie Kirschenbaum, MS, FASHP
“Reimbursement Matters” is a tool for maintaining your health system’s fiscal health. Please email the author at bkirschen@aol.com with suggestions on reimbursement issues that you would like to see covered.


The Protecting Access to Medicare Act of 2014 was signed into law on April 1 (http://1.usa.gov/​1lZnhgP). The act, which served as a 13-month Medicare sustained growth rate formula “patch,” prevented a 24% cut to Medicare physician payments. But for our purposes, I’d like to focus on another component of the legislation: its intent to push back implementation of the International Classification of Diseases, 10th revision (ICD-10), the next generation of diagnosis and inpatient procedure codes. The new codes were slated to kick in October 2014; now this has been delayed to no sooner than Oct. 1, 2015.

No, this wasn’t an April Fool’s prank on the part of the feds: It really happened! Was all that preparation work and testing wasted? What should happen now? What effect does this have on pharmacy?

First, a bit of background. ICD-10 is copyrighted by the World Health Organization (WHO), which owns and publishes the classification and has authorized the development of an adaptation of ICD-10 for use in the United States (http://1.usa.gov/​1mDyTo2). ICD-10 must conform to WHO conventions for the ICD. It is designed to replace the older ICD-9 codes that have been in use for many years and was designed to accommodate new diseases and procedures as well as be more descriptive and specific.

How much more? More than 68,000 new ICD-10 codes instead of about 14,000 ICD-9 codes. The codes are the language that transmits patient disease information to the payor. Using the old ICD-9 codes to accurately describe a patient with more than one chronic comorbid condition is time-consuming and painstaking. Hence the need for ICD-10, which seeks to add granularity and detail to the codes to more accurately describe the patient’s total level of health. Taking this one step further, it will indicate to the payor the complexity of medical management and how patient noncompliance weighs into this. With pharmacy on the cusp of achieving provider status, the ability to more specifically identify its role in patient care is critical.

What should we do while we wait out the delay? The delay may not be that long. The Centers for Medicare & Medicaid Services (CMS) recently updated its website on the ICD-10 decision (http://go.cms.gov/​1h4ZZjj), noting that the agency is “examining the implications of the ICD-10 provision and will provide guidance to providers and stakeholders soon.”

Needless to say, rarely is documentation complete. Since it’s often the major reason for payment denial, increase your focus on improving the consistency and quality of your clinical documentation related to medication use. Pull up those local coverage determination requirements, for example, and ensure that your clinical documentation fulfills them. Remember, CMS won’t pay for medications given to Medicare patients without proper documentation.

The same principle applies to prior authorizations required by commercial payors. Can you improve this with a change in computerized prescriber order entry drug orders for immunologics, biologics and chemotherapy? Has a pathway been established so that requirements are completed in the order required? The electronic medication administration record represents how the order was entered. Is it complete enough to be intuitive as to the information nursing must document? As the electronic record makes its way to coders to process, flaws in your current system and sparse documentation coded with ICD-9 become ever-worsening issues in the ICD-10 world. Take the time to review protocols and clinical trials that involve medication use and make changes and clarifications where needed.

Don’t Fall Off the Revenue Cycle

Any transition in coding changes will bring some degree of chaos and have an effect on revenue. Just think of the angst that accompanied the transition to using billing units that is still not resolved close to 10 years later. Do you really want to be left holding the responsibility for decreased revenue for medications because of flaws somewhere downstream in the revenue cycle? Take the initiative to do a few end-to-end audits (Pharmacy Practice News, May 2014, page 22) to identify critical areas and fix them. This delay gives you that opportunity.

An interesting perspective on this can be found on the website of the Association of Community Cancer Centers (ACCC-cancer.org) in the article, “ICD-10-CM Delay: What Next?” (April 11, 2014; http://bit.ly/​RsoXUq). The article addresses many of the same issues that pharmacy would have concerns about in terms of correct coding.

CMS Alert: Chemotherapy-Induced Emesis

Turning from ICD-10 to another important development affecting reimbursement, the CMS recently issued an important bulletin on how the agency is going to pay for the prevention of chemotherapy-induced emesis. This document, known as “Revised MM8418–Aprepitant for Chemotherapy-Induced Emesis” (http://go.cms.gov/​1gbJFhr) is a must-read so that you can fully understand the CMS’s position on this drug class. The most important thing to remember is that these products will not be separately payable but will be bundled into the visit payment. This is a classic example of why it is so important to understand both the concept of bundled payments and how to allocate payment. A portion of MM8418 is excerpted here:

Chemotherapy-induced emesis is the occurrence of nausea and vomiting during or after anticancer treatment with chemotherapy agents. The Social Security Act (the Act) permits oral drugs to be paid under Part B in very limited circumstances, one of which is antiemetic therapy administered immediately before and within 48 hours after anticancer chemotherapy.

These drugs must fully replace the non-self-administered drug that would otherwise be covered. On April 4, 2005, CMS announced a National Coverage Determination (NCD) for the use of the oral three-drug regimen of aprepitant, a 5HT3 antagonist, and dexamethasone for patients who are receiving certain highly emetogenic chemotherapeutic agents. On May 29, 2013, CMS announced an update to that NCD, to cover the use of the oral antiemetic three-drug combination of oral aprepitant (J8501), an oral 5HT3 antagonist (Q0166, Q0179, Q0180), and oral dexamethasone (J8540) for patients receiving highly and moderately emetogenic chemotherapy.

MM8418 goes on to detail all of the chemotherapeutic agents that CMS deems “reasonable and necessary” to be used with antiemetic therapy—specifically, a three-drug combination of oral aprepitant, an oral 5-HT3 antagonist and oral dexamethasone. The document also details the specific codes that must be used for the drug therapies in order to get reimbursed. In cases where no such code is available—for example, newly approved agents—MM8418 offers guidelines on how to use alternative, “not-otherwise-classified” (NOC) codes to ensure payment.

For more details—and there are many more useful ones that you really need to be cognizant of—be sure to download MM8418. It really should be required reading if you are at all invested in the reimbursement processes at your hospital or health system.

Price Corrections and New Pass-Through Products

Wrapping up this month’s reimbursement tips, know that the April 2014 Update of the Hospital Outpatient Prospective Payment System had several changes important to follow up with your revenue cycle team, including some payment revisions that allow for rebilling of the affected medications if the facility so chooses. Additionally, Healthcare Common Procedure Coding System code C9021 for injection, obinutuzumab, 10 mg has been given pass-through status. If you have been using a miscellaneous code for billing this drug, correct this immediately. See details at http://go.cms.gov/​1smAIcs.

Are there other reimbursement issues you’d like explored in this column? Send your ideas for topics to bkirschen@aol.com. We appreciate your feedback and input!