How administration and codes match up is important to understand.
New drugs become available for our patients all the time and with them, a slew of new factors that we as technicians and scribes have to know — how they are stored, how they work, how much our office uses on a daily basis so we don’t run short. For diagnostic drugs, such as dilating agents and topical anesthetics, they may have manufacturing issues or prices may rise, so we may need substitutes even though they are supply items and we can’t bill for their use. Nonetheless, when a new drug comes onto the market, our providers may make a decision to use them. And it’s up to us to know the details.
Ask the questions
If they are going to be administered at the office, we also have to know some important things:
- Is it billable?
- For what condition is it billable?
- Will our office use it for other, potentially noncovered conditions?
- How will we code for the condition and the drug?
- How many units of this drug get put onto the billing slip so we are reimbursed fairly?
- If there is “overfill” or “wastage,” is that billable? If not, how do we chart that it is properly disposed?
- How will it be stored?
- How much of it will we use?
- How are we going to order it?
- Does it require prior authorization from insurers?
- What might our patients be paying if our providers decide to use it? Will there be an assistance program for those who might not otherwise have access to the treatment?
Identify the code
Importantly, coding for these new drugs might not always be via a “new code.” Sometimes a drug comes onto the U.S. market and it may properly be able to use an existing code. Most billable drugs will have specific recommendations for reimbursement from manufacturers, but you should check with payers, outside consultants, and professional societies for advice.
Let’s look at three newly approved office- or surgery-center administered drugs. Only one of the below may be in your Healthcare Procedure Coding System (HCPCS) 2019 books, as the books may have been printed before the codes were released. None of the below requires special freezers, like some other recently released drugs, but that remains an important “ask.” The three codes we’ll discuss in this column are:
Riboflavin used in Corneal Collagen Cross-linking (CXL)
- Code and descriptor: J2787 - Riboflavin 5’-phosphate, ophthalmic solution, up to 3 mL
- This code was approved and released very late in the year. This drug can be used in the office or a facility, depending on where you treat your CXL patients.
- When you do CXL, you buy and use (or waste since it is not a reusable) 6 mg, not just the 3 mg in the descriptor, so be sure to bill for TWO units (2 X 3 ml = 6 ml) or you will end up with an incorrect payment.
- You can check here for more complete information about this drug/device combination: http://bit.ly/2UtjulT
DEXYCU - Dexamethasone intraocular suspension 9%, for intraocular administration
- This drug should be available for use in the near future. A pair of new codes are set for use:
- C9034 - Injection, dexamethasone 9%, intraocular, 1 mcg. This C code is mainly for hospitals to use.
- J1095 - Injection, dexamethasone 9%, intraocular, 1 mcg. This is the code for surgery centers or for use (unlikely) in the office setting.
- The route of administration for this new drug and its dose are as follows: 0.005 mL of DEXYCU is injected into the posterior chamber inferiorly behind iris at end of ocular surgery.
- CMS granted pass-through status at facility effective Oct. 1. Pass-through status means that Medicare has granted it coverage and payment. Cost is yet to be determined, but the patient or secondary insurance will be responsible for the 80% that Medicare does not cover.
- For those of you interested, you can link to the FDA’s prescribing information here: http://bit.ly/2UvWJxF .
YUTIQ - Fluocinolone acetonide intravitreal implant, 0.18 mg, for intravitreal injection
- An existing code applies.
- This drug is indicated for the treatment of chronic non-infectious uveitis affecting the posterior segment of the eye.
- The existing HCPCS code is J7313 - Fluocinolone acetonide, intravitreal implant, 0.01 mg. Be sure and bill for 18 units for proper payment, as the code is for 0.01 mg and the implant is 0.18 mg.
- Importantly, there is a similar code for fluocinolone, J7311, however this code is for the Retisert implant.
- To see the full prescribing information, check this link: http://bit.ly/2Ut5Or4 .
New drugs have a number of considerations important to understand. The proper codes might or might not be in your code books. As technicians and scribes, it is our duty to know the details. Researching proper documentation and coding is important so our patients are treated properly, and our offices are reimbursed appropriately for them.
As always, “good coding to you.” OP