Oncology & Hematology Coding Alert

Keep up with the latest on NDCs and the OIG Work Plan.

Crossover areas for Medicare and Medicaid are in the news. Here are the details on following CMS's new rule on adding NDC codes on Medicare claims and the OIG Work Plan's focus on Part B drug savings.

1. CMS: Add NDC for Every HCPCS

Keep an eye out for patients who are entitled to both Medicare and Medicaid, CMS states in MLN Matters SE1234. Effective Sept. 5, 2012, there are new national drug code (NDC) requirements for reporting physician-administered drugs.

To quote the MLN instruction, you should follow these rules on the electronic claim to Medicare:

• For each line level reporting of a Part B physician-administered drug, continue to report the associated HCPCS (e.g., J3140) in 2400 SV202-2, with SV202-1=HC; and
• For each Part B drug HCPCS reported in 2400 SV202-2, complete the required associated 2410 LIN and CPT04 segments as follows:

Include the NDC in 2410 LIN03, with LIN02=N4;
Include the quantity/unit count in 2410 CPT04; and
Input the needed information in 2410 CPT05 and CPT05-1.

Rationale: Medicaid agencies have to include NDCs for physician-administered drugs when they request a claim for drug rebates from manufacturers. The problem is that Medicare claims don't always include one-to-one assignment of an NDC for each Part B drug HCPCS code. The current instruction is designed to prevent denials and improve efficiency.

Resource: Review the full article online at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1234.pdf.

2. OIG: Medicare vs. Medicaid Drug Reimbursement

The 2013 OIG Work Plan is out, and it includes a comparison of "Medicare and Medicaid payments for commonly used physician-administered drugs and biologicals." The goal is to see whether changing Part B drug payment methods would save money for CMS. It's a plan described as "ominous" by Bobbi Buell, MBA, of onPoint Oncology in her October 2012 E-Reimbursement newsletter.

As the OIG states, "Medicare Part B pays for most covered drugs and biologicals on the basis of the reimbursement methodology of ASP plus 6 percent. (Social Security Act, § 1847A.) Medicaid also covers physician-administered drugs and biologicals. However, under Medicaid, States have flexibility in determining reimbursement for covered drugs and biologicals as long as the ingredient cost approximates an estimated acquisition cost. In addition, manufacturers must provide rebates for Medicaid-covered drugs."

Resource: See the complete work plan for yourself, including additional focus areas, at https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf.

For additional insight into the Work Plan, you also may want to review the OIG Outlook 2013 site at https://oig.hhs.gov/newsroom/outlook/index.asp. "Medicare and Medicaid serve one out of every four Americans," says Larry Goldberg, principal deputy inspector general, in a video posted to the site. "The Work Plan is written based on areas with the greatest potential for fraud, waste, and abuse, and the areas where the OIG can effectuate the most positive change."