Revenue Cycle Management - ASHP

Revenue Cycle ManagementClosing the Loop on Optimal Financial Performance

Bruce Bradley, PharmDMaxie Friemel, PharmD, MS, BCPS

Agatha Nolen, MS, PhD, FASHP

Disclosure

In accordance with the ACPE’s and ACCME’s Standards for Commercial Support, anyone in a position to control the content of an educational activity is required to disclose their relevant financial relationships. In accordance with these Standards, ASHP is required to resolve potential conflicts of interest and disclose relevant financial relationships of presenters. • In this session:

All planners, presenters, reviewers, and ASHP staff report no financial relationships relevant to this activity.

Disclaimer • Please note that this information may become obsolete with revised

regulations• Please review your current transmittals, program manuals, bulletins,

banner pages or other regulatory publications for updates• Please contact your payer should you have any questions regarding their

interpretation and retain the documentation for your records

23rd Annual ASHP Conference for Pharmacy Leaders Revenue Cycle Management Closing the Loop on Optimal Financial Performance

©2018 American Society of Health-System Pharmacists of 7

Learning Objectives

• Describe strategies for evaluating commercial contracts and federal and state coverage determinations to ensure payer requirements are met for payment of drugs and drug administration services to overcome challenges that affect the pharmacy’s bottom line.

• Evaluate formulary decisions for high cost drugs (e.g. biosimilars, CAR‐T therapy, and IPPS new technology add on‐payments).

• Describe key components of claims processing that ensure the integrity of submitted claims.

• Given various scenarios, practice the use of monitoring methods to maintain a robust and contemporary revenue cycle management system in light of evolving reimbursement changes.

• Evaluate key principles for establishing integrity and creating systems to avoid, and effectively appeal denials when they occur.

Revenue Cycle Process Flow

Billing ImpactsPharmacy Clinical Systems

• Medication Data– NDC– Strength– Package size & equivalency– SDV, MDV, PF– Bulk products

• Clinical Data– Dispensing unit– Order – Administration/preparation – Waste– Accumulation

• Automation/Systems– EMR– Automated dispensing cabinets– ED/OR modules– Other 3rd party interfaces



Billing ImpactsCharge Master or Patient Accounting

• Healthcare Common Procedure Coding System (HCPCS)• Procedure codes• Revenue codes• Alternate codes (based on payer)• Modifiers (e.g. JW, TB, JG, UD)• Charge tables• Status indicators (SI)• Other payer tables

Billing ImpactsPatient Care or Clinical Processes

• Registration– Advance Beneficiary Notice (ABN)– Prior authorizations– Local/National Coverage

Determinations (LCD/NCD)• Pharmacy

– Ordering– Preparation– Documentation of waste (when

necessary)

• Providers– Documentation of orders– Signed orders (when necessary)

• Nursing (or other end users)– Documentation administration– Documentation amount pulled from

ADS (when charge on dispense)– Reconciliation of charges

Billing ImpactsInternal Edits and Charge Router Rules

• Age discrepancies with billed HCPCS• Cost center allocations/accounting• High dollar or high billing quantity• Modification to any information placed in the charge master• Modifier check or additions• Medically Unlikely Edits (MUE)• National Correct Coding Initiatives (NCCI) edits



Billing ImpactsClaim Processors & Claim Edits

• Validates claim against respective payer rules• May modify claim details (i.e. NDC, HCPCS, revenue code) to meet payer

specifications• MUE• NCCI edits• Modifier checks and additions

Billing ImpactsPayer Edits and Denials

• Invalid or missing NDC• Invalid HCPCS, NDC mismatch • Medical necessity denial• NCD & LCD rejections• Non‐covered services• Line item vs. claim level denial

Billing ImpactsAppeals

• Medical necessity documentation• Medical records sent with appeals• Level of appeals (1 – 5)



Billing ImpactsReimbursement

• Validation of appropriate reimbursement based on payer contracts

Billing ImpactsReimbursement

• Validation of appropriate reimbursement based on payer contracts

Common Definitions • Advance Beneficiary Notice (ABN)

– Notice of non‐coverage, issued by all health care providers when Medicare payment is expected to be denied

• Hospital Outpatient Prospective Payment System (HOPPS or OPPS)– Created by CMS, sets the standards for billing, payment rates and other

relevant regulations for Part B services, and some inpatient services billed as Part B, for Medicare beneficiaries

• Inpatient Prospective Payment System (IPPS)– System of payments for acute care hospital inpatient services under Medicare

Part A based on prospectively set rates• Local or National Coverage Determinations (LCD/NCD)

– Decision by the Fiscal Intermediary to cover a particular item or service as a reasonable and necessary



Common Definitions • Status Indicator (SI)

– A letter code that is assigned by CMS that signifies how an individual HCPCS/CPT will be reimbursed and helps determine if policy rules and discounting apply

– SI = G Pass‐Through Drugs and Biologicals: paid under the OPPS and receive separate APC payment

– SI = K Non‐Pass Through Drugs and Biologicals: paid under the OPPS and receive a separate APC payment

– SI = N Packaged Item or Services: paid under the OPPS, payment is packaged into payment for other items or services

– SI = M Items or Services not billable to the Fiscal Intermediary: not paid under the OPPS

Common Definitions

• Medically Unlikely Edit (MUE)– Assigned for most HCPCS/CPT codes, represents the maximum units of service

that a provider would report in most circumstances• New Technology Add‐On Payment:

– Under the IPPS, CMS established a process for identifying and ensuring adequate payment for new medical services and technologies that are inadequately paid under the DRG.

• Target Probe and Educate (TPE):– Service provided by the Medicare Administrative Coordinators (MAC) designed

to help improve billing practices in areas that have a high national or specific providers/suppliers who have high claim error rates

Key Takeaways

1) REVENUE CYCLE COMPLEXITYThere are multiple complex steps, teams and intertwining builds that are essential to understand how a medication is charged, billed, and reimbursement received.

2) CONTINUAL CHANGERegulations are continually changing and there is a higher focus on medications. Teams need to be prepared and nimble to accommodate these changes.

3) INFORMED DECISIONSUtilizing the tools provided, allow you to make informed decisions on high cost formulary decisions, system build, denials, reimbursement and more.



Game Instructions• Object:

– To be the team with the most money at the end of the game.• Set up:

– Each table will be divided into 2 teams of about 5 people per team (10 people per table).

Game Instructions Cont.• Gameplay:

– Flip coin to determine who goes first.– Teams take a turn by rolling a dice and moving their game piece the respective number of

spaces. – The team will draw from one of the 3 piles of cards based on the space in which they

land. Each card consists of a billing question, discussion question or a trivia question. – If a team lands on a jail spot, they will need to pay $100 to the Banker to post bail. If a

team lands on the tourist attraction, they will need to pay $100 parking fee. – The team will have 3 minutes to answer the question. After the question is answered,

there will be 2 minutes to discuss the answer as a group.– The facilitator will serve as the Banker and pay the team up to the amount listed on the

card for a correct answer. The team will lose money up to the amount listed on the card for an incorrect answer.

– Discussion questions are open for the entire group to discuss, but only the team who landed on the space will receive the money value listed on the card.

– If a team goes bankrupt, you will be allowed to continue but will not receive any additional money.



Please note that this information may become obsolete with revised regulations Page | 0

CLOSING THE LOOP ON OPTIMAL

FINANCIAL PERFORMANCE

October 2018

Page | 1 Please note that this information may become obsolete with revised regulations


Table of Contents SECTION I: INTRODUCTION .................................................................................................................... 4

Closing the Loop on Optimal Financial Performance ............................................................................... 5

Objectives ............................................................................................................................................... 5

CONTACT INFORMATION ........................................................................................................................ 6

SECTION II: IMPLEMENTING STRATEGIES FOR MAXIMIZING COMMERCIAL CONTRACTS .................. 8

340B Reimbursement ............................................................................................................................. 9

No Cost Drug ......................................................................................................................................... 11

Influenza/Pneumonia Vaccine ............................................................................................................... 13

Inpatient Carve Outs ............................................................................................................................. 15

LCD Specific ........................................................................................................................................... 17

Discussion Questions (A - C) .................................................................................................................. 19

SECTION III: EVALUATING FORMULARY DECISIONS FOR HIGH COST DRUGS .................................... 20

CAR T-Cell Therapy ................................................................................................................................ 21

Biosimilar .............................................................................................................................................. 23

Specialty Drug ....................................................................................................................................... 27

IPPS New Technology ............................................................................................................................ 29

Hemophilia Products ............................................................................................................................. 33

Discussion Questions (D - F) .................................................................................................................. 35

SECTION IV: ENSURING THE INTEGRITY OF SUBMITTED CLAIMS ....................................................... 36

Bolus from the Bag ................................................................................................................................ 37

Unapproved Drugs ................................................................................................................................ 41

Overpayment ........................................................................................................................................ 43

Underpayment ...................................................................................................................................... 45

Not-Billable Services.............................................................................................................................. 47

Waste.................................................................................................................................................... 49

Discussion Questions (G & H) ................................................................................................................ 51

SECTION V: IMPLEMENTING & MONITORING REVENUE CYCLE MANAGEMENT SYSTEMS ............... 52

Packaged Drug ...................................................................................................................................... 53

Pass-Through vs. Non-Pass-Through Drug ............................................................................................. 55

Self-Administered Drug ......................................................................................................................... 57


Quarterly Maintenance Process for Billing Information ......................................................................... 59

Discussion Questions (I - L) .................................................................................................................... 63

SECTION VI: EFFECTIVLEY APPEAL DENIALS WHEN THEY OCCUR....................................................... 64

Targeted Probe and Educate ................................................................................................................. 65

MUE ...................................................................................................................................................... 67

MUE/Appeal ......................................................................................................................................... 69

SECTION VII: TEXAS TRIVIA .................................................................................................................. 72

Trivia Questions & Answers ................................................................................................................... 73

SECTION VIII: ADDENDUM ................................................................................................................... 76

Definitions ............................................................................................................................................. 77

Additional Resources............................................................................................................................. 78

Questions & Answers Key...................................................................................................................... 79

Disclaimer ............................................................................................................................................. 80


SECTION I: INTRODUCTION


Closing the Loop on Optimal Financial Performance Revenue cycle is a leading strategic imperative for hospital senior executives and pharmacy leaders

due to increasing drug costs and new payment models with declining reimbursement. An integrated

revenue cycle management system that encompasses charge master compliance, formulary

decisions, complex IT systems, payer requirement compliance, and contracting is critical. Pharmacy

leaders must lead the design and maintenance of a comprehensive revenue cycle management

system to keep pace with evolving reimbursement changes. In a creative gaming format, this

workshop will provide practical solutions to manage real-life challenges and provide an opportunity

for attendees to evaluate scenarios and model resolutions to improve revenue cycle management.

