Oncology & Hematology Coding Alert

Be precise for units; Medicare allows to bill for self-administration.

Are you confused for clotting factor codes? Clotting factor coding seems complex for the number and types of replacement options available. To simplify coding, just look at what clotting factor your physician usedand follow a stepwise approach to calculate billable units. 

Tip: There is a gamut of products prescribed for replacement of clotting factors. These are produced by varying mechanisms which are identified by their unique properties. When coding for clotting factors, look at which specific product your physician prescribed and if a specific code has been assigned for the product. 

Your physician will prescribe clotting factors to replace a deficient factor in the blood. According to the American Federation of Hemophilia, "Hemophilia is treated by replacing the protein that is missing in the blood." The federation also describes the plasma and recombinant products used to control bleeding in hemophilia. According to the federation, plasma derived products are 'factor concentrates that are made from human blood' whereas the recombinant factor concentrates 'are manufactured using hamster cells.'

Medicare Part B: Medicare covers clotting factors under part B (not under part D). "Per the CMS website in the Outreach and Education section, if a person with Medicare Part B has been diagnosed with hemophilia, Medicare helps pay for clotting factors they give themselves by injection under this special benefit category," says Leah Fuller, CPC, Associate Consultant, Pinnacle Enterprise Risk Consulting Services, LLC, CO. "For more information regarding Medicare Drug Coverage under Medicare Part A, Part B, Part C and Part D, visit: https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/downloads/11315-P.pdf."

Self-administration: Eligible patients should be able to use clotting factors to control bleeding and should be able to do so without any medical supervision. When billing for self-administration, indicate 'monthly billing' and write comments to explain the administration.

The bleeding disorders that are covered by Medicare include Factor VIII deficiency, Factor IX deficiency, and von Willebrand's disease.

Follow This Sequence for Billable Units

When you report clotting factors, you essentially follow three simple steps before you submit the claim. This approach applies to physicians and Ambulatory Surgical Centers for the number of HCPCS units billed.

Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Managing Director of Pinnacle Enterprise Risk Consulting Services, LLC ("PERCS"), a division of Pinnacle Healthcare Consulting, CO lists the following three steps for clotting factor coding:

Step 1: Check the type of vial in which the product is supplied. If the product/supply is a single dose vial (SDV), and most are, the practice should identify the most cost effective combination of vial sizes to accommodate the ordered dose. Because it is a SDV, the entire vial will be billed.

Step 2: Verify the number of units that your physician ordered and/or administered to the patient. And identify the number of units of the HCPCS code applicable to the dose(s) given. Bill the amount given on one line of the claim.

Step 3: Determine how many units were supplied in total that are to be discarded and report a second line on the claim with the total number of units wasted as documented and adding a modifier 'JW' to represent a SDV amount that was discarded.

Source of Factor VIII Guides You to the Right Code

When your physician administers human derived factor VIII, submit code J7190 (Factor VIII [antihemophilic factor, human] per IU). For porcine derived factor VIII, submit code J7191 (Factor VIII [antihemophilic factor (porcine)], per IU).

One unit for each IU: For each of the codes, J7190 and J7191, you submit one unit for each IU of factor VIII that your physician administers.

Look for acquired vs. congenital hemophilia A: Before you pick up a code for recombinant factor VIII products, confirm whether the patient received treatment for acquired or congenital hemophilia A.

Limit J7188 to acquired hemophilia A: The code descriptor for J7188 specifies that the code applies to 'OBIZUR.' 

What is OBIZUR? OBIZUR is a recombinant DNA derived antihemophilic factor. Your physician will prescribe OBIZUR for the treatment of bleeding episodes in adults with acquiredhemophilia A.

For every international unit (IU) of OBIZUR, submit one unit of code J7188 (Injection, factor VIII [antihemophilic factor, recombinant], [OBIZUR], per i.u.).

Other recombinant factor VIII: There are other recombinant factor VIII concentrates that your physician may administer to children and adults with congenital hemophilia A. The key to finding the right code is to determine which product was prescribed by your physician. "Having codes for clotting factors by brand allows coders to capture the most detail by coding for the specific brand the provider prescribed," Fuller says. For example, if you read that your physician used recombinant factor VIII called 'NovoEight,' you submit code J7182 (Injection, factor VIII, [antihemophilic factor, recombinant], [NovoEight], per IU).

Your physician may prescribe 'Xyntha,' the plasma/albumin free recombinant factor VIII that is without additives from human or animal material. In this case, you submit code J7185 (Injection, factor VIII [antihemophilic factor, recombinant] [XYNTHA], per IU).

Turn to J7192 for other recombinant factor VIII options: Carefully read for the exact brand of the factor VIII your physician prescribed. In the clinical note, your physician will mention the factor VIII that was administered to the patient. You should look for terms like 'advate,' 'recombinate,' or 'kogenate.' You may not find a dedicated code for one or more of the recombinant factor VIII options. In this case, you submit code J7192 (Factor VIII [antihemophilic factor, recombinant] per IU, not otherwise specified).

How is J7192 different from J7188? Both J7192 and J7188 are for recombinant factor VIII. However, note that J7192 is exclusively for OBIZUR. This factor VIII product is approved only for use in acquired hemophilia A. It is used only in adults. The code J7188 is for factor VIII products used in children and adults. J7188 applies when the factor VIII products, for example, 'advate' are used in congenital hemophilia A.

The prescribing information for "Advate" clearly states, "ADVATE [Antihemophilic Factor (Recombinant)] is a recombinant antihemophilic factor indicated for use in children and adults with hemophilia A (congenital factor VIII deficiency)." The full prescribing information is available at: http://www.shirecontent.com/PI/PDFs/ADVATE_USA_ENG.pdf.

Editor's note: Read more about factor VIII and factor IX codes in the next issue of the Oncology and Hematoloy Coding Alert Vol19n4.