Apheresis Reimbursement: Guide to Billing and Securing ... Apheresis Reimbursement: Guide to Billing

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  • Apheresis Reimbursement: Guide to Billing and Securing

    Appropriate Payment

    May 24, 2013

    Keith Berman, MPH, MBA

    Health Research Associates

    Pasadena, CA

    (626) 564-0456

    kberman@sbcglobal.net

  • Disclaimer

    Information and examples presented below are for

    general educational purposes only. They do not

    constitute advice for actual coding or billing by

    physicians or hospitals.

    Insurance billing codes, billing policies, coverage

    policies and payment rates are subject to change.

    Providers with questions should consult with

    representatives of their third party payers before

    submitting insurance claims.

  • Educational Objectives

     Coding basics for therapeutic apheresis services

     Medicare payment for hospital inpatient/outpatient apheresis

     Physician apheresis supervision: billing rules and payment

     Strategies for minimizing/addressing coverage denials

     Special issues:

     Plasma exchange and cytapheresis

     Photopheresis

     LDL apheresis

  • Codes: The Shorthand of Insurance Billing

    • CPT codes. 5-digit codes used by physicians and hospitals to bill insurers for outpatient procedures and services.

    • ICD-9-CM procedure codes. Used by hospitals to identify significant procedures during an inpatient stay.

    • ICD-9-CM diagnosis codes. Used to identify diagnoses that are both related and unrelated to the procedure or admission.

    • Revenue codes. 3-digit codes that define the hospital department or service category under which procedures or

    products are billed.

  • Hospitals and Physicians Submit Separate Claims for Payment

    Physicians: CMS-1500 Hospitals: UB-04

    Health Insurer

  • CPT Procedure Codes CPT Description

    36511 Therapeutic apheresis; for white blood cells

    36512 for red blood cells

    36513 for platelets

    36514 for plasmapheresis

    36515 with extracorporeal immunoadsorption/plasma reinfusion

    36516 with extracorporeal selective adsorption or filtration and plasma reinfusion (LDL apheresis)

    36522 Photopheresis, extracorporeal

    38205 Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic

    38206 autologous

  • Therapeutic Apheresis: Treatment Settings

    CPT Description

    36511 Therapeutic apheresis;

    for white blood cells

    36512 for red blood cells

    36513 for platelets

    36514 for plasmapheresis

    36516 with extracorporeal selective adsorption/filtration + plasma reinfusion (LDL apheresis)

    36522 Photopheresis, extracorporeal

    Hospital Inpatient (generally)

    Hospital Inpatient, Hospital

    Outpatient or Physician

    Office

  • Therapeutic Apheresis: Crosswalk to ICD-9-CM Procedure Codes

    CPT Description

    36511 Therapeutic apheresis;

    for white blood cells

    36512 for red blood cells

    36513 for platelets

    36514 for plasmapheresis

    36516 with extracorporeal selective adsorption/filtration + plasma reinfusion (LDL apheresis)

    36522 Photopheresis, extracorporeal

    ICD-9 Description

    99.72 Therapeutic leukopheresis

    99.73 erythrocytapheresis

    99.74 plateletpheresis

    99.71 plasmapheresis

    99.79 Therapeutic apheresis, other

    99.88 Therapeutic photopheresis

  • ICD-9-CM Diagnosis Codes Commonly Referenced in Therapeutic Apheresis Claims*

    ICD-9 Description

    446.6 TTP

    357.0 Guillain-Barré syndrome

    356.9 CIDP

    202.1X Mycosis fungoides

    996.85 Graft versus host disease (GvHD)

    272.0 Pure hypercholesterolemia

    *Both hospital and physician claims.

    Refer to Appendix 2 of ASFA’s “Therapeutic Apheresis: A Guide to Billing and Securing Appropriate Reimbursement” for other commonly referenced diagnosed codes

    also 202.2X; Sézary disease

    Plasma exchange (CPT 36514)

    Photopheresis (CPT 36522)

    LDL apheresis (CPT 36516)

  • Medicare Hospital Outpatient Billing and Payment:

    Ambulatory Payment Classifications (APCs)

  • Coding the UB-04 Hospital Claim Form for an Outpatient Plasma Exchange Procedure

    Scenario: A myasthenic patient is exchanged on 5/11/2013

    42 REV. CD. 43 DESCRIPTION 44 HCPCS 45 SERV

    DATE 46 SERV UNITS

    47 TOT CHARGES

    949 OTHER THER SVS 36514 05/11/13 1 $2,475.00

    67 PRIN. DIAG. CD.

    68 CODE

    69 CODE

    OTHER DIAG.