Objectives

Describe strategies for evaluating commercial contracts and federal and state coverage

determinations to ensure payer requirements are met for payment of drugs and drug

administration services to overcome challenges that affect the pharmacy’s bottom line.

Evaluate formulary decisions for high cost drugs (e.g. biosimilars, CAR-T therapy, and IPPS new

technology add on payments).

Describe key components of claims processing that ensure the integrity of submitted claims.

Given various scenarios, practice the use of monitoring methods to maintain a robust and

contemporary revenue cycle management system in light of evolving reimbursement changes.

Evaluate key principles for establishing integrity and creating systems to avoid, and effectively

appeal denials when they occur.


CONTACT INFORMATION

Agatha Nolen, B.S.Pharm., Ph.D., M.S, FASHP

Email: [email protected] Agatha Nolen, Ph.D., D.Ph., FASHP Assistant Vice President-Pharmacy

in Ethics and Compliance at the Corporate offices for HCA (Hospital

Corporation of America) in Nashville, TN with responsibility for billing

of pharmacy products and services for 28 million patient encounters

per year in 175 hospitals and 120 ambulatory surgery centers as well as

physician offices and imaging centers. Previously she held Director of

Pharmacy positions at health systems for more than15 years and

practiced as a decentralized pharmacist in ICU/Cardiac Care and OR

Pharmacies. Received B.S. and M.S. degrees from University of

Oklahoma and played Varsity Women’s Golf. She completed a Ph.D. in

Public Administration (Field of Study: U.S. Health Policy) at Tennessee State University. Assistant

Professor for the University of Tennessee and served as a faculty member in the inaugural ASHP

Pharmacy Leadership Academy. Member of the pharmacy department who received the Texas

Innovative and Collaborative Practice Award, served as an ASHP Board Member from 2003-2007

and currently serves on the Hospital Outpatient Payment Panel (HOPP) which advises CMS on

payment rates for outpatient services. Numerous publications and presentations on health policy

and clinical and administrative pharmacy including an analysis of ten years of public policy in

healthcare reform concentrating on improving patient safety with health information technology.

Adrianne (Maxie) Friemel, PharmD, MS, BCPS

Email: [email protected]

Maxie Friemel, PharmD, MS, BCPS, is the Revenue Integrity Specialist

for SCL Health since June 2016. She received her Doctor of Pharmacy

from Texas Tech University Health Science Center in 2011, and went

on to complete a two year PGY1 Pharmacy Practice and

Administration Residency program with master’s degree in healthcare

administration from the University of Wisconsin Hospital and Clinics.

Post residency Dr. Friemel served as the supply chain manager and

home infusion liaison for the University of Wisconsin Hospital and

Clinics for three years. In her current position with SCL Health, she

works closely with the eight hospital systems to develop workflows

for the pharmacy personnel and other clinical providers to ensure

optimal and compliant revenue capture. She is integral in collaborating with the clinical, informatics,

and revenue cycle teams to accomplish goals. Dr. Friemel has been an active member of pharmacy

organizations throughout her career. She currently services as the Vice Chair of the Section Advisory

Group on the Management of the Pharmacy Enterprise as a part of the ASHP Section of Pharmacy

Practice Managers. Dr. Friemel is also engaged with the local Colorado Pharmacist Society –

Academy of Health System Pharmacist has been nominated chair-elect 2018-2019.

mailto:[email protected]


Bradley Bruce, PharmD

Email: [email protected] Dr. Bradley Bruce is a Senior Consultant in Regulatory Compliance

Support (Regs) at Hospital Corporation of America (HCA). Regs

fundamental task is to reduce risk by supporting and educating

hospital sites on proper drug coding and billing. In his role, Dr. Bruce

manages the preservation of the corporate drug chargemaster,

maintains a claims data dashboard (Tableau), and researches drug

billing questions for HCA members. Dr. Bruce develops timely

communications on market shifts in drug reimbursement and

quarterly coding changes. Dr. Bruce servers as the Regs department

lead for HCA’s community outreach group where he lives out HCA’s

mission; “Above all else, we are committed to the care and

improvement of human life”. Dr. Bruce has experience in a variety of different healthcare settings

including midsize urban teaching hospital, large not-for-profit academic medical center, and a

national for profit integrated delivery network (IDN) system. He received his Doctor of Pharmacy

degree from the University of Missouri Kansas City and completed a pharmacy practice (PGY1)

residency at Henry Ford Hospital and was a Corporate Pharmacy Leadership (PGY2) residency at

HealthTrust in Nashville, TN.

mailto:[email protected]


SECTION II: IMPLEMENTING STRATEGIES FOR MAXIMIZING

COMMERCIAL CONTRACTS


QUESTION 1.

340B Reimbursement

In July 2018, the appellate court dismissed the American Hospital Association case to reverse the

CMS cuts to the 340B Drug Pricing Program. Your hospital is not an excepted site like sole rural

community hospitals, children’s hospitals, or cancer center hospitals. Calculate the reimbursement

impact to your 340B facility and select the correct modifier.

HCPCS, SI* Description Annual Volume ASP + 6% ASP -22.5%

J2350, G Ocrelizumab, 1 mg 90,000 mg $57.17 $41.80

J9310, K Rituximab, 100 mg 600,000 mg $915.30 $669.21

J9263, N Oxaliplatin 0.5 mg 720,000 mg $0.21 $0.15

A. Total loss of ($1,476,540)

a. Ocrelizumab – no additional loss in reimbursement, must apply TB modifier

b. Rituximab loss of ($1,476,540) apply JG modifier

c. Oxaliplatin – no additional loss in reimbursement, apply TB modifier

B. Total loss of ($2,859,840)

a. Ocrelizumab loss of ($1,383,300) apply TB modifier


c. Oxaliplatin – no additional loss as it is not separately reimbursable, apply TB modifier

C. Total loss of ($2,946,240)

a. Ocrelizumab loss of ($1,383,300) apply JG modifier


c. Oxaliplatin loss of ($86,400) apply JG modifier

D. Total loss of ($2,946,240)

a. Ocrelizumab loss of ($1,383,300) apply TB modifier


c. Oxaliplatin loss of ($86,400) no modifier necessary


ANSWER 1.

340B Reimbursement

Best Answer A

A. Total loss of ($1,476,540)

a. Ocrelizumab – no additional loss in reimbursement, must apply TB modifier


c. Oxaliplatin – no additional loss in reimbursement, apply TB modifier

EXPLANATION 1. 340B Reimbursement

Hospitals that are not exempt from the 2018 OPPS Payment Rate for 340B Purchased Drugs

requirements are as follows:

340B purchased drugs with “pass-through” status (G) will continue to be paid at ASP + 6%, a TB

modifier must be applied

340B purchased drugs with “non-pass-through” status (K) will continue to be paid at a reduced

rate of ASP -22.5%, and a JG modifier must be applied

340B purchased drugs with “packaged services” status (N) is not a separately reimbursable item

thus reimbursement is not impacted, no modifier is necessary or apply TB modifier.

Exempted 340B sites continue to receive ASP + 6% reimbursement rates, but a TB modifier must be

applied to all drugs with status indicator of K and G.

Resource:

Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS):

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HospitalOutpatientPPS/Downloads/Billing-340B-Modifiers-under-Hospital-OPPS.pdf

POINTS: $400

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/Billing-340B-Modifiers-under-Hospital-OPPS.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/Billing-340B-Modifiers-under-Hospital-OPPS.pdf


QUESTION 2.

No Cost Drug

You have a Medicare patient who comes to your infusion clinic for an Intravenous Immune Globulin

(IVIG) infusion every six weeks. The physician has followed the patient for years and is convinced

that only one brand of IVIG is safe for the patient and provides an appropriate response for treating

their Guillain-Barré syndrome. However that brand of IVIG is non-formulary at your institution. The

doctor has approached the drug company and they will ship the IVIG directly to the hospital

pharmacy at no cost to the hospital. How is the best way to bill for this encounter?

A. Bill for the drug administration services and place a token charge of $1.00 on the claim for the

IVIG under revenue code 636 and the appropriate HCPCS code of the brand of IVIG

administered.

B. Bill for the drug administration services and a regular charge for the IVIG on the claim based

upon what you would normally charge for the brand of IVIG that your routinely stock. You use

the HCPCS code for your normal IVIG brand in revenue code 636.

C. Don’t bill at all for the encounter as a courtesy to the physician for making arrangements for

the IVIG to be provided at no cost.

D. Don’t bill the encounter to Medicare, but bill the patient’s Medigap insurance for the usual

charge for both the formulary brand of IVIG and the drug administration services.


ANSWER 2. No Cost Drug

Best Answer A

Bill for the drug administration services and place a token charge of $1.00 on the claim for the IVIG

under revenue code 636 and the appropriate HCPCS code of the brand of IVIG administered.

EXPLANATION 2. No Cost Drug

As of June 29, 2018, CMS requires that a “no-cost” drug be billed on an outpatient claim with a

token charge and the appropriate HCPCS code in revenue code 636.

Other answers:

B. You cannot charge for a drug when you do not incur a cost.

C. You cannot “give away” services to a physician or patient as a courtesy as this may invoke

Stark Law violations for beneficiary or physician inducement.

D. When Medicare is primary and a Medigap policy is secondary, Medicare must be billed first

as the primary payer. It would not be appropriate to bill for one drug when dispensing a

different one when the HCPCS codes are different for the two products.

Resource: CMS Transmittal R4013- March 30, 2018: Institutional Billing of No Cost Items https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4013CP.pdf

POINTS: $400

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4013CP.pdf


QUESTION 3.

Influenza/Pneumonia Vaccine

Your Clinical Manager has read studies that pneumococcal infections in adults 65 years of older can

be deadly: pneumococcal pneumonia kills about 1 out of 20 who get it, pneumococcal bacteremia

kills about 1 out of 5 who get it, and pneumococcal meningitis kills about 1 out of 5 who get it. He

has just reviewed data from last year’s flu season that shows that only 15% of patients over 65 who

were outpatients and inpatients in your institution received a flu vaccine and pneumonia vaccine.

However, when reviewing the costs of the two pneumococcal vaccines (PCV13 (pneumococcal

conjugate vaccine) and PPSV23 (pneumococcal polysaccharide vaccine), you are concerned about

the impact on your budget. In response to your Clinical Manager’s request to set a goal that 90% of

patients over 65 who are eligible get a pneumococcal vaccine starting with the next flu season, you

suggest that he:

A. Set up the computer system so that only outpatients will receive the flu and pneumonia

vaccines

B. Set up the computer system so that patients are identified and receive an Advance

Beneficiary Notice (ABN) notifying them that they will get a separate bill from the hospital

for their flu and pneumonia shots and the estimated amount of the bill

C. Set up the computer system to screen all patients over 65 years of age and prepare to

administer the vaccines to all eligible inpatients and outpatients

D. Set up the computer system so that patients are identified and you administer the flu

vaccine, but you provide them with discharge instructions to go to their physician’s office

to receive their pneumonia vaccine


ANSWER 3.

Influenza/Pneumonia Vaccine

Best Answer C

Set up the computer system to screen all patients over 65 years of age and prepare to administer

the vaccines to all eligible inpatients and outpatients

EXPLANATION 3. Influenza/Pneumonia Vaccine

Medicare pays for both inpatients and outpatients to receive influenza vaccines each year and

pneumococcal vaccines when they are eligible without any co-pay. Accounts for inpatients are split

so that flu and pneumonia vaccines are billed on an outpatient claim and paid separately.

Why are these answers incorrect?

A. It is difficult to distinguish whether a claim may be billed as an inpatient or outpatient at the

time of service and most States require that hospitals report the percentage of all patients

vaccinated for the flu and pneumonia, not just outpatients.

B. An ABN is only issued to a Medicare inpatient when a service is non-covered. Since flu and

pneumonia shots are covered, an ABN would not be appropriate

D. Although answer “d” may lower your drug costs, the CDC recommends that eligible patients

receive both a flu and pneumonia vaccinations from all providers as appropriate. It would

inconvenient for the patient to receive a flu vaccine in the hospital and they might not schedule

an office visit just for a pneumonia vaccine, or the office visit will be delayed putting them at

risk when non-vaccinated.

Ensuring the Integrity of Submitted Claims

Resources: CMS Transmittal 202: December 31, 2014 Modifications to Medicare Part B

Coverage of Pneumococcal Vaccinations https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R202BP.pdf

Resources: CMS Transmittal 3159: December 31, 2014 Modifications to Medicare Part B

Coverage of Pneumococcal Vaccinations https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3159CP.pdf

POINTS: $300

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R202BP.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3159CP.pdf


QUESTION 4.

Inpatient Carve Outs

Your managed care team negotiated new contract terms with commercial payers to pay separately

for higher cost medications used while patients were admitted to the hospital for an inpatient stay.

To accomplish this, you must bill the medications using the unique HCPCS code and under revenue

code 636. The managed care team wants to be proactive and ensure everyone knows about the

sweet carve out deal. Who do you plan to communicate and what changes need to be made?

A. By definition pharmaceuticals requiring detailed coding must use revenue code 636. No

communication or changes are necessary.

B. By definition pharmaceuticals requiring detailed coding must use revenue code 636.

Communicate to the pharmacy & finance team letting them know of the additional revenue

stream.

C. According to the UB billing manual all pharmacy charges for inpatient claims roll to revenue

code 250 in a single line without detailed coding. This change is not possible on the inpatient

claim and communicate to managed care to renegotiate a separate agreement that the billing

team is able to operationalize.

D. According to the UB billing manual all pharmacy charges for inpatient claims roll to revenue

code 250 in a single line without detailed coding. This change requires communication to the

charge master team, billing team, charge capture, and pharmacy teams to ensure claims logic

is in place to accommodate billing a pharmaceutical with detailed coding under revenue code

636.


ANSWER 4.


Best Answer D

According to the UB billing manual all pharmacy charges for inpatient claims roll to revenue code

250 in a single line without detailed coding. This change requires communication to the charge

master team, billing team, charge capture, and pharmacy teams to ensure claims logic is in place to

accommodate billing a pharmaceutical with detailed coding under revenue code 636.

EXPLANATION 4.


The National Uniform Billing (UB) explains the standards for billing. The State and National Uniform

Billing Committees consisting of members from CMS, BCBSA, HIAA, Tricare, etc. determine the date

elements and design of the billing formats. Revenue code 636 is an extension of the pharmacy codes

that require more detailed coding.

Answer A & B are incorrect as not all payers require revenue code 636 for inpatient claims billed on

the UB-04. Majority of inpatient claims are reimbursed by DRG or per diem; thus, detailed coding is

not required.

Answer C is incorrect as the system may be modified through claims logic to allow charges to roll to

Revenue code 250. This may typically be the system default, but it is important to work with the

appropriate stake holders to ensure the logic is correct for any carve outs.

POINTS: $300


QUESTION 5.

LCD Specific

A patient is being seeing in your infusion center for prevention of skeletal-related events related to

bone metastases from a solid tumor. They have been prescribed Xgeva (denosumab) 120 mg syringe

starting their first dose today. You notice that you do not have any Xgeva on your shelf, but you do

have a couple syringes of Prolia (denosumab) 60 mg syringe. What is your best course of action to

serve this patient today?

HCPCS J0897, denosumab 1 mg

Please select the answer that is MOST correct:

A. Initiate a loan/borrow from the nearest health-system to provide the patient with Xgeva

B. Reschedule the patient for an alternative day and order in Xgeva

C. Both brand names consist of the same drug moiety and same HCPCS, denosumab, so it is safe

to administer 2 injections of Prolia

D. Administer 2 injections of Prolia, but change the NDC to Xgeva when billing.


ANSWER 5.

LCD Specific

Best Answer A

Initiate a loan/borrow from the nearest health-system to provide the patient with Xgeva

EXPLANATION 5.

LCD Specific

Prior authorizations are not required when billing for Medicare beneficiaries. Patients must meet

medical necessity in which the drugs administered must be used for an FDA approved indication.

Xgeva is in FDA indicated for skeletal-related events in patients with bone metastases from solid

tumors. Prolia is indicated in patients with osteoporosis and at high risk for fractures. Billing the

Prolia NDC non FDA approved indications will result in a medical necessity denial.

Answer B is not the best answer as you could attempt to service the patient today through

loan/borrow. If your organization does not support loan/borrow or it is not feasible, then B may be

an alternative option.

Answer C is incorrect as it does not matter in this case if the HCPCS is the same for both brand

names, the claim will deny based on the billed NDC (see answer explanation for A)

Answer D is incorrect and it is a standard that the NDC used on the patient should be the NDC that

is billed to the patient.

Resource: Medicare Coverage Database: National and Local Coverage Documents

https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

POINTS: $200

https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx


Discussion Questions (A - C)

Discussion A

Of the following, discuss what is the greatest need for better reimbursement for drugs on outpatients? 1. Education of pharmacists on billing requirements 2. System ability to report National Drug Codes (NDC) 3. Pharmacist on negotiating team for commercial contracts 4. Analysis of rules and transmittals from federal government

Discussion B

Medicare has started Targeted Probe and Education (TP&E) audits which are designed to provide

education to the providers on NCD/LCD interpretation and appropriate documentation. Some of

the TP&E topics from the MAC deal with drugs on outpatients. Describe your current involvement

in TP&E, and discuss what you believe is the pharmacy’s role in TP&E audits and education to

prevent pre-payment reviews and disrupted cash flow.

Discussion C

You have a patient that has been coming to your clinic for 10 years receiving rituximab for his rheumatoid arthritis. He is very disgruntled and states that he received a letter stating his insurance is no longer going to cover his infusions unless he seeks care at a an alternative free standing infusion center or receives care in home. What are some of the driving factors to letters similar to these and what are some next steps?

POINTS: $100


SECTION III: EVALUATING FORMULARY DECISIONS FOR HIGH COST

DRUGS


QUESTION 6.