    70 CODE

    202.14

    80 PRINCIPAL

    CODE

    PROCEDURE

    DATE

    81 OTHER

    CODE

    PROCEDURE

    DATE

    OTHER

    CODE

    PROCED

    DATE

    99.88

    A

    B

    Therapeutic plasma

    exchange

    CPT code

    ICD-9-CM

    procedure code

    $990 cost x 2.5

    charge-to-cost ratio

    (in this example)

    Myasthenia gravis ICD-9-CM

    diagnosis code

    Revenue

    code

  • CPT Description

    36511 Therapeutic apheresis; for white blood cells

    36512 for red blood cells

    36513 for platelets

    36514 for plasmapheresis

    38206 Blood-derived hematopoietic stem cell harvesting; autologous1

    APC 0111 (blood

    product exchange)

    Medicare (Hospital Outpatients): 2013 Plasma/Cellular Apheresis Payment

    $9512

    (U.S. average)

    1Allogeneic blood-derived hematopoietic stem cell harvesting is not covered by Medicare under the hospital outpatient prospective payment system (OPPS)

    2Medicare payment rate varies by locality: e.g. about $1,140 in Manhattan; $870 in Pittsburgh

  • Plasma Exchange: 2013 Medicare Hospital Outpatient Payment

    CPT/HCPCS Description

    36514 Therapeutic apheresis; for plasmapheresis

    +

    P9045 Infusion, albumin (human), 5%, 250 ml [14 units infused]

    Example: Human albumin used as plasma replacement fluid1

    Medicare assigns:

    2013 U.S. average rate:2

    APC 0111 $951

    APC 0963 $47.73 x 14

    = $668

    1Procedures that use cryo-poor plasma would use HCPCS code P9044 2Varies by geographic area in accordance with a local wage index-based formula

    Total: $1,619

    +

  • Photopheresis and LDL Apheresis: 2013 Medicare Hospital Outpatient Payment

    CPT/HCPCS Procedure Medicare assigns:

    2013 U.S. average rate:*

    APC 0112

    $2,889

    *Varies by locality in accordance with a local wage index-based formula

    36516 LDL apheresis

    36522 Photopheresis

    All procedure-related costs are paid under APC 0112

  • LDL Apheresis: Hospitals Continue to Underreport Costs

    *For Medicare outpatient claims for the period 1/2011 – 12/2011

    36522 Photopheresis

    36516 LDL apheresis

    $3,050 $2,889

    $1,792

    CPT code

    Procedure

    Reported median cost*

    2013 payment rate

    Some hospitals are also underreporting plasma exchange and photopheresis costs

  • Outpatient Apheresis: Commercial Insurers May Require Preauthorization

    • Necessary documentation may include:

    Detailed patient history

    Examination findings

    Treatment records

    Laboratory records

    Published evidence of clinical benefit

    • Scope of coverage – the covered time period or number

    of treatments – can vary by insurer

  • The Coverage Appeals Process: Get What the Patient Needs; Educate the Insurer

    • Insurer coverage policies often lag behind or miss recent

    published evidence in the clinical literature

    • Don’t give up when an insurer denies coverage:

     Ask for review on an individual consideration basis

     Provide available published studies to document efficacy

     As applicable, document failures with other treatment options

    • Current examples:

     Plasma exchange for treatment of NMO, relapsing MS

     LDL apheresis for very high LP(a)

     Photopheresis for drug-refractory post-lung transplant BOS

  • Medicare Hospital Inpatient Billing and Payment:

    Ambulatory Payment Classifications (APCs)

  • Medicare Payment for Hospital Inpatients: All-Inclusive “MS-DRGs”

    • 745 MS-DRGs (Medicare Severity-Adjusted Diagnosis-Related Groups)

    • Presence of (1) complications and comorbidities (CCs), (2) major CCs or (3) no CCs can now dictate up to three MS-DRGs with differing payment rates

    • Defining MS-DRGs with CCs and MCCs helps Medicare reimbursement on average better approximate actual costs of hospitalization

  • How Diagnosis Coding of an Inpatient Stay Yields an MS-DRG Assignment and Payment

    67 PRIN. DIAG. CD.

    68 CODE

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