CAR T-Cell Therapy

Your facility is part of a large health-system network with entities in multiple states. You are known as a leader in cancer diagnosis and treatment and have had a bone marrow transplant service for over 15 years and participate in hundreds of clinical trials. Although you did not participate in any clinical trials for CAR T-Cell therapy products, your VP of Cancer Care has requested that you prepare to order and dispense two new drug products, KYMRIAH and YESCARTA for adult patients. You have determined that the cost to the hospital for either product for adults will be ~$375,000 for one dose as it is an engineered product made from the patient’s own blood cells retrieved during leukapheresis. Because of the newness of the therapy, the VP of Cancer Care indicates that at least the first 30 patients will be admitted as inpatients and remain hospitalized during the infusion and for at least 7 days thereafter due to the high incidence of cytokine release syndrome and the need for immediate treatment. In working with your CFO, you determine that the products have been assigned HCPCS codes Q2040 and Q2041 with the following payment rates listed on Addendum B for July 1, 2018: Q2040- Tisagenlecleucel, up to 250 million CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per infusion [Kymriah] (payment rate: $500,915.367) Q2041- Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR T cells, including leukapheresis and dose preparation procedures, per infusion [Yescarta] (payment rate: $395,380.000) Because of the high cost of these drugs, you prepare a formulary monograph for presentation at the next P&T Committee for their approval and note that neither drug company is willing to sign a contract for pricing. What is your recommendation based upon the financial reimbursement for inpatients?

A. Recommend that only KYMRIAH be stocked since the inpatient payment rate is higher than for the YESCARTA.

B. Recommend that only patients with private insurance be allowed to be scheduled and treated with KYMRIAH or YESCARTA.

C. Recommend that both products be designated as non-formulary and not permitted at the facility since the therapy is so new and so expensive.

D. Recommend that both products be available based upon physician preference since the payment rate is the same when dispensed for Medicare inpatients.


ANSWER 6.

CAR T-Cell Therapy

Best answer: D.

Recommend that both products be available based upon physician preference since the payment

rate is the same when dispensed for Medicare inpatients

EXPLANATION 6. CAR T-Cell Therapy

CMS considered the products to be essentially similar during FY2019 IPPS rulemaking based upon

the new technology applications submitted by the company. The rate of reimbursement is the same

for Medicare inpatients independent of which product is used.

Other answers:

A. Addendum B is only used to determine payment rates for outpatient claims.

B. It would not be appropriate to offer a therapy to private patients only if the facility has signed

an agreement to be a Medicare provider and must adhere to the Medicare Conditions of

Participation.

C. Although this may be a good financial decision, it is unlikely that this recommendation would

be a physician satisfier if the facility is known for cancer treatment and has been performing

bone marrow transplants for a considerable period of time.

Resources:

1. CMS July 2018 Addendum B: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates-Items/2018-July-

Addendum-B.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

2. FY19 IPPS Final Rule: https://www.gpo.gov/fdsys/pkg/FR-2018-08-17/pdf/2018-16766.pdf

POINTS: $400

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates-Items/2018-July-Addendum-B.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending



https://www.gpo.gov/fdsys/pkg/FR-2018-08-17/pdf/2018-16766.pdf


QUESTION 7.

Biosimilar

What can we estimate the reimbursement to be for a Medicare patient who receives Inflectra for

Crohn’s disease who had an inadequate response to conventional therapy? Please note that this

patient received a dose in the ER on 4/1/2018 and the claim is being billed as an outpatient type

claim (Part B coverage). Your facility is currently NOT purchasing drugs under 340B.


A. Items and services are all packaged (SI: N) in the ER setting. No additional reimbursement at

this time

B. Inflectra is considered pass-through (SI: G) and will be reimbursed at 95% of AWP

C. Inflectra is considered Non-pass-through (SI: K) and will be reimbursed at ASP of biosimilar

minus 22.5% ASP of reference product

D. Inflectra is considered pass-through (SI: G) and will be reimbursed at ASP of biosimilar plus

6% ASP of reference product

E. All above are incorrect


ANSWER 7.

Biosimilar

Best answer: D.

D. Inflectra is considered pass-through (SI: G) and will be reimbursed at ASP of biosimilar plus 6%

ASP of reference product

EXPLANATION 7. Biosimilar

Drug and biologics with pass through status get reimbursed at a rate of ASP plus 6%. Drugs and

biologics in different status indictors may get different reimbursement rates. 340 B products

currently get reimbursed at ASP – 22.5%. HCPCS code Q5103 (INJECTION, INFLIXIMAB-DYYB,

BIOSIMILAR, (INFLECTRA), 10MG) currently has a Status indictor of “G” or pass-through status.

Based upon the Proposed OPPS Rule FY2019, the reimbursement will change for biosimilars to ASP

+ 6% (not of the reference product but the actual product.

A. Not all items or services in the ER setting are considered packaged (SI: N). The status indicator

determines the packaging for each product in the ER.

B. Inflectra is consider pass-through (SI: G) and but it gets reimbursed at ASP of biosimilar plus 6%

ASP of reference product.

C. Inflectra is not consider Non-pass-through (SI: K).

POINTS: $300


QUESTION 8. Biosimilar

You are the newly appointed pharmacist on the local P&T committee and the physician chair asks

you which infliximab biosimilars makes the most financial sense to add to formulary. Which item(s)

or activity would you want to explore?


A. Work with finance department to determine the major drug payers at your facility

B. Determine if there is a payer drug policy that excludes certain biosimilars or indications

C. Determine what the contract cost is for each biosimilar product per patient dose

D. All of the above

E. None of the above


ANSWER 8. Biosimilar

Best Answer: D

A. Work with finance department to determine the major drug payers at your facility

B. Determine if there is a payer drug policy that excludes certain biosimilars or indications

C. Determine what the contract cost is for each biosimilar product per patient dose

EXPLANATION 8. Biosimilar

All of these items are good to understand when making a well-informed formulary decision.

Understanding the output of drug contract costs and input of drug reimbursement can help shape

the full picture of the financial performance of each biosimilar product.

POINTS: $200


QUESTION 9.

Specialty Drug

You are asked by the Chief Financial officer (CFO) of the hospital what is considered a specialty drug.

What would be the best answer you can give him/ her?


A. Everyone defines specialty drug differently

B. Specialty drug are often biologics products

C. Drugs that are really expensive are considered specialty

D. Drugs that require special handling are considered specialty

E. None of the above


ANSWER 9. Specialty Drug

Best Answer: A

Everyone defines specialty drug differently

EXPLANATION 9. Specialty Drug

The definition of specialty drugs can vary from the person or perspective that you are talking about.

Specialty drugs can be a part of answers B, C, or D but the best answer is A.

POINTS: $200


QUESTION 10.

IPPS New Technology

You are speaking with someone in revenue integrity at your health system about MS-DRG payments

and reimbursement for drug products and they ask you a questions about CMS’s New Technology

Add-on inpatient payment. What is the time frame a drug product can receive add-on inpatient

payment?


A. Add-on inpatient payments are for 1-2 years

B. Add-on inpatient payments are for 2-3 years

C. Add-on inpatient payments are for 3-4 years

D. A time frame is not defined


ANSWER 10.

IPPS New Technology Best Answer: B

Add-on inpatient payments are for 2-3 years

EXPLANATION 10. IPPS New Technology

For IPPS new technology add-on payments, the time frame can be a maximum of 3 years and a

minimum of 2 year from the date of the application. In order to quality for this payment, the product

must be consider new under CMS regulations.

Resource: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/AcuteInpatientPPS/newtech.html

POINTS: $200

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/newtech.html



QUESTION 11.

IPPS New Technology

The revenue Integrity person asks you how the reimbursement is calculated for these products are

designated to receive inpatient new technology add-on payments.

A. Payment is the lesser of 25% of the average cost of the technology or 25% of the excess cost

over MS-DRG payment

B. Payment is the lesser of 50% of the average cost of the technology or 50% of the excess cost

over MS-DRG payment

C. Payment is the lesser of 75% of the average cost of the technology or 75% of the excess cost

over MS-DRG payment

D. Payment is the lesser of full amount of the average cost of the technology


ANSWER 11.

IPPS New Technology Best Answer: B

Payment is the lesser of 50% of the average cost of the technology or 50% of the excess cost over

MS-DRG payment

EXPLANATION 11. IPPS New Technology

For IPPS new technology add-on payments, payment is the lesser of 50% of the average cost of the

technology or 50% of the excess cost over MS-DRG payment. Areas may vary from the amount of

reimbursement they receive due to differences in cost of living. In order to quality for this payment,

the product must be considered new under CMS regulations

Resource: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/AcuteInpatientPPS/newtech.html

POINTS: $200




QUESTION 12.

Hemophilia Products You have been asked to review 5 accounts for Medicare hemophilia patients who received Wilate injection (Von Willebrand Factor/Coagulations Factor VIII Complex (Human) within the past 3 months. The HCPCS Code is J7183 Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco. You note according to the package insert that the ratio of VWF to RCO is 1:1. For each of the 5 accounts you review the medical record and provide the following summary:

Patient #

Patient Type

Physician Ordered in

VEF:RCO Units

Amount Administered

Billed Units of J7183 for each Date of

Service

#1 Inpatient 2100 units every

12 hours 2376 units @

0900 and 2100 5000

#2 Inpatient 2600 units every

24 hours 2500 units @

0900 3000

#3 Outpatient 1997 units x 1 2000 units @

1500 2000

#4 Outpatient 4400 units x 1 4347 units @

1000 5000

#5 Outpatient 2500 units x 1 2337 units @1200 2500

Based upon your medical record review you authorize rebilling for:

A. None of the claims need to be rebilled because they are all single dose vials

B. All of the claims need to be rebilled

C. Only the outpatient claims need to be rebilled as inpatient claims are paid under a fixed payment of the MS-DRG

D. Only patients #1, #2 and #4 need to be rebilled


ANSWER 12.

Hemophilia Products Best Answer: B

All of the claims need to be rebilled

EXPLANATION 12. Hemophilia Products

All the claims need to be rebilled as the lot-specific factors are billed per unit that is stamped on the top of each vial. Only the amount ordered by the physician or administered to the patient can be billed. When there is a discrepancy between what was ordered and what was administered, only the lower of the two can be billed. Hemophilia products are reimbursed separately on both inpatients and outpatients so all claims need to be rebilled as they all resulted in an overpayment. The indicator on the ASP quarterly file from CMS shows if a blood clotting factor is eligible for separate reimbursement on hemophilia patients.

A. Lot-specific factors have the actual lot stamped on top of each vial and only that amount can be

billed. It is recommended that a physician order be obtained to cover the full amount on hand due to the high cost of the products.

C. For this HCPCS code, there is a blood clotting factor additional payment which applies to both inpatients and outpatients.

D. Patient #3 needs to be rebilled since the physician ordered 1997 units and only that amount can be billed. Patient #5 needs to be rebilled because the pharmacy adjusted the dose to what was “on hand” in the pharmacy, 2337 units. Since 2337 units were administered, only 2337 units can be billed.

Resources: CMS ASP Pricing File, 2018- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2018ASPFiles.html

POINTS: $200

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2018ASPFiles.html



Discussion Questions (D - F) Discussion D

When making formulary decisions, how often do you take into consideration the reimbursement

impact in addition to the cost of the product? When you take reimbursement into consideration,

do you typically calculate based upon Medicare only, or do you consider major commercial

contracts?

Discussion E

Certain drugs have additional reimbursement on inpatients such as TPA for stroke and drugs eligible

for new technology add-on payments. However, the additional reimbursement is generated when

ICD-10-PCS codes are added to the claim, not for a HCPCS code related to the drug. Describe your

process for having inpatient claims correctly coded to generate the additional reimbursement.

Discussion F

Blood clotting factors used to prevent and treat certain congenital and acquired hemophilia

conditions are reimbursed separately on inpatient claims. Since each blood clotting factor has a

separate HCPCS code and payment, it is necessary to add the HCPCS codes back onto eligible

inpatient claims since individual HCPCS codes are not reported on inpatient claims only revenue

codes. Describe your process for having HCPCS codes added to inpatient claims for

hemophilia/blood clotting products that are eligible for additional reimbursement.

POINTS: $100


SECTION IV: ENSURING THE INTEGRITY OF SUBMITTED CLAIMS


QUESTION 13.

Bolus from the Bag

Your system just went live with a new workflow to document alteplase on the MAR. About a month

later, your 340B coordinator notices your 340B accumulations are significantly higher than your

purchases. You reviewed the workflow and realized the bolus dose and infusion dose are

documented using two separate orders. This facilitates the clinical workflow well, but the infusion

dose is set to drop a charge for the entire bag when a portion of this was used for the bolus dose

from the same bag.

Please assess the issues with this situation

A. The bolus dose amount is overcharged/billed to the patient creating an over accumulation in 340B

B. The bolus dose amount is overcharged/billed and may result in a direct overpayment by Medicare.

C. The bolus order and infusion order may incorrectly represent the total dose of alteplase given to the patient.

D. All of the above


ANSWER 13.

Bolus from the Bag

Best Answer: D

All of the claims need to be rebilled

EXPLANATION 13. Bolus from the Bag

This question highlights the importance of communication between clinical team builds and how they

may impact billing. It is important to assess and test front to back end workflow to ensure you do not

create a situation of overcharging or overbilling of the medication.

POINTS: $300


QUESTION 14.

Drug Shortage & Compounding

You find out from the pharmacy buyer that your pharmacy is going to be getting Hydromorphone

0.5 mg/ 1 ml from RJ’s Compounding Pharmacy (503-B) starting today. Which HCPCS code(s) would

be the best code to use in this scenario?


A. HCPCS code J1170 (INJECTION, HYDROMORPHONE, UP TO 4 MG) is the best

B. HCPCS code J7999 (COMPOUNDED DRUG, NOT OTHERWISE CLASSIFIED) is the best

C. HCPCS code J3490 (UNCLASSIFIED DRUGS) is the best

D. None of the above


ANSWER 14.

Drug Shortage & Compounding

Best Answer: B

HCPCS code J7999 (COMPOUNDED DRUG, NOT OTHERWISE CLASSIFIED) is the best

EXPLANATION 14. Drug Shortage & Compounding

HCPCS code J7999 should be used with truly compounded items. Compounding can vary by payer

or site. Since the case above states that it is purchased from a 503(B) compounding pharmacy, the

J7999 HCPCS code is the most appropriate.

POINTS: $300


QUESTION 15.

Unapproved Drugs

You recently received an email from the informatics pharmacist asking you how you would setup

and charge for the following drug product. What would the best response be?

Please add 14.6% sodium chloride NDC # 63323-0139-40 in both a 1 ml and 40 ml doses.

Please select the answer that is MOST correct: A. You would add this product in your clinical system and attach HCPCS code J7999

(COMPOUNDED DRUG, NOT OTHERWISE CLASSIFIED).

B. You would add this product in your clinical system and attach HCPCS code J3490 (UNCLASSIFIED

DRUGS).

C. You would add this product to your clinical system but set the system not to charge.


ANSWER 15.

Unapproved Drugs Best Answer: C

You would add this product to your clinical system but set the system not to charge

EXPLANATION 15. Unapproved Drugs

This NDC number (63323-0139-40) is listed by the FDA as an unapproved drug, therefore shouldn’t

be billed to payers unless they supply specific instructions.

Incorrect A: This drug product is manufactured by a Pharmaceutical company and therefore isn’t

considered a compounded product.

Incorrect B: Since this product is unapproved, you wouldn’t bill this product to payers unless they

supply specific instructions.

POINTS: $300


QUESTION 16.

Overpayment You are notified on June 11, 2018 that the billed units for two different antibiotics are double charged on a patient claim. Researching the account, you notice that the charges are for a Medicare outpatient (Part B coverage). You verify that the reported information is correct and proceed to the next step.

HPCPCS Code Manual Description Status Indicator Reimbursement

J0878 Injection, Daptomycin, 1 MG K $$$$

J3370 Injection, Vancomycin HCL 500 MG N SS

What should be the next you next steps? Please select the answer that is MOST correct A. You need to ensure that any overpayment received is reported and returned within 30 days of

June 11, 2018.

B. You need to ensure that any overpayment received is reported and returned within 60 days of

June 11, 2018.

C. You need to ensure that any overpayment received is reported and returned within 90 days of

June 11, 2018.

D. Wait until someone at Medicare contacts you with instructions.


ANSWER 16.

Overpayment

Best Answer: B

You need to ensure that any overpayment received is reported and returned within 60 days of

June 11, 2018.

EXPLANATION 16. Overpayment

It requires providers and suppliers receiving funds under the Medicare program to report and return

overpayments by the later of the date that is 60 days after the date on which the overpayment was

identified; or the date any corresponding cost report is due, if applicable.

Section 1128J (d) of the Social Security Act (the Act)

Resource: https://www.ssa.gov/OP_Home/ssact/title11/1128J.htm

POINTS: $200

https://www.ssa.gov/OP_Home/ssact/title11/1128J.htm


QUESTION 17.

Underpayment

Your Finance Department has been comparing purchase history records of drugs purchased and drugs billed for the past 3 months. They’ve sent you a report with discrepancies that have a difference of more than 20% showing that more drug was purchased than what has been billed. They send you a sample of claims for HCPCS code J0885 (Injection, epoetin alfa, (for non-esrd use), 1000 units) and note that they did not have any claims billed under Q4081 (Injection, epoetin alfa (for esrd on dialysis), 100 units). You retrieve a list of patients that received epoetin in the past 3 months and review the medical record and the claim for each account. You discover that patients who were on one outpatient unit of the hospital all received 20,000 units of epoetin but the billing reflects only 1 unit of J0885 (1000 units) with the patient charge for 1000 units of $178.00. Upon further investigation, you discover that the unit-based cabinet interface is not calculating the conversion correctly. When the nurse removes a 20,000 unit multi-dose vial, the quantity transmitting to Patient Account is 1 unit of J0885. You do an additional search and it appears that this discrepancy has been going on for at least 2 years. You contact the IT&S department to request that the interface programming be reviewed, but for the claims that you have researched for the past 2 years you recommend:

A. Review the revenue loss with your CFO to make them aware of the underbilling so they can

book a journal entry to account for the discrepancy in previous financial periods. B. Request that all outpatient Medicare claims with a date of service within the past year be

rebilled with the correct quantity of “20” and review other payer contracts for rebilling guidance.

C. Request that all outpatient Medicare claims with a HCPCS code of J0885 be rebilled if the dates of service were within the past 2 years and review other payer contracts for rebilling guidance.

D. Correct the billing manually in the clinical pharmacy system so that the charges on the claim will

be corrected.


ANSWER 17.

Underpayment

Best Answer: B

Request that all outpatient claims with a date of service within the past year be rebilled with the

correct quantity of “20”

EXPLANATION 17. Underpayment

This was an outpatient unit only and appears to be isolated to one area. Medicare and most

commercial payers have a rebilling limit for underbilling of 12 months although some payers like

Medicaid may be as short as 90 days.

Other Answers:

A. Although it would be good to review the event with your CFO it is unlikely that they will book

a journal entry for a previous year as this may have impacts on the cost reports that have already

been filed.

C. Medicare has timely filing limits of 12 months for underbilling. For overpayments, providers

are expected to rebill for 6 years and within 60 days of discovery of the overpayment.

D. Correcting the billing in the pharmacy system for charges more than 3-4 days, typically results

in late charges that may or may not be posted, even if the system allows changes. Charge

corrections also require “rebilling” of the claim which is not automated and must be requested

when there is significant time from the date of the provision of the service and the correction.

Resource: CMS Transmittal 2140: Changes to the Time Limits for Filing Medicare Fee-For-Service Claims- January 21, 2011: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2140CP.pdf

POINTS: $400

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2140CP.pdf


QUESTION 18.

Not-Billable Services The CDC is recommending all healthy adults over the age of 50 receive two doses of Shingrix (recombinant zoster vaccine) over one dose of Zostavax (live zoster vaccine). The two doses of Shingrix will cost an additional $60 per person vaccinated.

Organization’s population statistics:

Adults Age Total Volume Volume by Payer

0-18 years 24% Commercial – 16%

Medicaid – 8%


Medicaid – 12% Medicare – 1%



61+ years 23% Commercial – 3%


Shingrix

HCPCS 90750

Status Indicator: M

MUE: Facility = 1, Professional = 1

What is your recommendation to maximize revenue for the Shingrix vaccine?

A. Mandate a questionnaire for all newly admitted inpatients and ensure the vaccine is administered to all eligible adult greater than 50 years of age prior to discharge. Ensure documentation is acquired and bill the vaccine on the inpatient UB-04 claim.

B. Mandate a questionnaire for all newly admitted inpatients and ensure the vaccine is administered to all eligible adult greater than 50 years of age prior to discharge. Enroll in roster billing thereby splitting the Shingrix off the inpatient claim and submitting to Medicare Part B outpatient claim.

C. Encourage patients to follow up in an outpatient facility/clinic to receive the Shingrix vaccine. Ensure appropriate documentation and bill on the outpatient UB claim.

D. Encourage patients to follow up in a retail pharmacy and have a pharmacist administer the vaccine billing to the patient under Part D or other pharmacy benefit.


ANSWER 18.

Not-Billable Services

Best Answer: D

Encourage patients to follow up in a retail pharmacy and have a pharmacist administer the vaccine

billing to the patient under Part D or other pharmacy benefit.

EXPLANATION 18. Not-Billable Services

Governmental payers, Medicaid & Medicare, classify this medication with a status indicator of “M”

which is defined as “Items and Services Not Billable to the MAC”. Therefore, it is not appropriate to

bill for this medication on an outpatient claim will result in $0 revenue. Part D and other pharmacy

benefits managers do reimburse for the vaccine.

Answer A is incorrect as inpatient claims are subject to DRG or per diem rates. No additional revenue

will be made on the administration of the Shingrix.

Answer B is incorrect as only pneumococcal and influenza vaccines are eligible for roster billing.

Additionally, governmental payers will not reimburse for the status indicator of M.

Answer C is incorrect due the assignment of the status indicator of M. Status indicators are indicated

for OPPS billing; however, free standing clinics or other clinics that follow the physician fee schedule

rules also classify this as a non-billable service and will result in $0 payment.

Resources:

CDC Shingles Vaccination:

https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html

CMS Addendum B:


Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-

Updates.html?DLSort=2&DLEntries=10&DLPage=1&DLSortDir=descending

CMS Addendum D1:


Payment/HospitalOutpatientPPS/downloads/CMS1506FC_Addendum_D1.pdf

POINTS: $400

https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html?DLSort=2&DLEntries=10&DLPage=1&DLSortDir=descending



https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/downloads/CMS1506FC_Addendum_D1.pdf



QUESTION 19.

Waste Your finance department notices a large variance between purchases vs. charges of rituximab. After further research, patients on average received only 750 mg and the rest is wasted but not charged. What is the potential added revenue you could achieve if you started billing for waste on these patients?

Available formulations o Rituximab 100 mg/10 mL o Rituximab 500 mg/50 mL

Billing quantity = 100 mg

ASP + 6% = $884

A. Dose = 750 mg (billing qty = 8), Waste = 250 mg (billing qty = 3) Added revenue for waste = $884 x 3 = $2,652

B. Dose = 750 mg (billing qty = 8), Waste = 50 mg (billing qty = 0) Added revenue for waste = $884 x 0 = $0

C. Dose = 750 mg (billing qty = 8), Waste = 50 mg (billing qty = 1) Added revenue for waste = $884 x 1 = $884


ANSWER 19.

Waste

Best Answer: B

Dose = 750 mg (billing qty = 8), Waste = 50 mg (billing qty = 0) Added revenue for waste = $884 x 0 = $0

EXPLANATION 19. Waste

Medicare requires the smallest vial size to be used when preparing medications to minimize waste.

To prepare 750 mg, you may use a combination of 1 x 500 mg vial plus 3 x 100 mg vial or 8 x 100 mg

vials. Thus, only 50 mg of waste can be billed. The billing quantity is equal to 100 mg and you cannot

bill more than the volume contained in the vial. A quantity of 8 = 800 mg billed which is rounded up

(no decimals allowed).

Answer A in incorrect as it assumes you used 2 x 500 mg vials. In this case, you could have used the

smaller 100 mg vial to prepare the dose.

Answer C is incorrect because the total bill quantity is 9 but only a total of 8 billing units are

contained in the vials to prepare a 750 mg dose. This would be considered an overpayment.

What is your action step to resolve you purchases vs. charges variance?

Evaluate your preparation practices and ensure each preparation is being prepared using the

smallest vial size available to minimize the waste.

Other information regarding waste.

Waste is a valuable method to recoup payment. Requirements for billing waste:

• Only allowed for single dose vials

• Documentation of the waste must be contained in the medical record

• Each charge line must include a JW modifier

• The billed quantity must not exceed the amount in the vial

Resource:

CMS Waste FAQ updated August 26, 2016


Payment/HospitalOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf

POINTS: $300

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf


Discussion Questions (G & H)

Discussion G

Describe your current process for determining if a drug is “compounded” for billing purposes and

when the use of HCPCS code J7999-compounded drug, not otherwise classified is the most

appropriate HCPCS code to bill on a claim.

Discussion H

Describe your process when a billing error has occurred that resulted in an overpayment to a federal

payer (e.g. Medicare, TRICARE) and how you participate in ensuring that the overpayment is

refunded.

POINTS: $100


SECTION V: IMPLEMENTING & MONITORING REVENUE CYCLE

MANAGEMENT SYSTEMS


QUESTION 20.

Packaged Drug Your organization is in the process of reviewing procedural areas’ (i.e. GI, imaging, etc.) documentation and charging practices to improve safety and charging. Your team is implementing medication barcode scanning; therefore, will be dropping charges upon administration on the MAR. The procedural departments are pushing back and do not want to barcode scan heparin flushes or contrast. They state they should not have to document these as they are “not drugs” and should not have to bill for these items as they are included in the procedure charge (example: MRI with contrast). What is your best approach to overcome this hurdle? A. Contrast and heparin flushes are included in Level II HCPCS coding system. It is best practice to

bill out each code separately as the data is used to formulate long term decisions by Medicare to establish procedure payment rates.

B. The procedure code example, MRI with contrast, is the explanation of the procedure being performed. The contrast product has a separate code that should be used to bill along with the procedure “MRI with contrast”.

C. Some Heparin flush products and contrast products contain NDCs and have been approved by the FDA as a drug; therefore, may be billed as a packaged drug.

D. All of the above are true statements


ANSWER 20.

Packaged Drug Best Answer: D

All of the above are true statements

EXPLANATION 20. Packaged Drug

Each organization may vary in how items are billed and may interpret regulations differently. The Level II HCPCS system is a comprehensive standardized dataset used to identify products, supplies, and services not included in the CPT code. This data is used to formulate payment thresholds for rendered services among other things. The more detailed information provided will allow CMS to understand the additional services that are required for particular procedures/diagnoses. Some Heparin flushes and contrast (majority) are FDA approved drugs that are considered “packaged”. Packaged, identified by the CMS status indicator of N, is any drug that is less than an average of $120 per day (CMS calculation). These drugs are separately billable to Medicare, but are not separately payable.

POINTS: $200


QUESTION 21.

Pass-Through vs. Non-Pass-Through Drug

Your clinical coordinator is interested in adding a new antibiotic, IV delafloxacin, to the hospital

formulary. After speaking with the finance department, a difference is noted in the reimbursement

rates (see information below from Addendum B - OPPS Payment by HCPCS Code for CY 2018) when

comparing to IV levofloxacin, another injectable antibiotic in the same drug class. Of note, these

drugs were not purchased under a 340B account.

HCPCS Code Short Descriptor Status

Indicator (SI) Payment Rate

C9462 Injection,

delafloxacin G $0.47 per 1 mg

J1956 Injection,

levofloxacin N $0

After further review, the difference in reimbursement was noted due to the difference in the OPPS

status indicators. Which of the following descriptions defines the OPPS status indicator for IV

delafloxacin?

A. Items, codes, and services that are not paid under OPPS or any other Medicare payment system

B. Pass-through drugs and biologicals, paid under OPPS as a separate APC payment

C. Non-pass-through drugs and non-implantable biologicals, including therapeutic

radiopharmaceuticals, paid under OPPS as a separate APC payment

D. Items and services packaged into ambulatory payment classification (APC) rates, paid under

OPPS, no separate APC payment due to packaging


ANSWER 21.

Pass-Through vs. Non-Pass-Through Drug

Best Answer: B

Pass-through drugs and biologicals, paid under OPPS as a separate APC payment

EXPLANATION 21. Pass-Through vs. Non-Pass-Through Drug

IV delafloxacin is classified as OPPS status indicator G under pass-through drugs and biologicals.

Pass-through drug status was established to incentivize use of innovative medical drugs, biologics,

and devices. Other examples include orphan drugs or certain cancer biologics.

Answer A is incorrect since it is the description of status indicator E1, with examples being certain

vaccines or oral buprenorphine.

Answer C is incorrect since it is the description of status indicator K, with an example being

infliximab.

Answer D is incorrect since it is the description of status indicator N. IV levofloxacin would be

classified as OPPS status indicator N.

POINTS: $300


QUESTION 22.

Self-Administered Drug

The Director of Nursing has read an article in the New York Times about patients receiving a separate

bill for their home medications at inflated charges after an outpatient encounter. She sends you an

email asking you to endorse having all patients bring their home meds to the hospital and take them

so that they won’t get a separate bill. You set up a meeting with her to discuss her idea. From a

financial standpoint, what is your best recommendation?

A. Do not allow Medicare patients to take their own medications, but patients who have private

insurance can bring in their own medications

B. You explain that “self-administered drugs” apply only to Medicare and Medicare Advantage

patients, but the hospital is no longer obligated to bill them to the patient

C. No patients are allowed to ever bring any of their own medications into the hospital

D. All patients are mandated to bring in their own maintenance medications to the hospital and

take them themselves as self-medication


ANSWER 22. Self-Administered Drug

Best Answer: B

You explain that “self-administered drugs” apply only to Medicare and Medicare Advantage

patients, but the hospital is no longer obligated to bill them to the patient

EXPLANATION 22. Self-Administered Drug

Self-administered drugs apply only to Medicare patients who are billed on a claim as an outpatient.

In October 2015, the Office of Inspector General (OIG) issued a policy statement that hospitals may

fully discount self-administered drugs and not bill the patient separately for them.

The other answers:

A. Typically, the insurance status of a patient is not known to the pharmacists and nurse managers

so it would be difficult to treat one type of insurance differently than another for an issue that is so

broad.

C. There may be items that are non-formulary or restricted specialty drugs that can’t be ordered by

the hospital pharmacy. Investigational drugs that are issued to a patient at a different location

would also need to be supplied by the patient. This would be a very broad policy that would be

difficult to enforce.

D. With required medication identification and potential barcoding for BCMA systems, this would

be an operational challenge. In addition, even if requested, some patients would not bring their

medications to the hospital which would be confusing to providers who dispense and administer

the medications.

Resources:

OIG Policy Statement: https://oig.hhs.gov/compliance/alerts/guidance/policy-10302015.pdf

How Medicare Covers Self-Administered Drugs Given in Hospital Outpatient Settings:

https://www.medicare.gov/pubs/pdf/11333-How-Medicare-Covers-Self-Administered-Drugs-in-

Hospital-Outpatient.pdf

Medicare Claims Processing Manual- 100-04 Chapter 17, Section 80.5: Self-Administered Drugs:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c17.pdf

POINTS: $400

https://oig.hhs.gov/compliance/alerts/guidance/policy-10302015.pdf

https://www.medicare.gov/pubs/pdf/11333-How-Medicare-Covers-Self-Administered-Drugs-in-Hospital-Outpatient.pdf

https://www.medicare.gov/pubs/pdf/11333-How-Medicare-Covers-Self-Administered-Drugs-in-Hospital-Outpatient.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c17.pdf


QUESTION 23.

Quarterly Maintenance Process for Billing Information

Which of the following is correct in regards to the frequency that CMS publishes maintenance files?

Please select the answer that is MOST correct: A. The Alpha Numeric HCPCS file and Addendum B are updated every quarter.

B. The Alpha Numeric HCPCS file is updated every quarter

C. Addendum B is updated yearly

D. The Alpha Numeric HCPCS file is updated yearly

E. None of the above are correct


ANSWER 23.


Best Answer: D

The Alpha Numeric HCPCS file is updated yearly

EXPLANATION 23.


The Alpha Numeric file is published once yearly usually in the beginning of December for the

following year. The Addendum B can be published every quarter.

Alpha-Numeric HCPCS

https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html

Addendum B


Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html

POINTS: $200


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html



QUESTION 24.


How often does CMS release a new HCPCS code?

Please select the answer that is MOST correct: A. CMS can release a new HCPCS code once a week

B. CMS can release a new HCPCS code once a month

C. CMS can release a new HCPCS code once a quarter

D. CMS can release a new HCPCS code once a year

E. There is no set schedule


ANSWER 24.


Best Answer: C

CMS can release a new HCPCS code once a quarter

EXPLANATION 24.


CMS can release HCPCS code once a quarter and will be reflective in the Addendum B file that

quarter and the Alpha Numeric file the next year.

Alpha-Numeric HCPCS


Addendum B



POINTS: $200





Discussion Questions (I - L)

Discussion I Of the following which is the greatest barrier to getting paid for drug products? Choose one and

identify one way that you have overcome this barrier. drug chargemaster setups

preauthorization

clinical requirements

documentation requirements

NDC reporting

Discussion J The requirement to report wasted drug on a separate charge line from single dose vials that are

separately payable was mandated by Medicare effective January 1, 2017 and includes the reporting

of the wasted amount on a separate charge line with a JW modifier and a statement in the medical

record that the amount was wasted. Health systems have taken different approaches to meeting

this requirement, including the following. Discuss how your health system is meeting this

requirement.

Only Billing what was administered to the patient from single dose vials even if the remainder

is wasted

Billing for waste for only targeted, very expensive drugs

Billing for all discarded waste to fully meet the regulatory requirements and maximize drug

reimbursement

Discussion K Describe your current process for self-administered drugs on outpatients. Do you allow patients to

bring in their own medications? If so, how do you verify integrity and document administration? If

not and you supply the drugs, do you bill the patients for the drugs directly, bill the insurance

company only, or discount the drugs so that the Medicare patients do not receive a bill.

Discussion L Your state Medicaid agency completed an audit of drugs billed from Jan 2015 through December 2017

and has provided you with a list of 215 patients that they are stating the NDC was invalid for the date

of service. The compliance department is very concerned that an invalid NDC has been billed. How do

you assess your organization and ensure the correct (administered) NDC is billed?

Review ADS machines for charge on dispense mechanisms

Validate default NDC are represented of current NDC

Ensure barcode scanning of each drug is in place wherever feasible

Validate new NDC purchased are updated in EMR prior to being dispensed

POINTS: $100


SECTION VI: EFFECTIVLEY APPEAL DENIALS WHEN THEY OCCUR


QUESTION 25.

Targeted Probe and Educate

Your facility has just been notified by Novitas (your Medicare Administrative Contractor (MAC)) that you have received the results for a Round 1 Targeted Probe and Educate audit on Denosumab injection and your compliance rate is 30%. You review the TP&E criteria and determine that the largest deficiency in the records is in the documentation of medical necessity. An educational call is scheduled for next Thursday. How do you respond to this request for assistance?

A. The TP&E program from Medicare doesn’t impact pharmacy since they are only reviewing

medical records which is the responsibility of the Health Information Management (HIM) department.

B. Decline to participate in the educational call since there are no fees or penalties associated with the audit.

C. Recommend that an order form be jointly developed between Pharmacy and the Oncology Physicians to ensure that all required information including previous history, indication for the drug, risk of fracture or bone metastases, and bone density scan results are provided when the drug is ordered through a paper order sheet or electronic order entry.

D. Suggest that you will only stock Xgeva in the future since it appears that only the Prolia product

is subject to the TP&E audit.


ANSWER 25.

Targeted Probe and Educate

Best Answer: C

Recommend that an order form be jointly developed between Pharmacy and the Oncology

Physicians to ensure that all required information including previous history, indication for the drug,

risk of fracture or bone metastases, and bone density scan results are provided when the drug is

ordered through a paper order sheet or electronic order entry.

EXPLANATION 25. Targeted Probe and Educate

Pharmacy should assist in obtaining complete documentation from the physician when drugs are

ordered to ensure that they are used appropriately and that all payer documentation requirements

are met.

Other answers:

A. Although TP&E audits are based upon a review of the medical record, all disciplines with

input into the appropriate care of the patient should participate in the TP&E process since

non-compliance in future Rounds can result in further actions by CMS including pre-

payment reviews, extrapolation for additional refunds, referral to Recovery Audit

Contractor (RAC) or other actions.

B. The TP&E educational call is provided to educate providers on where care or documentation

is insufficient. Pharmacies can assist with ensuring that the drugs are appropriately ordered

and administered and that the medical record supports what was billed on the claim (i.e.

physician order and complete documentation of administration)

D. Although the “Prolia” product is named in the Novitas checklist, CMS pulls records based

upon the HCPCS code on the claim. Since both Prolia and Xgeva are billed with the same

HCPCS code (J0897), both drugs are subject to the TP&E audit.

CMS Website: Targeted Probe and Educate:

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-

Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

Consider adding the link to the Novitas TPE on denosumab:https://www.novitas-

solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00184116&_afrLoop=8667406

34047517#!%40%40%3F_afrLoop%3D866740634047517%26centerWidth%3D100%2525%26conte

ntId%3D00184116%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse

%26showHeader%3Dfalse%26_adf.ctrl-state%3Dbpiq5iugx_33

POINTS: $400

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00184116&_afrLoop=866740634047517#!%40%40%3F_afrLoop%3D866740634047517%26centerWidth%3D100%2525%26contentId%3D00184116%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3Dbpiq5iugx_33






QUESTION 26.

MUE

Background

Medicare OP claim was rejected for a published MUE (Medically Unlikely Edit)

Rejected HCPCS code is J1650- Injection, enoxaparin sodium, 10 mg

MUE limit for J1650 is “30” as a Date of Service Edit and the rationale is Clinical: Data

FDA labelling for enoxaparin dosing is: In outpatient treatment, patients with acute deep vein thrombosis without pulmonary embolism who can be treated at home, the recommended dose of Enoxaparin Sodium Injection is 1 mg/kg every 12 hours administered SC.

The patient weighs 275 lbs (124.738 kg)

Case

A review of the medical record documentation shows the following administrations for enoxaparin

documented by barcode medication administration (BCMA) for the date of service in question.

Dose ordered: 1 mg/kg every 12 hours

Administered at: 0939

Dose: 120 mg using one 120 mg/ml 0.8 ml syringe sc

Record filed at: 0944

NDC captured in record: 0703861021

Administered at: 0943

Dose: 124.738 mg using two 100 mg/ml 1 ml syringes sc

Record filed at: 0944

NDC captured in record: 0703858021

(both doses administered by the same nurse)

The patient was discharged to home before the evening dose was due.

The claim shows that 32 units were billed but rejected by Medicare due to the MUE.

What is the best solution to process the claim?

A. Lower the billed units to 30 to match the published MUE without a medical record review

B. Lower the billed units to 12 and remove 20 units

C. Call the nurse on duty to ask what she administered

D. Prepare a paper claim with 32 billed units and request an appeal of the MUE due to the patient’s weight


ANSWER 26.

MUE Best Answer: B

Lower the billed units to 12 and remove 20 units

EXPLANATION 26. MUE

It is most likely based upon the physician order and the sequencing of the documentation that the

nurse only administered the 1 x 120 mg dose since both records were filed at the exact same time.

It appears that the clinical system calculated based upon the patient’s weight, but the caregiver

rounded the dose down from 124.738 to 120 mg and administered only 1x120 mg dose.

Other explanations:

A. It would never be appropriate to just match the published MUE without a medical record

review.

C. MUE are only active in the Outpatient Code Editor (OCE). Since the after discharge there are

usually 3-4 days of claims corrections and late charges, the claim would not be sent to the OCE

grouper until at least 4 days. The same nurse would not be on duty and even if you were able

to reach her, she may not remember exactly what occurred after a span of days or weeks as the

claim is being processed.

D. For a patient weighing 124 kg and with a physician order of 1 mg/kg every 12 hours, billed units

of 32 equal a dose of 320 mg which would be unlikely for a morning dose. The patient was

discharged before an evening dose was due, so only one dose should appear on the claim.

Resources:

1. CMS Published MUEs (updated quarterly): General Information:

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html

2. CMS Published MUEs (Current and Previous Quarter):

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes.html

POINTS: $400


https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes.html


QUESTION 27.

MUE/Appeal In March 2018, the FDA approved a new 4 week dosing regimen for nivolumab (Opdivo). This 480 mg dosing regimen has been proven just as efficacious as the previous 2 week at 240 mg, and now offers patients the convenience and flexibility to meet their needs. Your physicians jumped on board and switched 83% of their patients to the new dosing regimen. 3 months later your denial team approached you and stated the Opdivo is denied and is not being reimbursed by Medicare. You notice the MUE has been exceeded, what is your next step to recoup your loss? HCPCS: J9299, nivolumab 1 mg MUE: 440 MAI: 3 ASP + 6%: $27.15

A. Talk to your physicians and state they must convert the dose back to 240 mg to stay under

the MUE limit

B. Instruct the billing staff they should only bill up to the MUE limit as required by Medicare

C. Bill for the full 480 billing units and work with your denial management team to write a letter to Medicare and appeal the denial

D. Instruct patients to find an alternative facility to receive their nivolumab infusion


ANSWER 27.

MUE/Appeal Best Answer: C

Bill for the full 480 billing units and work with your denial management team to write a letter to

Medicare and appeal the denial

EXPLANATION 27. MUE/Appeal

An MAI indicator of 3 means, Medicare has set the MUE based upon clinical benchmarks. This means

when a claim is denied it may be appealed with appropriate documentation to support the excess

billed services.

Answer A is not the best answer in this case. Converting back to the original dosing will stay under

the MUE limit and allow the claim to process without denial. However, this regimen may not be the

preference of the patient or provider when there is another clinically appropriate option available.

Writing the appeal will provide feedback back to Medicare and in turn provide more support for

changing the MUE value.

Answer B is incorrect as it will generate a loss of 40 mg or $1,086 each time a dose is given at 480

mg.

Resource:

CMS MLN Matters: MM8853

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/downloads/MM8853.pdf

POINTS: $300

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8853.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8853.pdf


SECTION VII: TEXAS TRIVIA


Trivia Questions & Answers

1. Which major Gas Station Company was created/founded in Dallas?

A. Twice Daily

B. 711 C. Shell

D. Mobil

E. Speedway

2. Which professional sports team is NOT currently located in Texas?

A. Cowboys

B. Mavericks

C. Stars

D. Thunder E. Astros

F. Comets

G. Rockets

H. Spurs

I. Rangers

3. Dallas is the ___ largest city by population in the United States (2014).

A. 12th

B. 9th

C. 3rd

D. 5th E. 7th

4. What time zone is Dallas located in?

A. AT

B. CT C. MT

D. ET

5. How many golf courses does Dallas have?

A. 0-99

B. 100-199

C. 200-299 D. 300+

6. How big is Dallas’s Fort Worth international airport?

A. 13 square miles

B. 19 square miles

C. 27 square miles D. 31 square miles


7. What percentage of America’s paper bills are printed in Dallas?

A. 25%

B. 35%

C. 48%

D. 60%

8. Sam Houston, arguably the most famous Texan, was born in which state?

A. South Carolina

B. Virginia C. Tennessee

D. Texas

E. Missouri

9. How tall is the Big Tex statue?

A. 59 feet

B. 68 feet

C. 43 feet

D. 52 feet

10. Texas is the only state to have the flags of six different nations fly over it. Which nation is

NOT one of these six?

A. Spain

B. France

C. Mexico

D. Republic of Texas

E. Confederate States

F. England G. All answers are correct

11. Texas is popularly known as the __________ State?

A. Show Me

B. Lone Star

C. Natural

D. Golden

E. First

12. Which City in Texas is the Alamo located?

A. Dallas

B. Houston

C. Austin

D. Fort Worth

E. San Antonio

POINTS: $100


SECTION VIII: ADDENDUM


Definitions

Advance Beneficiary Notice (ABN)

Notice of non-coverage, issued by all health care providers when Medicare payment is expected

to be denied

Hospital Outpatient Prospective Payment System (HOPPS or OPPS)

Created by CMS, sets the standards for billing, payment rates and other relevant regulations for

Part B services, and some inpatient services billed as Part B, for Medicare beneficiaries

Inpatient Prospective Payment System (IPPS)

System of payments for acute care hospital inpatient services under Medicare Part A based on

prospectively set rates

Local or National Coverage Determinations (LCD/NCD)

Decision by the Fiscal Intermediary to cover a particular item or service as a reasonable and

necessary

Status Indicator (SI)

A letter code that is assigned by CMS that signifies how an individual HCPCS/CPT will be

reimbursed and helps determine if policy rules and discounting apply

SI = G Pass-Through Drugs and Biologicals: paid under the OPPS and receive separate APC

payment

SI = K Non-Pass Through Drugs and Biologicals: paid under the OPPS and receive a separate APC

payment

SI = N Packaged Item or Services: paid under the OPPS, payment is packaged into payment for

other items or services

SI = M Items or Services not billable to the Fiscal Intermediary: not paid under the OPPS

Medically Unlikely Edit (MUE)

Assigned for most HCPCS/CPT codes, represents the maximum units of service that a provider

would report in most circumstances

New Technology Add-On Payment

Under the IPPS, CMS established a process for identifying and ensuring adequate payment for

new medical services and technologies that are inadequately paid under the DRG.

Target Probe and Educate (TPE):

Service provided by the Medicare Administrative Coordinators (MAC) designed to help improve

billing practices in areas that have a high national or specific providers/suppliers who have high

claim error rates


Additional Resources

Acute Inpatient Prospective Payment System (IPPS):


Payment/AcuteInpatientPPS/index.html

CMS Addendums & Crosswalks

o A and B: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-


o D1: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HospitalOutpatientPPS/downloads/CMS1506FC_Addendum_D1.pdf

o ASP Drug Pricing Files: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-

B-Drugs/McrPartBDrugAvgSalesPrice/2018ASPFiles.html

Federal Register, Physician Fee Schedule, Proposed Rule CY 2019:

https://www.federalregister.gov/documents/2018/07/27/2018-14985/medicare-program-

revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions

Federal Register, Hospital Outpatient Prospective Payment System, Proposed Rule CY

2019


proposed-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical

Federal Register, Hospital Inpatient Prospective Payment Systems, Final Rule CY 2019


hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the

Hospital Outpatient Prospective Payment System (last updated December 2017)


MLN/MLNProducts/downloads/HospitalOutpaysysfctsht.pdf

Medically Unlikely Edits (last updated August 2018)


Medicare Advance Written Notices of Noncoverage (last updated September 2017)


MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html







https://www.federalregister.gov/documents/2018/07/27/2018-14985/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions

https://www.federalregister.gov/documents/2018/07/27/2018-14985/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions

https://www.federalregister.gov/documents/2018/07/31/2018-15958/medicare-program-proposed-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical

https://www.federalregister.gov/documents/2018/07/31/2018-15958/medicare-program-proposed-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical

https://www.federalregister.gov/documents/2018/08/17/2018-16766/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the

https://www.federalregister.gov/documents/2018/08/17/2018-16766/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/HospitalOutpaysysfctsht.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/HospitalOutpaysysfctsht.pdf


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf


Questions & Answers Key

Question 1. Answer: A


Question 3. Answer: C

Question 4. Answer: D






Question 10. Answer: B



















Disclaimer

Please note that this information may become obsolete with revised regulations

Please review your current transmittals, program manuals, bulletins, banner pages or other

regulatory publications for updates

Please contact your payer should you have any questions regarding their interpretation and

retain the documentation for your records

Revenue Cycle Management - ASHP

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